corrected curriculum sleep health hsc 440
TRANSCRIPT
1
A to ZzZz Sleep Health
Nathan Cleveland
Sandra Lopez
Christian /Monsalud
Kiran Athreya
HSC 485
Fall 2014
Professor Victoria Bisorca
2
Table of Contents
1. Introduction……………………………………………………………………………......3
2. Group Philosophy of Health Education…………………………………………………...5
3. Justification………………………………………………………………………………..7
4. Scope and Sequence……………………………………………………………………….
5. Content Outline……………………………………………………………………………
6. Sample Learning Opportunities…………………………………………………………...
7. Evalaution Techniques…………………………………………………………………….
8. Reference List……………………………………………………………………………..
3
Introduction
The purpose of this curriculum is to educate the learner on how to increase optimal health
through achieving sufficient quality sleep. The target population in most need of better sleep
quality in the United States is CSU Long Beach college students 18-25 years old. The following
curriculum includes a wide range of topic areas including justification towards the need for better
sleep, the consequences of poor sleep health, and understanding specific sleep disorders. At the
end of the program, the learner will develop management skills to create a plan to increase their
overall sleep health.
Managing sleep health becomes a challenge as adolescents transition into living
environments with limited supervision and more individual freedom. Without the pressure of
acquiring a job but still having the ability to be financially dependent on family members,
college students have more time to engage in leisure and social activities. The party, nightlife
scene, sleeping in on the weekends, and all-nighters portrayed by American mainstream society
can affect sleep health in college students. The rapid advancement of mobile technology can also
cause a major distraction. The early onset of sleeping disorders such as insomnia and sleep apnea
as well as chronic disorders such as diabetes and depression are just some examples of health
problems caused by insufficient sleep in college students (Centers for Disease Control and
Prevention, 2014).
Human interaction plays a very integral role on a daily basis in society. Whether it be
face to face, online communication such as e-mail or something as simple as a voicemail, an
individual's attitude and mindset is displayed, which can be affected by one’s sleep health. In the
healthcare setting, a physician's sleep health can tremendously affect their ability to perform and
communicate adequately in order to save lives. A lack of sleep for one individual can have great
4
tolls on society such as vehicle accidents caused by drowsy driving and workplace injuries
(Division of Health Harvard Medical School, 2007). This curriculum will help its target
population address these issues using intervention techniques designed to eliminate the negative
effects of sleeplessness through development of healthy sleep habits.
In this comprehensive sleep health curriculum, the students will learn important topics
that will give greater insight into the importance of sleep health. The curriculum will review
acute and chronic health problems that can arise from lack of sleep, how sleep affects mental
health, types of sleep disorders, and comprehensive sleep management skills. First, the learner
will identify the physical and mental health benefits of sufficient sleep as well as learning about
the disorders caused by poor sleep health. Afterwards, the student will learn comprehensive sleep
management and preparation techniques that they can utilize at home to increase the amount of
sleep, improve overall sleep quality, and minimize sleep disturbance.
5
Group Philosophy of Health Education
Health education is a vital field of study needed to increase the longevity of the human
race and to improve the quality of life. According to the World Health Organization (2003),
“health is a state of complete physical, mental and social well-being and not merely the absence
of illness or disease. As the human population begins to evolve and the environment changes,
new health challenges and health problems arise that could cause potential detrimental effects
The need of health education will increase with the continuing advancement of urbanized,
industrial populations, new technology inventions, and an increasingly competitive economy.
Simultaneously, the socioeconomic gap continues to widen as health resources become less
accessible due to the competitive economy. It should also maintain a didactic and symbiotic
system in which both ends of the economic inequality can benefit from one another. We believe
health education should also be universal meaning the description of health disparities and
methods to alleviate the problem is understood and can be applied in any area across the world.
Equal accessibility and cultural sensitivity will help decrease economic inequality.
Health education aims to utilize all levels of prevention to eradicate disease and help
promote healthy habits. Chronic diseases such as obesity and diabetes are health problems that
are highly preventable. As health educators, it is our moral responsibility to help solve the health
problems that we have caused ourselves. Health education should not focus on how well
individuals can memorize numbers or name definitions. The focus should derive from the
development of self-efficacy and confidence within individuals to use the knowledge and skills
they have learned in the classroom and apply them to reality. Changes in attitudes and beliefs are
a primary factor in creating healthy behaviors.
6
While the majority of health education is managed by healthcare professionals, teaching
healthy behaviors requires collaboration with other areas of academic discipline to provide
successful comprehensive programs. For example, business marketers and advertisers are
essential in promoting various health programs across a global market. All health educators or
healthcare providers should receive the proper training and education to practice in their field.
Healthcare personnel should demonstrate the attitude Health educators must be also flexible and
adaptable to any type of learning style. Working in teams and collaborating in groups is also a
skill that must be mastered by health educators.
Although there is an increased demand for health education, there are limited amount of
health resources available. As health educators, it is our moral obligation to help the community
and those in need to create a brighter future. Health education should emphasize the importance
of sleep and sleep management skills. Learning how to manage sleep can help decrease certain
chronic illnesses and improve overall health. Lifestyle choices such as increased amount of
leisure activities and the importance of working long, extra to boost income decreases the
amount of sleep. Sleep health is an important part of health education because it is a universal
health need regardless of cultural and ethnic groups.
7
Justification
Topic: SLEEP HEALTH
● How to optimize health using sleep
● Connecting sleep with health
Target Population:
● CSU Long Beach college students 18-25 years old
A. Survey of Experts and Curricular Resources.
1. Learner Oriented Goals
Based upon the Survey of Experts and Curricular Resources, the learner oriented goals
for optimizing sleep health are:
Goal #1: “To investigate differences in sleep duration of overweight/obese and
normal weight groups, and the association between sleep deprivation and obesity,
dietary intake, and physical activity” (Parvaneh, Poh, Hajifaraji, & Ismail, 2014).
Goal #2: “[To examine] the inter-relationships among sleep duration, sleep
quality, and circadian chronotype and their effect on alertness, depression, and
academic performance” (Short et al., 2013).
Goal#3: “[To explore] if bedtimes influenced school performance and
motivation, as well as the odds ratio (OR) for health-related concerns in
adolescents” (Merikanto, Lahti, Puusniekka, & Partonen, 2013).
Goal #4: To assess prevalence of drowsy driving amongst U.S citizens”
(Wheaton AG, Chapman DP, Presley-Cantrell LR, Croft JB, and Roehler DR.
Centers for Disease Control and Prevention [CDC], 2013).
8
Goal #5: “To assess the association between BMI categories and days of
insufficient sleep
after adjusting for sociodemographic variables, smoking, physical activity, and
frequent mental distress” (Liu et al., 2013).
Goal #6: To evaluate the effects of a mHealth intervention (intervention using
mobile technology) consisting of tailored advice regarding exposure to daylight,
sleep, physical activity, and nutrition, and aiming to improve health-related
behavior, thereby reducing sleep problems and fatigue and improving health
perception” (van Drongelen et al., 2014).
Goal #7: “To increase sleep knowledge, and effect a change in behavior that
would improve sleep parameters (e.g., sleep latency, total sleep time, regularize
bedtimes), and associated improvements in daytime functioning (e.g., daytime
sleepiness, depressed mood)” (Moseley & Gradisar, 2009, p.335).
Goal #8: “To list indications, efficacy, and risk/benefits of prescription hypnotics
and of over-the-counter medications or alternative treatments to promote sleep”
(Strohl et al., 2003, p. 334).
Goal #9: “(To) identify normal sleep patterns and common sleep disorders”
(Richardson, 2010). Goal #10: “(To) illustrate behavior-intervention treatments
for insomnia” (Strohl et al., 2003, p. 334).
Goal #11: “(To) recognize the classifications of sleep disorders, including sleep
architecture” (Baptist Health South Florida, 2013).
9
Goal #12: “(To) identify and assess the impact of non-REM (non-rapid eye
movement sleep) and REM (rapid eye movement) sleep characteristics on sleep
disorders and daytime sleepiness” (Baptist Health South Florida, 2013).
Goal #13: “(To) explain the association between sleep and epileptic syndromes.”
(Baptist Health South Florida, 2013)
Goal #14: “(To) identify initial behavior patterns associated with insomnia”
(Baptist Health South Florida, 2013).
Goal #15: “(To) list the sleep abnormalities associated with chronic alcoholism”
(Strohl et al., 2003, p. 334).
2. Identify 4 different health education curriculum:
1. ”Sleep, Sleep Disorders, and Biological Rhythms, National Institutes of
Health Curriculum Supplement Series Grades 9-12”
Topics:
● Misconceptions about sleep
● Homeostasis and sleep
● Functions of sleep
● Sleep loss and wakefulness
● Sleep is a dynamic process
● Physiological changes during sleep
● Sleep and the brain
● Biological clock
● Sleep disorders
2. “Adolescent Well-Being: Day and Night” (Moseley & Gradisar, 2009, p.
10
335)
Topics:
● Adolescent sleep needs and practices
● Consequences of poor sleep practices
● Good sleep hygiene practices
● Regularization of sleep/wake schedule and early morning
bright light exposure
● Stimulus control therapy instructions
● Sleep-compatible cognitive and behavioral strategies
3. “Healthy Sleep: Understanding the third of our lives the we so often take
for granted” (Mullington, 2007).
Topics:
● Why Sleep Matters: Health, memory, safety, and the
cultural significance of sleep
● The Science of Sleep: The brain, jet lag, caffeine, and
aging, and how they influence sleep
● Getting the Sleep You Need: Achieving better health, and
knowing when to seek treatment
4. “Disordered Sleeps Effects on Growth, Development and Good Health”
(Klykylo, Kay 2012).
