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Passport to Whole Health: Chapter 9

Chapter 9.  Recharge: Sleep & Refresh

An icon of a battery with wheeled arrows signifying recharging.
If there’s a secret to a good night’s sleep, it’s a good day’s waking.
―Rubin Naiman

The Importance of Sleep and Rest

Most people need 7-8 hours of sleep to function physically, mentally, emotionally, and socially, but 30% of the American population has chronic insomnia.  As of 2012, 70 million Americans were sleeping fewer than six hours nightly, and the number is growing.[468]  On average, 20% of the adult population is sleep deprived.[469]  Sleep has a significant impact on Whole Health.  For example, it is closely linked to cardiometabolic health.[470]  When people who sleep under five hours nightly are compared with people who sleep over seven hours, they have[471]:

  • 42% greater chance of obesity
  • 69% greater chance of hypertension
  • 40% greater risk of diabetes
  • 36% greater likelihood of having elevated lipids
  • 62% greater risk of stroke
  • 152% increase in risk of having a heart attack

It has even been found that sleep loss is comparable to physical inactivity when it comes to increasing the risk of insulin resistance; even one night of less than four hours of sleep leads to measurable blood glucose differences.2  We also know that people who sleep less have increased sensitivity to pain.[472]  They also have much higher mortality rates, as was noted in a recent systematic review that included over 70,000 elderly individuals.[473]  In one study, men who averaged under six hours per night were four times more likely to die over 14 years.[474]  If people have a concussion, sleep deprivation increases brain damage,[475] and sleep and immune system function are bidirectionally linked.[476]  Poor sleep is linked to poor glucose control in people with diabetes.[477],[478]  Long (>9 hours) sleep duration, like short duration, is also associated not only  with higher risks of stroke and heart disease, but also with a higher likelihood of colorectal cancer, increased mortality, cognitive decline and poor diet.[479]  Obstructive sleep apnea (OSA) is linked with metabolic disease and cognitive decline as well.[480]

Poor sleep is also closely linked to suicidal ideation.[481]  In a study of Veterans, those who reported sleeping less were much more likely to report having suicide attempts in the past year.15  One 2012 study found that sleep disorders were more likely to correlate with suicidal ideation in military personnel than depression or hopelessness.[482]  Insomnia is predictive of subsequent mental illness, particularly for depression.[483]  Sleep impairments have been linked to increased allostatic load, the “wear and tear” that happens if the body loses its ability to effectively respond to stress.[484]  Sleep and inflammation are closely linked.[485]

Sleep serves many purposes.  It is a time when hormones, neurotransmitters, and other compounds are regenerated.  It is a time when short-term memories are converted to long-term memories.[486]  Sleep is important to maintaining a healthy weight (it allows ghrelin and leptin levels to balance),[487] and it is closely linked to mental health,[488] including emotional stability.[489]  Good sleep prevents work and motor vehicle accidents.[490],[491]  Being awake for 17-19 hours is like having a blood alcohol level of 0.05; after 24 straight hours, our brains function as though we have a level of 0.1.  Not only that, but sleep deprivation is linked to increased alcohol use.  Poor sleep can also lead to permanent cognitive defects and may contribute to risk of Alzheimer’s.[492]

In addition to sleep, daytime rest and opportunities to recharge are also important to health.  These are discussed toward the end of this chapter.  We know that people who do not take breaks from sitting during the day are at much higher risk of health concerns.  Leisure time, hobbies, and vacations are also important to well-being. 

For ideas for Personal Health Plan (PHP) content, you can look at the "subtopics" developed for skill-building courses for Veterans.  These are intended to help them zero in on areas they could focus on.  Figure 9-1 shows the subtopics for the Recharge circle.

Six subtopics surround the Self-Care header of Recharge (Sleep and Refresh). Those subtopics include: Sleep Better, Take Breaks, Boost Your Energy, Take Time Just for You, Work with and Expert, and Make One Small Change.

