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Lifestyle modifications


  • "The ability to fall asleep at the desired time and maintain sleep  without excessive waking is fragile and influenced by multiple factors.  Identification of these factors is at the core of insomnia treatment" (1)

  • Insomnia etiology is best conceptualized as a combination of  predisposing, precipitating, and perpetuating factors that vary over  time. Each of these factors should be assessed to formulate an  individualized treatment plan." (1)

Cognitive behavioral therapy for insomnia

  • Behavioral components: A) Stable wake time and bedtime all days a week. B) Sleep restriction. C) Good sleep hygiene: Avoid daytime napping, limit/avoid caffeine, alcohol and nicotine particularly close to sleep, perform regular physical activity/exercise at least 4-6 hours before sleep, dark and quiet sleep environment, avoid large evening meals (1)


  • Carbohydrates: High carbohydrate intake may increase REM sleep compared to low carbohydrate intake. Low carbohydrate intake may increase deep sleep (3)

  • Vitamin D deficiency is associated with increased risk of sleep disorders (4), and vitamin D supplementation may improve sleep quality (5)


  • Regular physical exercise has moderate positive effect on sleep quality, a small to moderate positive effect on sleep onset latency, and a small positive effect on total sleep time and sleep efficiency (6)


  • Smoking within 4 hours before sleep is associated with incerased sleep fragmentation (2)


  • Psychological stress is associated with reduced deep sleep, REM sleep and sleep efficiency, as well as an increase in awakenings (7)



Evidence Pyramid


Evidence based on guidelines and evidence based Clinical Decision Systems is written in BOLD

Evidence based on meta analysis or systematic reviews is written in BOLD and CURSIVE

Evidence based on randomized controlled trials is written in plain font

Evidence based on observational / cohort studies is written in CURSIVE

Figure: Evidence pyramid

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