Topics:
● Stages of Normal Sleep, and how they change throughout
infancy, childhood, and into adulthood.
11
● Characteristics and Significance of Dreams
● Sleep hygienes effect on Initiation and Maintenance of
Sleep
● Influence of Medication, Psychological factors, and
changes in the Circadian rhythm
● Cognitive and Emotional consequences of Sleeplessness
3. Identify 3 different, local community resources:
Three community resources for improving sleep health include:”
1. Sleep Center Orange County (Sleep Center Orange County, n.d.).
Address: 4980 Barranca Parkway, Suite 170 Irvine, CA 92604
Phone #: (949) 679-5510
Website: http://www.sleepcenteroc.com
Contact Person: No contact person listed
Materials & Services offered:
● Diagnostic sleep study (nocturnal polysomnogram--NPSG) followed by a
CPAP titration on a second night, if positive for sleep apnea
● Sleep clinic consultation (specialist evaluation, testing, and treatment as
needed)
● CPAP/BiPAP study (continuous or bi-level positive airway pressure
titration)
● Split-Night Sleep Study (NPSG + CPAP/BiPAP on same night PRN)
● Other sleep studies (Not stated which other ones)
Cost of Materials & Services:
12
● Depending on service, but they do accept patients with and without
insurance
● All pay/ co-pays are due in full by time of service
Restrictions:
● Need at least 24-hour “Business day” cancellation of appointment,
otherwise you may be billed (up to $300 for a sleep study cancellation) or
the services will be cancelled
● If insurance does not pay, they will not look into why, and patient will
have to pay in full out of pocket
2. MemorialCare Sleep Disorders Center (MemorialCare Health System, 2014).
Address: Elm Ave. Medical Plaza Suite 307 Long Beach, CA 90806
Phone #: (562) 933-8645
Website: www.memorialcare.org/services/sleep-disorders-care
Contact Person: Stephen E. Brown MD. Specialities in Sleep Disorders &
Pulmonology. (562) 422-1110
Materials & Services offered:
● Sleep Apnea Risk Assessment where anyone can fill out a survey online
for free to see if they might have sleep apnea
● Sleep Disorder Care Diagnostics such as a Multiple Sleep Latency Test
(MSLT) and a Polysomnogram (PSG)
● MSLT determines extent of daytime sleepiness and tests for narcolepsy
● PSG is a night time study to monitor sleep rhythms
● Continuous Positive Airway Pressure (CPAP): primary treatment for
13
obstructive sleep apnea (OSA). A small mask or nasal cannula is applied
to the nose which is connected by tubing, helps the blockage of nasal and
oral passages during sleep
● Bi-Level Positive Airway Pressure (BiPAP): variant of CPAP where the
pressurized air is delivered at higher pressure when you breathe in than
when you exhale
Cost of Materials & Services: price dependent on insurance
Restrictions: None
3. Good Samaritan Hospital Comprehensive Sleep Center (Good Samaritan
Hospital, 2014).
Address: 1225 Wilshire Blvd. Los Angeles, CA 90017
Phone #: (213) 977-2260
Website: http://goodsam.org/clinical/sleep-center.php
Contact Person: Sterling Malish, M.D. (213) 977-2260
Materials & Services offered:
● Sleep studies: 7 days week with final physician reports provided within 3
days after study
● Studies: in-home, private rooms with twin size bed, television &
bathrooms; includes overnight stays
● Knowledgeable staff (certified sleep technicians & physicians) to answer
any questions patients may have about the sleep study
● Comprehensive follow-up care with one our sleep physicians are available
● Nasal CPAP & BiPAP
14
● Weight loss therapies to alleviate sleep apnea
● Uvulopalatopharyngoplasty - surgical removal of the tonsils, the uvula,
and part of the soft palate
● Somnoplasty - radiation therapy to shrink enlarged organs that obstructs
airways
● Septopalsty - repair deviated nasal septum, to reduce snoring & sleep
apnea
Cost of Materials & Services:
● Does not state costs, only list of health plan contracts they accept:
● All preferred provider organization (PPO) plans
● Medicare
● Medi-Cal
● Other major health plans such as Aetna and HealthNet
Restrictions:
● Must have health insurance to gain access & receive services
● Will assist individuals without health insurance to identify alternative
financial options
4. UCLA Sleep Disorders Center (UCLA Health, n.d.).
Address: 10833 Le Conte Ave, Suite 216, Los Angeles, CA 90095
Phone: (310) 26- SLEEP (310-267-5337)
Website: http://www.sleepcenter.ucla.edu
Contact Person: Avidan, Alon Yosefian MD, MPH (310-267-1062)
Materials and Services Offered:
15
● New and returning patients can schedule appointments to meet with sleep
specialists to:
o Discuss their problems
o Explain and examine medical histories
o Undergo physical examinations
● Outpatient clinic focuses on diagnosis and treatment of sleep disorders in
which the clinicians do a sleep study individually for the specific needs of
the patient. Once data is collected, the clinicians then provide:
o In-depth analysis of the results gathered
o Formulated treatment plans
o Further appointments to review progress
Costs of Materials and Services: Insurance representative determines your
coverage
Restrictions:
● Patients must be referred by a primary care physician or subspecialty
physician to be seen at the UCLA Sleep Disorders Center.
● Patients who fail to notify appointment cancellations within 48 hours,
will be fined a $50 cancellation fee.
B. Study of Contemporary Society and Learners
1. Prevalent Health Problems in Society
16
Based upon the Study of Contemporary Society and Learners, the prevalent health problems in
society related to poor sleep quality includes:
1. Type 2 Diabetes - “Sleep duration and quality have emerged as predictors of levels of
Hemoglobin A1c, an important marker of blood sugar control” (CDC.gov, 2013).
2. Cardiovascular Disease - “Sleep apnea and hardening of the arteries (atherosclerosis)
appear to share some common physiological characteristics, further suggesting that sleep
apnea may be an important predictor of cardiovascular disease” (CDC.gov, 2013).
3. Obesity - “Laboratory research has found that short sleep duration results in metabolic
changes that may be linked to obesity...insufficient sleep in youngsters may adversely
affect the function of a region of the brain known as the hypothalamus, which regulates
appetite and the expenditure of energy” (CDC.gov, 2013).
4. Depression - “Evidence suggests that people with insomnia have a ten-fold risk of
developing depression compared with those who sleep well. Depressed individuals may
suffer from a range of insomnia symptoms, including difficulty falling asleep (sleep onset
insomnia), difficulty staying asleep (sleep maintenance insomnia), unrefreshing sleep,
and daytime sleepiness... NSF's 2006 Sleep in America poll of adolescents aged 11 to 17
revealed that among those who reported feeling unhappy, 73% reported not getting
enough sleep at night..” (National Sleep Foundation).
5. Immunodeficiency - “Prolonged sleep curtailment and the accompanying stress response
invoke a persistent nonspecific production of pro-inflammatory cytokines, best described
as chronic low-grade inflammation, and also produce immunodeficiency, which both
have detrimental effects on health” (Besedovsky, Lange, & Born, 2012, p. 134).
6. Decreased Life Expectancy – “Data from three large cross-sectional epidemiological
17
studies reveal that sleeping five hours or less per night increased mortality risk from all
causes by roughly 15 percent” (Harvard University, 2007).
7. Vehicle accidents - “National Highway Traffic Safety Administration estimates that
2.5% of fatal crashes and 2% of injury crashes involve drowsy driving...up to 5,000 or
6,000 fatal crashes each year may be caused by drowsy drivers. Among nearly 150,000
adults aged at least 18 years or older in 19 states and the District of Columbia, 4.2%
reported that they had fallen asleep while driving at least once in the previous 30 days”
(CDC, 2014).
8. Cognitive Impairment -”Objectively measured disturbed sleep was consistently related
to poorer cognition, whereas total sleep time was not. This finding may suggest that it is
disturbance of sleep rather than quantity that affects cognition” (Blackwell, Ancoli-Isreal,
& Yaffe. PubMed, 2006).
9. Mood Disorders - “A single sleepless night can cause people to be irritable and moody
the following day, it is conceivable that chronic insufficient sleep may lead to long-term
mood disorders. Chronic sleep issues have been correlated with depression, anxiety, and
mental distress. In one study, subjects who slept four and a half hours per night reported
feeling more stressed, sad, angry, and mentally exhausted. In another study, subjects
showed declining levels of optimism and sociability as a function of days of inadequate
sleep. All self-reported symptoms improved dramatically when subjects returned to a
normal sleep schedule” (Mullington, 2007).
10. Alcohol Use - “Studies have shown that alcohol use is more prevalent among people who
sleep poorly. Alcohol acts as a mild sedative and is commonly used as a sleep aid among
people who have sleep problems such as insomnia. Also, the sedative quality of alcohol is
18
only temporary. As alcohol is processed by the body over a few hours it begins to
stimulate the parts of the brain that cause arousal, in many cases causing awakenings and
sleep problems later in the night” (Mullington, 2007).
2. Health Problems in the Population
Based upon the Study of Contemporary Society and Learners, the health problems in the target
population related to poor sleep quality include:”
1. Insomnia
According to the CDC (2011), the prevalence rate of California adults 18-24 years who
have reported more than 14 days of insufficient sleep in the past 30 days was 27.9-
30.8%. Insufficient sleep is caused by a variety of factors that are common within the
target population such as lifestyle and occupational factors that include access to
technology and work hours. Medical conditions, medications, and sleep disorders also
affect the quantity and quality of sleep hours. Insomnia is also linked to a number of
chronic diseases including diabetes, cardiovascular disease, obesity, and depression.