Figure 9-1.  Subtopics within the Recharge Circle of Self-Care

Questions to Ask Related to Recharge

  • Are you satisfied with your energy level?
  • At what time of day are you most energized?
  • What activities energize you and leave you feeling refreshed?
  • At what time of day is your energy lowest?
  • What drains or lowers your energy?
  • When your energy is depleted, what do you do?  Nap?  Eat?
  • How many hours of sleep do you usually get each night?
  • Do you sleep well? 
  • Do you wake up feeling well-rested?
  • If you nap, can you sleep briefly and feel refreshed?
  • Describe any problems you have with sleep.
  • What have you tried to help you sleep better?  Any medications or dietary supplements?
  • Do you ever listen to guided imagery recordings to fall asleep?
  • Do you do restorative practices like gentle yoga or mediation?

Eleven Tips for Improving Sleep

As you work with someone on the Recharge section of the Circle of Health, consider the following to promote good sleep:

  1. Rule out sleep disorders and other health conditions that can lead to sleep problems.
  2. Keep active during the day.
  3. Consider Cognitive Behavioral Therapy for Insomnia (CBT-I).
  4. Follow good sleep hygiene.
  5. Consider light therapy.
  6. Use mind-body practices.
  7. Focus on nutrition and sleep.
  8. Consider dietary supplements.
  9. Give yoga a try.
  10. Consider Chinese Medicine.
  11. Know how to nap.
1.  Rule out sleep disorders and other health conditions that can lead to sleep problems

Ask about snoring and whether a person has been observed to intermittently stop breathing at night, which may indicate obstructive sleep apnea.  People may also note having restless legs (periodic limb movements of sleep).  Are bladder problems playing a role?  Could the thyroid be involved?  Pain can also have a significant effect on sleep.  24% of patients report fatigue as a significant problem, and chronic fatigue syndrome/myalgic encephalomyelitis is a challenging problem that can be due to a number of different causes.[493]

Recent literature indicates that men and women who have recently served in the military have much higher rates of insomnia than the general population, at 25-54%.[494]  Sleep problems are particularly common in people with posttraumatic stress and traumatic brain injury.[495]  One study, focused on female service members, found that 75% of the women reported a traumatic event that correlated with the beginning of sleep problems; 10% reported sexual harassment, trauma, abuse, or rape.[496]

2.  Keep active during the day

Exercise improves a number of sleep outcomes.[497]  A review of six trials focused on people over 40 found that people who engage in moderate intensity aerobic and high-intensity resistance training had better insomnia scores and fell asleep faster, but they did not sleep longer at night or function differently during the day.[498]  A 2018 study found that people ages 45-86 had better sleep efficiency if they were more active and/or less sedentary.[499]  One study found that people over age 60 who exercised had improved sleep at 16 weeks, including both sleep quality and time to fall asleep.[500]  No studies have shown conclusively that exercising before bed causes sleep problems.[501]  Benefits have also been found specifically for people with cancer.[502]

Benefits for sleep seem to be tied to a variety of types of exercise.  For example, results were similar for those who followed general activity recommendations or did high-intensity interval training.[503]  A 2019 review found benefit for tai chi, qi gong, and yoga as well.[504]

3.  Consider Cognitive Behavioral Therapy for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is widely considered to be the gold standard for insomnia treatment.[505]  It is highly effective,[506] including in VA and military populations,[507] and it is widely available in the VA, compared to other organizations.  People are taught how to work with both behaviors and thought patterns that interfere with sleep.  Some key elements of CBT-I include the following[508]:

  • Sleep restriction.  With sleep restriction, the time a person sleeps is limited, especially during the day, to increase the drive to sleep and shift to a consistent sleep schedule. 
  • Stimulus control focuses on reducing anything that contributes to arousal.  These approaches are often recommended as part of “sleep hygiene,” described in the next section.
  • Relaxation involves the use of mind-body tools to help a person relax and move more easily into sleep. 
  • The cognitive component of CBT-I addresses unhelpful beliefs or feelings about sleep.  For example, a person might have an exaggerated sense of how poor sleep will affect their function or have a strong emotional response to waking up before they intended to do so.  Simply normalizing how sleep is for people—letting them know that nighttime awakenings are normal—and helping them to respond more calmly to insomnia or early awakening can be quite helpful.