2. Alcoholism
22% of adults who slept 6 hours or less had five or more alcoholic drinks in 1 day in the
past year as compared to the 19% of adults who slept 7 hours or more. The association
between having five or more drinks in 1 day and hours of sleep was most notable for
men and for younger adults. “Alcohol shortens sleep latency, but then promotes
fragmented sleep in the latter half of the night. One study found that 11.6% of students
who drank used alcohol as a sleep aid. Alcohol may also increase the risk for obstructive
sleep apnea (Hershner & Chervin, 2014, p. 76 & 79).
3. Anxiety
19
Research by Kenney, Lac, LaBrie, Hummer & Phan (2012) suggests that the prevalence
of insomnia in patients with anxiety disorders ranges from 70% to 90%. In people with
comorbid anxiety and insomnia, for example, poor mental health preceded the onset of
the insomnia in 73% of cases. “The lifetime prevalence of anxiety in adults 18-29 years
old is 30.2%” (National Institute of Health [NIH], 2014).
4. Motor Vehicle Accidents
Martiniuk et al. (2013) stated that “less sleep per night significantly increases risk for
crash in young adults.” They also stated that “60% of US youth aged 17 to 24 years
frequently say they get inadequate sleep and experience daytime sleepiness. In the
United States, it is estimated that drowsy driving is responsible for 20% of all motor
vehicle crashes, meaning that in the United States alone, drowsy driving may cause 1
million crashes, 50 000 injuries, and 8000 deaths each year. Young drivers are involved
in a disproportionate number of these crashes” (p. 648). The World Health Organization
(WHO) reported that each year, almost 400,000 young people under 25 years old are
killed in a road traffic crash (WHO, 2007).
5. Narcolepsy
“It is estimated that about one in every 3,000 Americans are affected with narcolepsy. In
most cases, symptoms first appear when people are between the ages of 7 and 25”
(National Institute of Neurological Disorders and Stroke, 2013). The CDC states that
“excessive daytime sleepiness (including episodes of irresistible sleepiness) combined
with sudden muscle weakness (also known as cataplexy) are the hallmark signs of
narcolepsy that profoundly reduces the quality of life and performance at work and in
school. The sudden muscle weakness seen in narcolepsy may be elicited by strong
20
emotion or surprise. Episodes of narcolepsy have been described as ‘sleep attacks’ and
may occur in unusual circumstances, such as walking and other forms of physical
activity” (CDC, 2013).
6. Depression
“Depression is common during the college years: 14.8% of students report a diagnosis
of depression and an estimated 11% have suicidal ideation. Irregular sleep schedules
have been associated with greater depressive symptoms. Prolonged sleep latency was
associated with loss of pleasure, punishment feelings, and self-dislike” (Hershner &
Chervin, 2014, p. 79-80).
7. Delayed Sleep-Phase Disorder (DSPD)
Hershner & Chervin (2014) states that DSPD is a circadian rhythm disorder
characterized by sleep-onset insomnia and difficulty waking at the desired time.
Consequences of DSPD may include missed morning classes, increased sleepiness, and
decreased concentration, especially in morning classes. Studies suggest that there is a
correlation between DSPD and poor academic performance. The prevalence of DSPD in
the U.S. college population may be as high as 6.7%-17% (p. 79).
8. Increased use of stimulants
Hershner & Chervin (2014) state that the “use of either prescribed or nonprescribed
stimulants is a growing problem in young adults. The most commonly reported reason is
to “stay awake to study” or increase concentration. A survey at 119 colleges and
universities across the U.S. found a 6.9% lifetime prevalence for the use of stimulants
such as Dexedrine, Adderall, Ritalin, and Concerta. Other studies show prevalence as
high as 14%. Men are more likely than women to use stimulants, as well as caffeine and
energy drinks. Nonprescribed use of stimulants is associated with increased use of
21
alcohol, cocaine, and marijuana. Not all stimulant use is illicit, as between 2%–8% of
college students’ self-reported symptoms are consistent with attention deficit
hyperactivity disorder (ADHD). Stimulants increase sleep latency and suppress REM
sleep; subjects who use stimulant medications report worse sleep quality (p. 76-77).
9. Sleep Paralysis
In Sharpless & Barber’s (2011) analysis of sleep paralysis studies conducted in the
United States as well as international data, the prevalence of sleep paralysis in the
general population was 7.6%. However, the prevalence of college students experiencing
at least one episode of sleep paralysis was 28.3% and 31.9% in psychiatric patients.
Episodes of SP have been linked with conditions such as narcolepsy, hypertensio n, and
seizure disorders, but are also associated with a general lack of sleep, sleep disturbances,
jet lag, student status, African descent, and shift work (p. 311).
10. Obesity
In 2011-2012, 20.5% of 12- to 19-year-olds had obesity (CDC, 2014, Sept 3). The
prevalence rate of younger adults age 20-29 is 30.3% (CDC, 2014, Sept 9). Evidence has
grown over the past decade supporting a role for short sleep duration as a novel risk
factor for weight gain and obesity. A number of causal pathways linking reduced sleep
with obesity have been posited based on experimental studies of sleep deprivation.
Chronic partial sleep deprivation causes feelings of fatigue which may lead to reduced
physical activity. Sleep deprivation may also have neurohormonal effects that increase
caloric intake. Because of the rapidly accelerating prevalence of sleep deprivation, any
causal association between short sleep durations and obesity would have substantial
importance from a public health standpoint (Patel & Hu, 2008, p. 643).
22
3. Religious, Cultural and/ or Ethnic Beliefs .
The religious belief pertaining to CSU Long Beach college students 18-25 years old
comes from the United States Presbyterian Church. Practitioners believe that individuals who
declare faithfulness to a religion and regularly participate in religious activities have less
psychological distress and a more positive perspective on life. Therefore, these individuals have
less sleeping problems. On the other hand, individuals who have doubts about their own religion
or do not formally declare a religion experience more distress and anxiety that lead to sleeping
problems. (Ellison, Bradshaw, Storch, Marcum, & Hill, 2011, p. 120-121). The role of religion
plays a major role in decision-making and lifestyle choices among a significant portion of this
target population.
The cultural belief pertaining to CSU Long Beach college students 18-25 years old comes
from African African American caregivers in the U.S. The cultural belief is that infants who are
placed lying face down in the prone position when they go to sleep will help prevent choking and
improve comfort. However, the American Academy of Pediatrics suggests infants should be
placed face up in the supine position to prevent sudden infant death syndrome (Boergers &
Koinis-Mitchell, 2010, p. 921). Cultural factors and parenting styles in regards to sleep and sleep
positioning have a great impact on the target population.
4. Misconceptions, Myths and Fads
1. [Myth] “Snoring is a common problem, especially among men, but it isn’t
harmful.” “[Snoring] can be a symptom of a life threatening sleep disorder called
sleep apnea...People with sleep apnea awaken frequently during the night gasping for
breath. Snoring on a frequent or regular basis has been directly associated with
hypertension” (National Sleep Foundation [NSF], 2014).
23
2. [Myth] “You can ‘cheat’ on the amount of sleep you get.”
When we don't get adequate sleep, we accumulate a sleep debt that can be difficult to
"pay back" if it becomes too big. The resulting sleep deprivation has been linked to
health problems” (NSF, 2014).
3. [Myth] “Insomnia is characterized by difficulty falling asleep.”
“Difficulty falling asleep is but one of four symptoms generally associated with
insomnia. The others include waking up too early and not being able to fall back
asleep, frequent awakenings, and waking up feeling unrefreshed. Insomnia can be a
symptom of a sleep disorder or other medical or psychological/psychiatric problem,
and can often be treated” (NSF, 2014).
4. [Misconception] “The older you get the fewer hours of sleep you need.”
“Sleep experts recommend a range of seven to nine hours of sleep for the average
adult. While sleep patterns change as we age, the amount of sleep we need generally
does not. Older people may wake more frequently through the night and may
actually get less nighttime sleep, but their sleep need is no less than younger adults”
(NSF, 2014).
5. [Myth] “If you wake up in the middle of the night, it is best to lie in bed, count
sheep, or toss and turn until you eventually fall back asleep.”
“Waking up in the middle of the night and not being able to go back to sleep is a
symptom of insomnia. Relaxing imagery or thoughts may help to induce sleep more
than counting sheep, which some research suggests may be more distracting than
relaxing. Whichever technique is used, most experts agree that if you do not fall back
asleep within 15-20 minutes, you should get out of bed, go to another room and
24
engage in a relaxing activity such as listening to music or reading. Return to bed
when you feel sleepy” (NSF, 2014).
5. Physical, Mental-Emotional, Social, Growing and Developing and Learning
Characteristics
1. Physical Growth and Development Characteristics
As seen in younger children and teens, sleep helps the body to grow and develop.
Deep sleep allows the body to release a specific hormone that promotes normal
growth in these individuals. This hormone also helps repair damages done to any
tissues and cells. Sleep is also proven to have a role in the developmental stages of
puberty.
2. Mental/emotional characteristics
Attributable to any age, sleep helps an individual’s brain work properly. While
asleep, the brain is forming pathways to remember information learned and enhance
problem solving skills. Similarly to how an adult feels groggy when they have a lack
of sleep, children feel a more intense emotional toll where they experience angry and
impulsive mood swings, feel sad, depressed or lack emotion. As far as gender is
concerned, a girl with less sleep might feel more introverted and shy. A young boy
with a lack of sleep might also feel shy and quiet, however a teenage boy might
express a sense of aggression.