CBT-I is an effective treatment for and seems to help treat depression.[509]  One systematic review noted that CBT-I has more durable long-term benefits than standard sleep medications.[510]  Best of all, patients treated with CBT-I continue to maintain and, in many cases, improve even more after the completion of treatment.  CBT-I even works when people do it remotely on the Internet.[511]  It has been noted that for all of its benefits, more research is still needed to gauge CBT-I benefit for military personnel or Veterans who are women, or who have substance use disorders.41  For more information, including information about a CBT-I app created by the VA, refer to the Resources section at the end of this chapter.

4.  Follow good sleep hygiene

Sleep hygiene is closely connected with stimulus control in CBT-I.  Essentially it involves optimizing surroundings and circumstances to allow for good sleep.  It works much better when used in conjunction with CBT.  Recommendations to improve sleep hygiene include the following42:

  • Only use the bed for sleep and sex.  Do not read or watch TV in bed.
  • Make sure that where one sleeps is comfortable.
  • Avoid daytime napping.
  • Go to bed and get up at the same time each day.  A ritual, or standard set of activities followed before bed, can be helpful.
  • If sleep is not happening, go somewhere else and do something relaxing.
  • If worries come up, practice a mindfulness exercise, such as writing about concerns in a journal, so that they can be attended to during waking hours.
  • Ensure the environment is dark.  Use light-opaque curtains or a sleep mask, as needed.
  • Keep the sleep environment quiet.  Earplugs, if practical, can be considered.
  • Keep the sleep environment cool.
  • Avoid light exposure from anything with a screen before bed (some people suggest for at least an hour before bedtime).  That includes tablets and smartphones.
  • Move the alarm clock or turn it away to avoid watching the clock.
  • Electromagnetic fields can affect sleep in a dose-related fashion,[512] suppressing melatonin release in the brain.[513]  It is best to minimize how many electrical devices are in the bedroom.  Keep them as far away from the head of the bed as possible.  It is best to use a battery-powered clock versus an electric one.
  • Make sure certain allergies are not triggered by the sleep area.  Keep the bedroom dust-free and clean, and if allergies seem to be a factor, consider a HEPA filter, mold control, removal of carpets, and hypoallergenic bedding that can be washed frequently.
  • Aromatherapy.  A very small trial found that vaporized lavender oil improved insomnia scores.[514]  A few drops of lavender oil can be placed on a cotton ball a foot or so from a person’s head.  Another review of 13 general aromatherapy studies concluded that readily available treatments effectively promote sleep.[515]
5.  Consider light therapy

A 2019 Cochrane review found that evidence is limited for using light therapy to prevent seasonal affective disorder,[516] but many people report feeling recharged when they use this safe and relatively inexpensive therapy.  Sitting within three feet of a light for 20-60 minutes, 2-3 times daily, can boost energy levels.  Morning therapy seems to be most effective, and light levels should be from 2500 to 10,000 lux.  Recent studies indicate that this is not only beneficial to people with seasonal affective disorder, but also to people with depression of any sort[517] and possibly also for those with bipolar disorder.[518]  Depression is a common cause (or effect) of sleep disturbance.  For more information about light therapy, go to the Resources section at the end of this chapter.

6.  Use mind-body practices

Any mind-body approaches, which elicit the relaxation response, can be used.  The goal is to tailor the technique to individual preference. 

Meditation.  A 2019 review includeing 18 trials with 1654 participants concluded that preliminary findings suggest that mindfulness meditation “...may be effective in treating some aspects of sleep disturbance.”[519]  A study of 24 long-term meditators and 24 meditation-naïve controls found that even two 8 hour sessions of compassion or other types of meditation led to alterations in non-REM sleep patterns.[520]  A 2015 randomized controlled trial that compared mindful awareness training to sleep hygiene found that the mindfulness group had improvements in sleep quality superior to the other group.[521]  A 2016 meta-analysis found mild improvement of some sleep parameters with mindfulness meditation.[522]  Another systematic review found that meditative movements (tai chi, qi gong, and yoga) significantly improve sleep.[523]

Mindfulness-Based Sleep Induction Technique.  A useful tool you can encourage patients to try on their own, when appropriate, is the Mindfulness-Based Sleep Induction Technique.42,[524]  It is designed to calm a racing mind when you are trying to fall asleep.  Follow these steps:

  1. Begin with abdominal breathing.  Place one hand on your chest and the other on your abdomen.  When you take a deep breath, the hand on the abdomen should rise higher than the one on the chest.  This ensures that the diaphragm is expanding, pulling air into the bases of the lungs.  (Once you have this mastered, you do not have to use your hands).  This diaphragmatic breathing stimulates the vagus nerve, which enhances the relaxation response. 
  2. Take slow, deep breath in through your nose for a count of 3-4, and exhale slowly through your mouth for a count of 6-7.  (Your exhalation should be twice as long as your inhalation).
  3. Allow your thoughts to focus on your counting or your breath as the air gently enters and leaves your nose and mouth.
  4. If your mind wanders, gently bring your attention back to your breath. 
  5. Repeat the cycle for a total of eight breaths. 
  6. After each eight-breath cycle, change your body position in bed and repeat for another eight breaths.

It is rare that a person will complete four cycles of breathing and body position changes before falling asleep.

Other Approaches

  • Guided imagery (discussed in Chapter 12) has been found to improve sleep as well.  Focusing on imagery was found to reduce time to fall asleep in one small study.[525]
  • Image Rehearsal Therapy can help those with chronic insomnia related to nightmares.[526]  (Image rehearsal therapy is successfully used for nightmares in patients with PTSD.  The approach should be done with a trained therapist.)
  • Breathwork (also discussed in Chapter 12) involves conscious manipulation of breathing.  Various breathing patterns can have an immediate effect on relaxation.[527]
  • iRest® Yoga Nidra.  The military has done pilots of the use of iRest® Yoga Nidra, which is a secularized practice of a specific form of yogic meditation.  Elements include deep relaxation, attention training, self-management tools, and mindful awareness of thoughts and emotions.  A pilot study related to sleep found a trend toward decreasing waking somnolence.[528]  Other studies are in process. 

A 2017 review looking at various mind-body interventions for college students with insomnia found that CBT had large effects.[529]  Sleep hygiene-based interventions had medium effects, as did other approaches, such as mindfulness and hypnotherapy.  The effects of relaxation approaches were variable. 

7.  Focus on nutrition and sleep

Here are some general suggestions to keep in mind:

  • When considering dietary changes to enhance sleep, remember that caffeine has a significant effect.  It influences sleep onset and quality even in people who otherwise do not have sleep problems.[530]  People tolerate caffeine less well with age; its half-life in the body increases.[531]
  • Alcohol may result in faster sleep onset, but sleep is disrupted in the second half of the sleep period.  In people who drink frequently, the sleep benefit may go away while the disruption worsens.[532]
  • A healthy diet in general can provide the raw materials needed for the body to synthesize melatonin, which can lead to better sleep[533],[534]:
    • Nuts and seeds have the highest amounts, particularly walnuts, peanuts, flaxseeds, and sunflower seeds.
    • Vegetables and fruits with the most melatonin include asparagus, broccoli, cucumber, corn, olives, pomegranates, and tart charries.
    • Good grain sources include rolled oats, barley, and rice.
    • Eggs and fish have more than other animal-sourced foods.
  • Foods that contain tryptophan (e.g., turkey, milk, chicken, eggs, cheese, fish, peanuts, pumpkin seeds, and seame seeds).[535]
  • Avoid foods that can promote gastroesophageal reflux, like chocolate, tomatoes, onions, fats, mint, and alcohol. 
8.  Consider dietary supplements

Several supplements are commonly used for sleep, and it is worth it for clinicians to be familiar with them.[536] 