3. Social Characteristics
Sleep deficiencies greatly hinder an individual's ability to interact with others around
them. As mentioned above, the mental and emotional characteristics experienced can
have a significant impact on their social skills.
25
4. Learning Characteristics
Overall individuals with sleep deficiencies are less productive in their work or
school environment. They take longer to learn and carry out tasks. In addition
they have slower reaction times and tend to make more mistakes. As our
population of college students is concerned, sleep negatively affects the amount of
retention of material learned, especially in congruence with stress (National Heart
Lung and Blood Institute, 2012).
6. Needs and interests
The health needs for CSU Long Beach college students 18-25 years old are to stay
healthy, as far as their sleep is concerned, are no different than any other college students.
To enhance the sleep they do get, they need to:
● Establish a regular sleep schedule: they must try to go to bed and wake up around
the same times everyday.
● Reflect on their diet: they need to consume adequate amounts of B-complex
vitamins, as they can reduce fatigue and enhance restful sleep. Supplements need
to be used if their diets are not well balanced as well.
● Reduce caffeine intake: they need to make sure they do not consume caffeinated
beverages within 4 hours of going to bed, as it disrupts sleep.
● Practice diaphragmatic breathing: deep breathing practiced before bed will help
feel more relaxed and also help achieve restful sleep.
● Set realistic goals: If goals are sometimes unattainable, worriers and anxious
individuals tend to have more disrupted sleep.
● Exercise regularly: regular exercise results in a higher amount of deep sleep with
26
fewer awakenings during the night. However they must not exercise right before
going to bed (GUNESEO, The State University of New York, 2013).
The health interests for CSU Long Beach college students 18-25 years old are most
commonly:
● Combating Insomnia: College students find themselves combating insomnia due
to various amount of reason such as a high amount of stress, working very hard,
rigorous time schedules etc.
● Staying in shape: Most college students find their appearance quite important, and
as a result sometimes do whatever it takes to look good. Many college students
work out too soon before going to sleep simply to ensure they got their exercise
for the day completed. This boost of enzymes released can greatly impact sleep.
Many girls and boys might also make bad decisions regarding what to eat when it
concerns their health. They might eat reduced amounts of food to stay in shape or
indulge in fatty foods to satisfy cravings, both negatively affecting sleep.
● Sleeping with another individual: Many college students find themselves in an
emotional state or depending on the circumstances, and want to sleep with their
significant other or another friend in the same bed. This can also affect the sleep
they get depending on the sleep patterns of the other individual.
27
7. Survey of Health Needs and Interests of Target Population
A to ZzZz SLEEP HEALTH PROGRAM SURVEY
This survey is kept confidential. Feel free to exclude any answer.
Directions: Please circle or write your answers. All questions are being asked “on average”
basis. Please answer appropriately.
1. What year are you?
a. Freshman
b. Sophomore
c. Junior
d. Senior +
e. Graduate
2. What is your gender?
a. Male
b. Female
c. Other: __________
3. On a scale of 1-10, how good do you feel after waking up? (1 = terrible -> 10 = amazing)
_________
28
4. How many hours of sleep per night do you get?
a. 4 hours or less
b. 4-5 hours
c. 6-8 hours
d. 9+ hours
5. How many naps do you take per week?
a. don’t take naps
b. 1-2
c. 3-4
d. 5+
6. How long do your naps last?
a. I don’t take naps.
b. 1-30 minutes
c. 31 minutes-1 hour
d. 1 hour-3 hours
7. Do you go to sleep around the same time every night?
a. Yes
b. No
29
8. Do you sleep with the light ON or light OFF?
a. On
b. Off
9. How many times on average do you get up during the night?
a. None
b. 1-2 times
c. 3-4 times
d. 5 or more times
10. Do you share a bed with another individual when you go to sleep?
a. Yes
b. No
11. How long do you use an electronic device while in bed prior to going to sleep?
(computer, tv, phone, tablet, video games...etc.)
a. I don't use it in bed
b. 1 minute - 30 minutes
c. 31 min - 1 hr
d. I leave it on until i fall asleep (tv, music, laptop)
30
12. How often do you drink or eat within an hour prior to going to sleep per week?
a. None
b. Once or twice per week
c. 3-5 times per week
d. 5+ times per week
13. How many hours do you work per week?
a. I don’t have a job
b. Part-time (10-35 hours)
c. Full-time (36+hours)
14. How many hours per week do you spend completing homework or studying?
a. None
b. 1-3 hours
c. 4-8 hours
d. 8+ hours
15. How many hours per week do you devote your time to extracurricular activities/sports
activities?
a. None
b. 1-3 hours
c. 4-8 hours
d. 8+ hours
31
16. How many hours per week do you exercise?
a. 1-5 hours per week
b. 5-10 hours per week
c. 10-20 hours per week
d. 20+ hours per week
17. How many caffeinated/ energy drinks do you consume per day?
a. None
b. 1-2 drinks
c. 3-4 drinks
d. 5+ drinks
18. Do you take a prescribed drug to help you go to sleep? (Ex. Ambien)
a. Yes
b. No
19. Do you take an over-the-counter drug to help you go to sleep? (Ex. Z-Quil, natural
supplements)
a. Yes
b. No
32
20. Do you regularly drink alcohol to help you go to sleep (3 times a week or more)?
a. Yes
b. No
21. Do you take any other substances (marijuana, narcotics, etc.) before you go to sleep?
a. Yes
b. No
22. How often do you fall asleep during school or work per week?
a. None
b. Once or twice
c. 3+ times
24. How often do you pull all-nighters per semester? (all nighter = less than 2 hours of
sleep)
a. None
b. 1-3 times
c. 4-6 times
d. 7 or more
25. Have you ever fallen asleep while driving?
a. Yes
b. No
33
Survey Results: Visual Aids
Question 1:
Question 2:
Question 3:
On a scale of
1-10, how
good do you
feel waking
up? (1 =
terrible, 10
= amazing)
Scale Frequency Scale Frequency
34
1 2 6 10
2 0 7 12
3 6 8 10
4 4 9 2
5 11 10 1
Question 4:
Question 5:
35
Question 6: Question 7:
36
Question 8:
Question 9:
37
Question 10: Question 11:
Question 12:
Question 13:
38
Question 14:
Question 15:
39
Que
stio
n
16:
Question 17:
40
Question 18:
Question 19:
Question 20:
Question 21:
41
Question 22: Question 23:
42
Question 24:
c. Summary of Survey Results
The survey of health needs and interests of this sample target population (whom are the
students of Cal State Long Beach) found that there were not too many patterns that were
observed. We initially believed that people who would drink many caffeinated drinks and who
would exercise and put in many hours into extracurricular activities would possibly not sleep as
long or would not sleep as great as others. But, there would be some students that would prove
that belief wrong. In one case, there was a student who would sleep the 6-8 hours of
43
recommended sleep, not use any substances to help them go to sleep, would rate 8/10 in how
they felt when they would wake up, but they would state that they had fallen asleep while
driving, which was pretty scary to know. There would still be those students who would only
sleep less than 4 hours a night, take 5 or more naps in a week, would drink many caffeinated
drinks and would feel terrible when they would wake up, but have not fallen asleep while
driving.
Most of the responses were the ones that we expected, the type of sleep people should be
getting. This was getting 6-8 hours of sleep a night, not drinking more than 2 caffeinated drinks a
day, having a healthy study, workout, and extracurricular life, not having a hard time staying
asleep, as well as not falling asleep when driving. But the amount of positive responses that we
received from the question “Have you fallen asleep while driving?” was very eye-opening. Out
of 58 respondents, 13 responded that they have fallen asleep while driving. This was just a small
sample and knowing that 23% of them have fallen asleep can mean that this percentage might
possibly be higher in the overall population.
The surveys were administered in a multiple choice form. They were distributed in two
different ways, one being in person on paper and the other one being on the website titles
surveymonkey.com. The only requirement to take the questionnaire was that they needed to be a
Cal State Long Beach student.
C. Foundation Factors, laws, Mandates Codes or Initiatives
1. Maggie’s Law, New Jersey Statues 2C:11-5
44
a.) “A driver that has been without sleep for 24 hours is considered to be driving
recklessly, in the same class as an intoxicated driver” (National Conference of State
Legislature, 2014).
b.) Maggie’s Law would fit into the Adolescent Well-Being: Day and Night curriculum
by providing real life examples of the specific topic “Consequences of Poor Sleep
Practices.”
2. New York AB 8629
a.) “Creates the offense of driving while drowsy, a class A misdemeanor; includes
driving while drowsy under the offense of vehicular assault in the second degree;
creates the crime of vehicular homicide caused by driving while ability impaired by
fatigue, a class E felony, subject to an indeterminate term of imprisonment of up to
three years and license revocation” (National Conference of State Legislature, 2014).
b.) As stated previously, this law would fit into the Adolescent Well-Being: Day and
Night curriculum and it would be another example to include with the topic of
“Consequences of Poor Sleep Quality.”