    • Melatonin is secreted by the pineal gland when the brain senses declining light levels, and its release stops when light is present.  Optimal dose varies greatly from one person to the next.  A systematic review and meta-analysis of melatonin looked at 17 studies involving 284 study participants.[537]  Its effects are statistically significant, but they may not be all that meaningful clinically.  Melatonin treatment reduced sleep onset latency by 4 minutes (95% CI 2.5-5.4), increased sleep efficiency by 2.2% (95% CI 0.2-4.2) and increased total sleep duration by 12.8 minutes (95% CI 2.9-22.8).  It is more effective in the setting of delayed sleep phase syndrome.[538] Melatonin is well tolerated.  It should be taken about two hours before bedtime.  A typical dose is 1-3 milligram(s), taken orally.  Lower doses, like 0.3 milligrams, may be more effective for some people.  Note: Melatonin is on the VA formulary.
    • Valerian must be taken daily for 2-4 weeks to take effect.  It seems to increase the availability of the neurotransmitter GABA.  Safety seems to be quite good, with just a few people reporting grogginess in the morning after taking it.  A systematic review and meta-analysis that focused on 16 studies noted methodological problems and variability, but concluded the available evidence suggests it may improve sleep quality with minimal side effects.[539]  A 2020 review noted that valerian shows some promise for sleep and anxiety, but more studies are needed.[540]
    • Lavender oil shows some promise as a sleep aid, in very small trials.74,[541]
    • Other commonly use supplements have less research favoring their use.70  These include German chamomile, 5-hydroxytryptophan (5-HTP), L-tryptophan, and teas that contain hops and passionflower.  These tend to be safe, but efficacy is not clear from current research.

The tool “Botanical Medicines to Support Healthy Sleep and Rest” has additional information on dietary supplements for sleep.  Chapter 15 has more information about the safe and appropriate use of dietary supplements.

9.  Give yoga a try

Yoga was found in a large 2020 systematic review to be beneficial for women as a way of managing sleep problems.[542]  A 2014 study concluded that yoga is beneficial for sleep in older adults in terms of sleep quality, sleep efficiency, and sleep duration and sleep latency.[543]  Another trial involving 139 people over age 60 found that all aspects of sleep improved.[544]  A large review of 18 studies found that sleep quality scores, time to sleep, and sleep duration were improved,[545] and yoga was found to improve sleep in patients with breast cancer.[546]  Yoga also seems to help with restless legs syndrome.[547]  Chapter 5, “Moving the Body,” has more information about yoga.

10.  Consider Chinese medicine

Acupuncture has wide use in China as an insomnia treatment, and data is favorable.  For example, a 2020 review of 13 trials with 911 participants found it had a significant effect on insomnia compared to sham acupuncture groups.  Similarly, a 2012 review of 46 trials of 3,811 participants found it was a safe and effective treatment.79  A Cochrane review focusing on 33 trials found improvement in sleep measures but noted that effect sizes were small and that more study is needed.[548]  A 2017 trial including 72 people found that acupuncture was more effective than sham treatment for increasing sleep quality and psychological health in people with primary insomnia.[549]  Another 2017 review found acupuncture to benefit depression-related insomnia.[550]  Yet another 2017 review for cancer-related insomnia was less conclusive.[551]  A 2020 review and meta-analysis found that acupuncture has benefits in OSA as well.[552]

11.  Know how to nap

A nap’s length determines how recuperative it is, and longer is not necessarily better.  Naps less than 30 minutes have been found to restore alertness, as long as they are not “ultrabrief” (30-90 seconds).[553]  They have benefits that last from 1-3 hours.  With short naps the brain moves through sleep stages 1 and 2, without rapid eye movement (REM) sleep; it appears that stage 2 is needed for a nap to be beneficial.  Naps longer than 30 minutes are associated with more sleep inertia (grogginess), but 40-60 minute naps have longer-lasting cognitive benefits than shorter naps.[554]  Relative risk of cardiovascular disease decreases when people regularly take short (under 30 minute) naps, then increases when naps are longer, especially when they are longer than 45 minutes.[555]  Daytime napping is linked to more severe symptoms for people with fibromyalgia syndrome.[556] 