D. Summary
1. Based on the Survey of Experts and Curricular Resources, a majority of the learner
oriented goals are designed to identify patterns and associations between sleep behaviors and
chronic diseases such as obesity, mood disorder, and cardiovascular disease. By increasing
knowledge and awareness in regards to sleep health, one aim of the goals is to increase the
frequency and amount of sleep among CSULB college students 18-25 years old. A portion of the
goals focuses on educating individuals with foundational knowledge of sleep health such as the
45
components of the sleep cycle and REM sleep. Another main goal is to optimize the quality of
sleep among college students to improve academic performance thereby improving and
increasing the quality of life. The four different health education curriculum provided in this
section consists of topics that educate students on different sleep hygiene practices and how to
improve sleep by changing certain sleep behaviors. Local community resources that deal with
sleep health are mostly sleep clinics that conduct research in a home care setting. Individuals
who qualify for these programs stay overnight at the facility for a certain amount of days in order
for clinicians and researchers to diagnose sleep disorders such as narcolepsy and sleep apnea.
Depending on the diagnosis, the facilities will provide direct solutions to the sleep health
problem or referrals are issued to other physicians. However, there is a need for programs and
services that promote good sleeping habits and behaviors in order to prevent sleep-related
chronic illnesses such as obesity and cardiovascular disease.
A review on the Study of Contemporary Society and Learners shows that lack of sleep
and poor sleep quality are associated with a variety of chronic illnesses among the general
population. Obesity, depression, motor vehicle accidents, and alcoholism are some examples of
health disparities shared by the general population and college students 18-25 years old. It is
vital that the sleep health program educates individuals on how to maintain long-term, healthy
sleeping habits to prolong the symptoms of chronic illnesses. However, there are a variety of
surgical procedures and behavior therapy services available to treat sleep disorders such as
DSPD and narcolepsy. These services can be accessed at sleep clinics, sleep health centers, and
outpatient clinics with proper referrals. Overall, the challenging part of this health program will
be decreasing the prevalence and incidence rates of chronic illnesses caused by sleep deficiency.
46
To further investigate the association between sleep health problems and U.S. college
students 18-25 years old, a needs assessment was conducted using a sample of college students
from CSU Long Beach. College students are a unique population to study sleep behaviors due to
the varying lifestyle choices. The impact of technology has a huge impact on the growth and
development of the target population in regards to sleep. The use of the internet, mobile devices,
and social media applications promotes distraction and procrastination among the target
population delaying sleep time and productivity. College students are adaptable to advanced
learning environments which could lead to more stress. Even with part-time jobs and
extracurricular activities, college students have more free time to spend. Therefore, in order to
improve the sleep quality among this population, the curriculum should also consider social and
behavioral factors such as cultural and religious traditions.
2. Topics that are important to include in the curriculum:
● Health benefits of sleep
● Sleep management skills
● Types of sleep disorders
● Long-term and short-term outcomes of insufficient & inadequate sleep
● Stages/cycles of sleep
● REM sleep vs NREM sleep
3. By the end of the lesson, the learner will identify at least 5 problems that can occur from not
getting sufficient sleep.
47
Scope & Sequence
Goal: To increase optimal health through achieving sufficient quality sleep.
Unit I: Health Problems Associated with Insufficient Sleep
Unit Objective: Upon completion of the unit, the learner will be able to express sleep health as a
vital health need for college students
Instructional Objectives: By the end of the lesson, the learner will:
1. Be able to evaluate how the amount of sleep affects academic and work performance
2. Be able to justify reasons that drowsy driving is similar to drunk driving
3. Be able to describe two biological processes that link insufficient sleep with Type 2
diabetes.
4. Be able to explain how insufficient sleep is associated with obesity by identifying the
different levels of BMI categories to support their examples.
5. Be able to describe two biological processes that occur when insufficient sleep weakens
the immune system.
6. Be able to construct an anatomical model with colored play dough detailing how sleep
apnea is a risk factor for atherosclerosis.
7. Be able to identify the side effects of over the counter sleeping aids
8. Be able to identify the side effects of prescribed sleeping aids.
9. Be able to distinguish the effects of illicit drug use on sleep behaviors.
10. Be able to describe two biological mechanisms that can cause cardiovascular disease with
people who have sleep apnea.
11. Be able to explain how caffeine affects sleep behavior.
48
12. Be able to explain how aging affects sleep behavior.
13. Be able to create an argument for the need for sufficient sleep by describing three health
problems associated with inadequate sleep
Unit II: Sleeps Effects on Mental Health
Unit Objective: Upon completion of the unit, the learner will be able to interpret the mental
effects of insufficient and inadequate sleep.
Instructional Objectives: By the end of the lesson, the learner will:
1. Be able to state five cognitive consequences of sleeplessness.
2. Be able to identify three ways insufficient sleep is a risk factor for depression.
3. Be able to list three ways sleepless nights can affect overall mood.
4. Be able to identify methods to eliminate stressors leading to anxiety.
5. Be able to give three examples of different types of mood disorders.
6. Be able to list three types of sleep abnormalities associated with chronic alcoholism.
7. By the end of the lesson, the learner will be able to describe why alcohol use is more
prevalent amongst people with poor sleep habits.
Unit III: Types of Sleep Disorders
Unit Objective: Upon completion of the unit, the learner will be able to analyze the link between
common sleep disorders and inadequate sleep.
Instructional Objectives: By the end of the lesson, the learner will:
1. Be able to identify three symptoms of sleep apnea.
2. Be able to explain the association between sleep and epileptic syndromes.
49
3. Describe the prevalence rates of narcolepsy in the U.S.
4. Be able to identify three sleep behavioral patterns associated with insomnia
Unit IV: Sleep Management Skills
Unit Objective: Upon completion of this unit, the learner will synthesize a weekly plan to
increase the amount of sleep.
Instructional Objectives: By the end of the lesson, the learner will:
1. Be able to differentiate between rapid eye movement (REM) sleep and non-rapid eye
movement (non-REM) sleep.
2. Be able to list 3 community resources that improve sleep health.
3. Be able to list five benefits of sleep hygiene practices
4. Be able to dispute the misconception that the older you get, the fewer hours of sleep you
need.
5. Be able to demonstrate relaxation techniques to fall back asleep.
6. Be able to perform three different exercises that will help the learner stay awake during
during productive hours.
7. Be able to record bedtimes and wake-up times for 7 days.
8. Be able to differentiate the types of food that affect sleep health.
9. Be able to prioritize daily tasks and responsibilities in order to improve time management
and organizational skills.
10. Choose to change sleep pattern in order to increase the amount of sleep.
11. Be able to develop healthier sleep behaviors
50
Content Outline
Goal: To increase optimal health through achieving sufficient quality sleep.
Unit Objective: Upon completion of the unit, the learner will be able to express sleep health as a
vital health need for college students:
Instructional Objectives: By the end of the lesson, the learner will:
A. Be able to justify the need for sufficient sleep by describing three health problems associated
with inadequate sleep.
1. “Long-term injurious health outcomes associated with inadequate sleep include
premature mortality, cardiovascular disease, diabetes, metabolic syndrome, inflammation,
obesity, and psychiatric disorders” (Knowlden & Sharma, 2014).
B. Be able to evaluate how the lack of sleep is associated with poor academic performance
(National Institute of Neurological Disorders and Stroke, 2014).
1. Nerve-signaling patterns such as encoding data, information, and memories that
occur during the day, while people are awake can be mirrored and repeated during sleep.
2. According to the American Sleep Association’s 2008 report, people experienced a
decrease in cognitive function when subjects got less than eight hours of sleep.
3. Lack of sleep is associated with the inability to concentrate, impaired memory and
physical performance abilities, and a reduced ability to carry out math calculations.
4. Some experts believe sleep gives neurons used while we are awake a chance to shut
down and repair themselves. Without sleep, neurons may become so depleted in energy
or so polluted with byproducts of normal cellular activities that they begin to
malfunction.
51
5. Sleep may even stimulate various neurological connections that would otherwise
deteriorate; therefore, sleep can help restore cells and memory and may even prevent
potential brain damage from developing.
C. Be able to justify reasons on how drowsy driving increases the risk of vehicular accidents
1. Drowsiness makes drivers less attentive, affects a driver's ability to make decisions,
and slows reaction times. (Centers for Disease Control and Prevention [CDC], 2014).
2. Warning signs of drowsy driving (National Sleep Foundation, 2014a)
a. Difficulty focusing, frequent blinking, or heavy eyelids
b. Daydreaming; wandering/disconnected thoughts
c. Trouble remembering the last few miles driven; missing exits or traffic signs
d. Yawning repeatedly or rubbing your eyes
e. Trouble keeping your head up
f. Drifting from your lane, tailgating, or hitting a shoulder rumble strip
g. Feeling restless and irritable
3. “In the United States, conservative estimates have implicated drowsy driving in 2.2%
to 2.6% of fatal crashes, annually” (Knowlden & Sharma, 2014).
4. Cognitive impairment after approximately 18 hours awake is similar to that of
someone with blood alcohol content (BAC) of 0.05% (CDC, 2014).
5. After about 24 hours awake, impairment is equivalent to a BAC of 0.10%, higher
than the legal limit in all states (CDC, 2014).
6. Among nearly 150,000 adults aged at least 18 years or older in 19 states and the
District of Columbia, 4.2% reported that they had fallen asleep while driving at least once
52
in the previous 30 days.7 Individuals who snored or usually slept 6 or fewer hours per day
were more likely to report this behavior. (CDC, 2014).
7. The National Highway Traffic Safety Administration conservatively estimates that
100,000 police-reported crashes are the direct result of driver fatigue each year. This
results in an estimated 1,550 deaths, 71,000 injuries, and $12.5 billion in monetary losses
(National Sleep Foundation, 2014b).
D. Be able to describe two biological processes that link insufficient sleep with Type 2 diabetes
(Touma & Pannain, 2011, p. 553).
1. Decreased brain glucose utilization has been shown on positron emission tomography
in sleep-deprived subjects.
2. Sleep deprivation is associated with disturbances in the secretion of the
counterregulatory hormones growth hormone and cortisol.
a. Young, healthy volunteers who were allowed to sleep only 4 hours per night
for 6 nights showed a change in their patterns of growth hormone release, from a
normal single pulse to a biphasic pattern.
b. Exposure to higher amounts of growth hormone in the sleep-deprived
condition contributes to higher glucose levels.
c. Also, evening cortisol levels were significantly higher in young, healthy men
who were allowed to sleep only 4 hours per night for 6 nights, as well as in
young, healthy women who were allowed to sleep only 3 hours for 1 night.
d. Elevated evening cortisol levels can lead to morning insulin resistance.
3. Patients who have been sleep-deprived have been shown to have higher sympathetic
nervous system activity, lower parasympathetic activity, or both.
53
a. The sympathetic nervous system inhibits insulin release while the
parasympathetic system stimulates it, so these changes both increase glucose
levels.
b. Moreover, overactivity of the sympathetic nervous system results in insulin
resistance.
E. Be able to explain how insufficient sleep is associated with obesity by identifying the
different levels of BMI categories to support their examples.
1. Sleep insufficiency increases appetite by measuring two appetite-related hormones
(Colten & Altevogt, 2006, p. 60).
2. Sleep insufficiency was associated with lower levels of leptin, a hormone produced
by an adipose tissue hormone that suppresses appetite, and higher levels of ghrelin, a
peptide that stimulates appetite (Colten & Altevogt, 2006, p. 60).
3. Individuals with short sleep duration (less than 6 hours) were 7.5 times more likely to
have a higher body mass index, after controlling for confounding factors such as family
history, levels of physical activity, and demographic factors (Colten & Altevogt, 2006, p.
60).
4. A primary mechanism linking sleep deprivation and weight gain is likely to be
hyperactivity of the orexin system (Touma & Pannain, 2011, p. 553).
a. Orexigenic neurons play a central role in wakefulness, but, as suggested by
the name, they also promote feeding.
b. Studies in animals have indicated that the orexin system is overactive during
sleep deprivation, and this could be in part mediated by the increase in
sympathetic activity.
54
5. Increased sympathetic activity also affects the levels of peripheral appetite hormones,
inhibiting leptin release and stimulating ghrelin release (Touma & Pannain, 2011, p. 553).
a. Lower leptin levels and higher ghrelin levels act in concert to further activate
orexin neurons, resulting in increased food intake.
F. Be able to describe two ways in which sufficient sleep can improve the immune system
(Besedovsky, Lange, & Born, 2012, p. 134).
1. Differentiated immune cells with immediate effector functions, like cytotoxic NK
cells and terminally differentiated CTL, peak during the wake period thus allowing an
efficient and fast combat of intruding antigens and reparation of tissue damage, which are
more likely to occur during the active phase of the organism.
2. In contrast, undifferentiated or less differentiated cells like naïve and central memory
T cells peak during the night, when the more slowly evolving adaptive immune response
is initiated.
3. Nocturnal sleep, and especially slow wave sleep prevalent during the early night,
promotes the release of growth hormone and prolactin, while anti-inflammatory actions
of cortisol and catecholamines are at the lowest levels.
4. The endocrine milieu during early sleep critically supports:
a. The interaction between APC and T cells, as evidenced by an enhanced
production of interleukin 12
b. A shift of the Th1/Th2 cytokine balance towards Th1 cytokines
c. An increase in T helper cell proliferation
d. Facilitation of the migration of naïve T cells to lymph nodes.
55
5. The endocrine milieu during early sleep likely promotes the initiation of Th1 immune
responses that eventually supports the formation of long-lasting immunological
memories.
6. Prolonged sleep curtailment and the accompanying stress response invoke a
persistent unspecific production of pro-inflammatory cytokines, best described as chronic
low-grade inflammation, and also produce immunodeficiency, which both have
detrimental effects on health.
G. Be able to describe two biological mechanisms that can cause cardiovascular disease with
people who have sleep apnea. (Weingarten & Chowdhuri, 2012).
1. Obstructive sleep apnea (OSA) is a condition in which you stop breathing during
sleep because of a narrowed or closed breathing passage (airway).
2. Common symptoms of obstructive sleep apnea include snoring, stopping breathing
during sleep and frequent awakenings during the night and difficulty staying asleep
throughout the night.
3. Obstructive sleep apnea causes you to have frequent pauses in your breathing; these
pauses mean that you actually stop breathing and this causes you to wake up at night.
a. When these breathing pauses happen, the oxygen level in your blood gets
low. It is thought that the frequent bouts of low oxygen levels during sleep
damages the blood vessels that supply the heart.
b. With each one of the episodes, your body tells your heart to beat faster and
your blood pressure to go up.
56
c. Severe obstructive sleep apnea can also cause stress on your heart causing the
heart to get enlarged. An enlarged heart can cause the heart to get less oxygen and
work less efficiently.
H. Be able to identify the side effects of over the counter sleeping aids
1. Diphenhydramine: sedating antihistamine (Simon, 2012).
a. Benadryl, Unisom sleep
b. Daytime drowsiness, dry mouth, dizziness, and memory problems
2. Doxylamine: sedating antihistamine (Simon, 2012).
a. Unisom Tablets
b. Dry mouth, nose, throat; drowsiness, nausea, increased chest congestion,
headache, excitement, nervousness, vision problems, difficulty urinating
3. Melatonin (Ehrlich, 2012).
a. Helps control natural sleep-wake cycle and reduces the time it takes to fall
asleep to treat jet lag and those who work the night shift
b. Daytime sleepiness, dizziness, headaches, abdominal discomfort, mild
anxiety, irritability, confusion, short-lasting feelings of depression
4. Valerian (Ehrlich, 2011)
a. Helps people fall asleep faster and have better quality of sleep
b. Headache, abdominal discomfort, excitability, uneasiness, and heart
disturbances
I. Be able to identify the side effects of prescribed sleeping aids (Simon, 2012).
1. Non-Benzodiazepine Hypnotics
a. Have fewer side effects, most preferred sedative hypnotic drugs
57
b. List of non-benzodiaepine hypnotics and their active ingredient
i. Ambien, Ambien CR: Zolpidem
ii. Sonata: Zaleplon
iii. Lunesta: Eszopiclone
iv. Rozerem: Ramelteon
c. Side effects
i. Drowsiness
ii. Dizziness
iii. Fatigue
iv. Headache
v. Unpleasant taste
vi. Diarrhea
vii. Morning grogginess
viii. Nausea
ix. Dangerous sleep-related behaviors: sleep-walking, sleep-
driving, sleep-eating
2. Benzodiazepine Hypnotics
a. Nonselectively target receptor sites in brain that modulate the effects of the
GABA neurotransmitter
b. List of benzodiaepine hypnotics and their active ingredient
i. Dalmane: flurazepam
ii. Klonopin: clonazepam
iii. Doral: quazepam
58
iv. Halcion: triazolam
v. Atvian: lorazepam
vi. Xanax: alprazolam
vii. Restoril: temazepam
viii. Serax: oxazepam
ix. ProSom: estazolam
c. Side effects
i. Severe allergic reactions: facial swelling
ii. Respiratory problems: abnormal slow and shallow breathing
iii. May increase depression
iv. Long-acting drugs have high rate of residual daytime
drowsiness
v. Memory loss
vi. Sleepwalking, sleep driving, eating while asleep
vii. Urinary incontinence in older patients
viii. Withdrawal symptoms: gastrointestinal distress, sweating,
ix. disturbed heart rhythm, seizures, hallucinations
Unit II: Sleeps Effects on Mental Health
Unit Objective: Upon completion of the unit, the learner will be able to interpret the mental
effects of insufficient and inadequate sleep.
Instructional Objectives: By the end of the lesson, the learner will:
A. Be able to state five cognitive consequences of sleeplessness.
59
1. “Both short term recall and working memory performances decline”.
2. “ Performance requiring divergent thinking deteriorates”.
3. “Tasks may begin well, but performance deteriorates as task duration increases”.
4. “Psychomotor response time slows”.
5. “Cognitive slowing occurs in subject-paced tasks, whereas time pressure increases
cognitive errors”.
6. “Reduced learning (acquisition) of cognitive tasks occurs”. (National Institutes of
Health, 2013)
B. Be able to identify three ways insufficient sleep is a risk factor for depression.
1. “Depressive symptoms are important risk factors for insomnia, and depression is
considered an important comorbid condition in patients with chronic insomnia.”
(NIH, 2013)
2. “Severe sleep disturbance in young children is one of the best predictors of the
onset of depression in later childhood and adolescence”. (University of Michigan
Depression Center, 2014)
C. Be able to list ways sleepless nights can affect overall mood.
1. “Virtually all forms of sleep deprivation result in increased negative mood states,
especially feelings of fatigue, loss of vigor, sleepiness, and confusion.”(NIH,
2013)
2. “Cognitive functions particularly affected by sleep loss include psychomotor and
cognitive speed, vigilant and executive attention, working memory, and higher
cognitive abilities”. (National Institutes of Health (NIH), 2013)
D. Be able to identify methods to eliminate stressors leading to anxiety.
60
1. “Exercise interventions repeatedly have been shown to be efficacious for the
treatment of anxiety conditions.”
2. “Alternatives to sedative medications, such as music therapy, may alleviate the
anxiety...”.