Beyond Sleep: Additional Recharging Tips

Of course, Recharge does not just include sleep.  Here are some additional recommendations to help people recharge in other ways.  There are three areas to consider here:

  1. Ensure a person is finding time for leisure, creativity, and hobbies or other non-work interests.  Ideally, this time should not all be sedentary.[557]  This is discussed further in Chapter 7, “Personal Development.”
  2. Vacations and rest periods decrease job stress and burnout and improve life satisfaction, even though the benefits may fade quickly after one goes back to work.[558]  One small study did find that anticipating a vacation may have beneficial affects in terms of how stress affects heart rates.91  A study of 4- to 5-day vacations found that people reported higher health and well-being during vacations, especially if they had more time for conversations with their partner, had more fun, and had fewer negative experiences.[559]  Not surprisingly, working during vacation had negative effects.  When you go on vacation, really detach from work.  Be careful not to let a vacation become a different form of stress.  Length of vacation does not seem to matter. 
  3. Taking breaks while working is also important to health.  We know that cardiac risk is decreased based on how often one interrupts times of inactivity.  Frequent breaks for movement lower waist circumference and blood sugars.[560]  Here are some tips related to taking breaks that you can share with Veterans92:
  • Be clear about your workplace’s break policy, and discuss it with your supervisor, as needed.
  • Build break time into your daily schedule.  A five-minute break every 30 minutes is a common suggestion.  Try for at least one per hour and take longer breaks (15 minutes or so) in the middle of the morning and the afternoon.  You can set a clock, watch, smartphone, or computer to give you reminders about when it is break time.
  • Be clear on how you will spend your break time.  You can do nothing, stretch, have a healthy snack, take a moment for mindful awareness, listen to music, or even take a power nap.
  • Change locations during breaks, to help you make a clean break from working.
  • Consider a standing workstation to keep yourself from becoming too sedentary.

Part of personal health planning can involve helping a Veteran be strategic about leisure time, breaks, and vacations.  Just as you can create an activity prescription (as outlined in Chapter 5, “Moving the Body”), you can also create a prescription for rest.

For more information on work breaks and vacations, check out “Taking Breaks: When to Start Moving, and When to Stop.”

Recharge Resources

Websites

VA Whole Health and Related Sites

  • A Patient Centered Approach To: Recharge, Rest, Sleep.  Part of the Components of Health and Well-Being Video Series.  https://www.youtube.com/watch?v=zT-bbZmeW4I&feature=youtu.be
  • Veterans Whole Health Education Handouts.
  • https://www.va.gov/WHOLEHEALTH/veteran-handouts/index.asp
    • An Introduction to Recharge for Whole Health
    • Hints for Encouraging Healthy Sleep
    • Change Your Habits to Sleep Better
    • How Pausing and Taking Breaks Leads to Whole Health
    • Counseling for Insomnia
  • VA CBT-I. https://vaww.portal.va.gov/sites/OMHS/cbt_insomnia/Lists/CBTAbout/AllItems.aspx
  • Assessment and Treatment of Sleep Problems in PTSD.  National Center for PTSD Continuing Education Course.  https://www.ptsd.va.gov/professional/continuing_ed/assessment_tx_sleep_problems.asp

  • Whole Health Library Website

    Other Websites

    Books
    • Healing Night: The Science and Spirit of Sleeping, Dreaming and Awakening, Rubin Naiman (2005)
    • Insomnia: The Integrative Mental Health Solution, James Lake (2015)
    • Say Good Night to Insomnia, Greg Jacobs (2009)
    • Sleep Smarter, Shawn Stevenson (2016)
  • Apps and Monitoring Software

    The phone app listed below is free.  Find it by searching online or in your device’s app store.

    CBT-I Coach
        .  National Center for PTSD.  An excellent app that makes CBT-I techniques more portable.

    Special thanks to John McBurney, MD, who wrote the original Whole Health Library materials on Recharge that inspired some of the content for this chapter, as well as Vinny Minichiello, MD, who updated the materials in 2018.

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