3. Relaxation techniques such as yoga triggers a response that “slows the heart rate,
lowers blood pressure, and decreases oxygen consumption and levels of stress
hormones”.
E. Be able to give three examples of different types of mood disorders.
1. Major Depression: “ A two -week period of a depressed mood or a noticeable
2. Manic Depression (Bipolar disorder): “At least one episode of a depressed or
irritable mood and at least one period of a manic elevated mood”.
3. Dysthymia (dysthymic disorder): “a chronic, low-grade, depressed or irritable
mood for at least two years”. (John Hopkins Health Library, 2014)
F. Be able to list three types of sleep abnormalities associated with chronic alcoholism.
1. “Alcohol prevents you from getting the deep sleep and rapid eye movement
(REM) sleep you need because alcohol keeps you in the lighter stages of sleep.”
2. “ The sleep disruption resulting from alcohol use might lead to daytime fatigue
and sleepiness.”
3. “Alcohol increases the number of times you awaken in the later half of the night
when the alcohol's relaxing effect wears off”. (The Cleveland Clinic Foundation,
2013)
61
Unit III: Types of Sleep Disorders
III. Unit Objective: Upon completion of the unit, the learner will be able to analyze the link
between common sleep disorders and inadequate sleep.
Instructional Objectives: By the end of the lesson, the learner will:
A. Be able to identify three symptoms of sleep apnea.
1. “Sleep apnea is a common disorder in which you have one or more pauses in
breathing or shallow breaths while you sleep” (National Institute of Health [NIH],
2012).
2. “When your breathing pauses or becomes shallow, you’ll often move out of deep
sleep and into light sleep” (NIH, 2012).
3. “Chronic snoring is a strong indicator of sleep apnea” (National Sleep Foundation
[NSF], 2014).
4. “People with sleep apnea tend to be sleep deprived, they may suffer from
sleeplessness and a wide range of other symptoms such as difficulty
concentrating, depression, irritability, sexual dysfunction, learning and memory
difficulties, and falling asleep while at work, on the phone, or driving. Left
untreated, symptoms of sleep apnea can include disturbed sleep, excessive
sleepiness during the day, high blood pressure, heart attack, congestive heart
failure, cardiac arrhythmia, stroke or depression” (NSF, 2014).
B. Be able to explain the association between sleep and epileptic syndromes.
1. “Epilepsy is a brain disorder that causes people to have recurring seizures”
(Medline, 2014).
62
2. “Seizures are episodes of disturbed brain activity that cause changes in attention
or behavior” (Medline, 2014).
3. “The seizures happen when clusters of nerve cells, or neurons, in the brain send
out the wrong signals. People may have strange sensations and emotions or
behave strangely. They may have violent muscle spasms or lose consciousness”
(Medline, 2014).
4. “Sleep activates the electrical charges in the brain that result in seizures and
seizures are timed according to the sleep wake cycle” (NSF, 2014).
5. “Epilepsy patients are often unaware of the seizures that occur while they sleep.
They may suffer for years from daytime fatigue and concentration problems
without ever knowing why” (NSF, 2014).
6. “Epilepsy disturbs sleep and sleep deprivation aggravates epilepsy. The drugs
used to treat epilepsy may also disturb sleep. Because lack of sleep is a trigger for
seizures, achieving healthy sleep on a nightly basis is essential for people with
epilepsy” (NSF, 2014).
C. Describe the prevalence rates of narcolepsy in the U.S.
1. “Narcolepsy is a chronic brain disorder that involves poor control of sleep-wake
cycles. People with narcolepsy experience periods of extreme daytime sleepiness
and sudden, irresistible bouts of sleep that can strike at any time. These “sleep
attacks” usually last a few seconds to several minutes” (NIH, 2014).
2. “Narcolepsy can greatly affect daily activities. People may unwillingly fall
asleep while at work or at school, when having a conversation, playing a game,
63
eating a meal, or, most dangerously, when driving or operating other types of
machinery” (NIH, 2014).
3. “People with narcolepsy experience various types of day- and nighttime sleep
problems that are associated with REM sleep disturbances that tend to begin
subtly and may change dramatically over time. The most common major
symptom, other than excessive daytime sleepiness (EDS), is cataplexy, which
occurs in about 70 percent of all people with narcolepsy. Sleep paralysis and
hallucinations are somewhat less common. Only 10 to 25 percent of affected
individuals, however, display all four of these major symptoms during the course
of their illness” (NIH, 2014).
4. “Narcolepsy affects both sexes equally and develops with age; symptoms usually
first develop in adolescence or young adulthood and may remain unrecognized as
they gradually develop” (NSF 2014).
5. “Some of the highest estimates of prevalence come from studies in which subjects
report having been diagnosed with narcolepsy, ranging in four studies from 168 to
799 per 100,000, with broad and overlapping 95% confidence intervals” (Journal
Sleep, 2007).
6. “The prevalence of narcolepsy is higher when cataplexy is not required: 56 per
100,000 with a 95% confidence interval 42 to 73 in the study from Olmsted
County” (Journal Sleep, 2007).
7. “Many more people are affected by narcolepsy that would be suggested by
considering only those symptomatic with typical cataplexy” (Journal Sleep,
2007).
64
D. Be able to identify three sleep behavioral patterns associated with insomnia
1. “Insomnia is difficulty falling asleep or staying asleep, even when a person has
the chance to do so” (NSF, 2014).
2. “Roughly 30 percent of the general population complains of sleep disruption, and
approximately 10 percent have associated symptoms of daytime functional
impairment consistent with the diagnosis of insomnia” (NIH, 2007).
3. “According to guidelines from a physician group, people with insomnia have one
or more of the following symptoms:
● Difficulty falling asleep
● Difficulty staying asleep (waking up during the night and having trouble
returning to sleep)
● Waking up too early in the morning
● Unrefreshing sleep (also called "non-restorative sleep")
● Fatigue or low energy
● Cognitive impairment, such as difficulty concentrating
● Mood disturbance, such as irritability
● Behavior problems, such as feeling impulsive or aggression
● Difficulty at work or school
● Difficulty in personal relationships, including family, friends and
caregivers (NSF 2014).
65
Unit IV: Sleep Management Skills
Unit Objective: Upon completion of this unit, the learner will synthesize a weekly plan to
increase the amount of sleep.
Instructional Objectives: By the end of the lesson, the learner will:
A. Be able to differentiate between rapid eye movement (REM) sleep and non-rapid eye
movement (non-REM) sleep
1. Sleep follows a pattern of alternating rapid eye movement (REM) and non-rapid
eye movement (non-REM), which the cycle repeats itself throughout the night
every 90 minutes. (NSF, n.d.)
2. Non-REM: happens 75% of the night and happens in 4 different stages
a. Stage 1: in between being asleep and being awake. It is referred to as light
sleep. (NSF, n.d.)
b. Stage 2: The onset of sleeping, body temperature drops, breathing and
heart rate are regular, and you start becoming disengaged with the
surroundings (NSF, n.d.)
c. Stage 3 and 4: deepest and most restorative sleep, blood pressure drops,
breathing becomes slower, blood pressure to muscles increase, muscles
relax, tissue growth and repairs occur, energy is restored, and hormones
are released (NSF, n.d.)
3. REM: happens 25% of the night
a. first times is 90 minutes after falling asleep, then every 90 minutes (NSF,
n.d.)
66
b. provides energy to brain and body, supports daytime performance, brain is
active and dreams occur, eyes dart back and forth, body becomes
immobile and relaxed, muscles are turned off (NSF, n.d.)
B. Be able to list 3 community resources that improve sleep health.
1. Sleep Center Orange County (Sleep Center Orange County, n.d.).
Address: 4980 Barranca Parkway, Suite 170 Irvine, CA 92604
Phone #: (949) 679-5510
Website: http://www.sleepcenteroc.com
Contact Person: No contact person listed
2. MemorialCare Sleep Disorders Center (MemorialCare Health System, 2014).
Address: Elm Ave. Medical Plaza Suite 307 Long Beach, CA 90806
Phone #: (562) 933-8645
Website: www.memorialcare.org/services/sleep-disorders-care
Contact Person: Stephen E. Brown MD. Specialities in Sleep Disorders &
Pulmonology. (562) 422-1110
3. Good Samaritan Hospital Comprehensive Sleep Center (Good Samaritan
Hospital, 2014).
Address: 1225 Wilshire Blvd. Los Angeles, CA 90017
Phone #: (213) 977-2260
Website: http://goodsam.org/clinical/sleep-center.php
Contact Person: Sterling Malish, M.D. (213) 977-2260
4. UCLA Sleep Disorders Center (UCLA Health, n.d.).
Address: 10833 Le Conte Ave, Suite 216, Los Angeles, CA 90095
67
Phone: (310) 26- SLEEP (310-267-5337)
Website: http://www.sleepcenter.ucla.edu
Contact Person: Avidan, Alon Yosefian MD, MPH (310-267-1062)
5. Judy and Richard Voltmer Sleep Center (Neurosciences Institute Orange County,
2014)
Address: 33900 West Coast Highway, Newport Beach, CA 92663
Phone: (949)764-8070
Website: http://www.hoag.org/Specialty/neurosciences/Pages/Sleep-
Disorders/Sleep-Disorders.aspx
Contact Person: No specific contact person, only phone number listed above, as
well as email: [email protected]
6. Sleep Disorders Center of Excellence (St. Joseph Health, 2014).
Address: 1100 W. Stewart Drive, Orange, CA 92868
Phone: (714)771-8950 or (88)766-7363
Website: http://www.sjo.org/Our-Services/Sleep-Disorders-Center.aspx
Contact Person: Maricruz Gutierrez, phone numbers listed above or email:
7. Sleep Diagnostic Center (Sleep Diagnostic Center, n.d.).
Address: 15775 Laguna Canyon Rd #290, Irvine, CA 92618
Phone: (949)364-6600
Website: http://www.sleepdiagnosticcentersite.com/index.html
Contact Person: No contact person, only phone numbers listed above
68
C. Be able to dispute the misconception that the older you get, the fewer hours of sleep you
need.
1. The National Sleep Foundation States:
a. “Sleep experts recommend a range of seven to nine hours of sleep for the
average adult. While sleep patterns change as we age, the amount of sleep
we need generally does not. Older people may wake more frequently
through the night and may actually get less nighttime sleep, but their sleep
need is no less than younger adults” (NSF, 2014).
D. Be able to demonstrate relaxation techniques to fall back asleep.
1. Relaxation techniques are a skill, and with any skill, practice makes it better. If
one practice does not help, move on to another.
2. Autogenic Relaxation: Autogenic means something that comes from within you.
In this relaxation technique, you use both visual imagery and body awareness to
reduce stress.You repeat words or suggestions in your mind to relax and reduce
muscle tension. (Mayo Clinic Staff, 2014)
a. For example, you may imagine a peaceful setting and then focus on
controlled, relaxing breathing, slowing your heart rate, or feeling different
physical sensations, such as relaxing each arm or leg one by one. (Mayo
Clinic Staff, 2014)
3. Progressive muscle relaxation: In this relaxation technique, you focus on slowly
tensing and then relaxing each muscle group. This helps you focus on the
difference between muscle tension and relaxation. You become more aware of
physical sensations. (Mayo Clinic Staff, 2014)
69
a. One method of progressive muscle relaxation is to start by tensing and
relaxing the muscles in your toes and progressively working your way up
to your neck and head. You can also start with your head and neck and
work down to your toes. Tense your muscles for at least five seconds and
then relax for 30 seconds, and repeat. (Mayo Clinic Staff, 2014)
4. Visualization. In this relaxation technique, you form mental images to take a
visual journey to a peaceful, calming place or situation. During visualization, try
to use as many senses as you can, including smell, sight, sound and touch. If you
imagine relaxing at the ocean, for instance, think about the smell of salt water, the
sound of crashing waves and the warmth of the sun on your body. You may want
to close your eyes, sit in a quiet spot and loosen any tight clothing. (Mayo Clinic
Staff, 2014)
5. Deep Breathing: The key to deep breathing is to breathe deeply from the
abdomen, getting as much fresh air as possible in your lungs. When you take deep
breaths from the abdomen, rather than shallow breaths from your upper chest, you
inhale more oxygen. The more oxygen you get, the less tense, short of breath, and
anxious you feel.
a. Sit comfortably with your back straight. Put one hand on your chest and
the other on your stomach.
b. Breathe in through your nose. The hand on your stomach should rise. The
hand on your chest should move very little.
70
c. Exhale through your mouth, pushing out as much air as you can while
contracting your abdominal muscles. The hand on your stomach should
move in as you exhale, but your other hand should move very little.
d. Continue to breathe in through your nose and out through your mouth. Try
to inhale enough so that your lower abdomen rises and falls. Count slowly
as you exhale. (Robinson et al, 2014)
6. Mindfulness: the ability to remain aware of how you’re feeling right now, your
“moment-to-moment” experience—both internal and external. Thinking about the
past—blaming and judging yourself—or worrying about the future can often lead
to a degree of stress that is overwhelming. But by staying calm and focused in the
present moment, you can bring your nervous system back into balance.
Mindfulness can be applied to activities such as walking, exercising, eating, or
meditation. (Robinson et al, 2014)
7. Progressive muscle relaxation: Most progressive muscle relaxation practitioners
start at the feet and work their way up to the face.
a. Loosen your clothing, take off your shoes, and get comfortable.
b. Take a few minutes to relax, breathing in and out in slow, deep breaths.
c. When you’re relaxed and ready to start, shift your attention to your right
foot. Take a moment to focus on the way it feels.
d. Slowly tense the muscles in your right foot, squeezing as tightly as you
can. Hold for a count of 10.
e. Relax your right foot. Focus on the tension flowing away and the way
your foot feels as it becomes limp and loose.
71
f. Stay in this relaxed state for a moment, breathing deeply and slowly.
g. When you’re ready, shift your attention to your left foot. Follow the same
sequence of muscle tension and release.
h. Move slowly up through your body, contracting and relaxing the muscle
groups as you go.
i. It may take some practice at first, but try not to tense muscles other than
those intended. (Robinson et al, 2014)
8. Tai Chi: Tai chi is a self-paced, non-competitive series of slow, flowing body
movements. These movements emphasize concentration, relaxation, and the
conscious circulation of vital energy throughout the body. Though tai chi has its
roots in martial arts, today it is primarily practiced as a way of calming the mind,
conditioning the body, and reducing stress. As in meditation, tai chi practitioners
focus on their breathing and keeping their attention in the present moment. Tai chi
is a safe, low-impact option for people of all ages and levels of fitness, including
older adults and those recovering from injuries. Like yoga, once you’ve learned
the basics of tai chi or qi gong, you can practice alone or with others, tailoring
your sessions as you see fit. (Robinson et al, 2014)
E. Be able to perform three different exercises that will help the learner stay awake during
productive hours.
1. Stretch every extremity for 15 seconds: limber up your muscles and joints and
enhance the flow of blood through your body, providing an extra shot of oxygen
to all your tissues. (Reader’s Digest, n.d.)
72
2. Hop on the treadmill for 30 minutes: you will produce endorphins that will last
most of the day. (Reader’s Digest, n.d.)
3. Take a short walk: Some people take a short walk to re-energize themselves. It's
generally thought to be a good distraction, especially if you're sitting in front of a
computer screen all day long. Studies show that taking short breaks from work
actually helps your productivity. So if you're worried about missing that deadline,
don't stress! Walking breaks will help you.(Reader’s Digest, n.d.)
4. Try simple exercises: jumping jacks, push-ups, crunches, and squats. Don't push
yourself like you do in the gym; instead, just exercise enough to get your blood
flowing (Reader’s Digest, n.d.)
5. Stay on your feet as much as possible: If you're sitting most of the time, get
yourself up every 20-30 minutes. If you need any motivation to stand more of the
time, consider this: people who stay seated for less than three hours a day add
almost two years to their life expectancy (Reader’s Digest, n.d.)
6. Use your sense of smell: A pungent scent, good or bad, can make you more alert
very quickly. Aromatherapists often recommend essential oils of the following
plants to stimulate the nervous system and reduce fatigue. Open the bottle and
take a big whiff of the following when you're feeling drowsy:
a. Rosemary
b. Eucalyptus blue gum
c. Peppermint
d. Coffee; beans or brewed, both work: a study has shown that simply
smelling coffee can awaken a person (Reader’s Digest, n.d.)
73
7. Listen to music: Spend 5 to 10 minutes each morning listening to music or sitting
on the deck or porch just thinking. This allows the creative thinking that takes
place during the night to gel and form into a plan of action, grounding you for the
day. (Reader’s Digest, n.d.)
8. Use acupressure. Massaging any of the following points will improve circulation
and ease fatigue.
a. The top of your head. Lightly tap it with your fingertip or use a scalp
massager.
b. The back of your neck.
c. Back of your hands. Right between the thumb and index finger is best.
d. Just below the knees.
e. Earlobes. (Hussain, 2007)
F. Be able to record bedtimes and wake-up times for 7 days.
1. Have a sleep journal/notebook next to your bed so you will be able to record your
sleep and wake times right away
G. Be able to differentiate the types of food that affect sleep health.
1. Foods containing the amino acid tryptophan could potentially make you drowsy
because tryptophan is the building block of the sleep-related chemical, serotonin
(National Sleep Foundation, 2012).
2. Foods that contain tryptophan include eggs, chicken, fish, and nuts. Another well
known food to contain tryptophan is turkey, which may be the cause of the after-
Thanksgiving nap that occurs (National Sleep Foundation, 2012).
74
3. Carbohydrates make tryptophan more available to the brain (National Sleep
Foundation, 2012).
4. Foods to avoid before bed should be foods that upset the stomach, such as fatty,
fried, or spicy foods (National Sleep Foundation, 2012).
5. Alcohol might make you drowsy and help a person fall asleep, but it can prevent a
person from falling into a deeper and continuous sleep (National Sleep
Foundation, 2012).
6. Caffeine is a stimulant and can last in the body for many hours, so it is best to
avoid drinking it after the mid-afternoon (National Sleep Foundation, 2012).
7. Not only can eating certain foods affect the way that you sleep, but the way you
sleep can affect the way you eat because sleep loss alters the chemical signals that
are associated with metabolism and hunger (National Sleep Foundation, 2012).
8. People who are more sleep deprived tend to eat more fatty foods, less vegetables,
and simple carbohydrates (National Sleep Foundation, 2012).
H. Be able to prioritize daily tasks and responsibilities in order to improve time management
and organizational skills.
a. On a blank paper, list out the items that need to be done during the following day.
make sure that they are separated enough because cutting will be involved.
b. Cut each task so it is on its own.
c. Figure out how you would like to complete these task, either by priority, by time
it would need to take to accomplish, or however you would like it to be.
d. When the final set-up is done, write the order of the tasks done in your calendar
book/phone/paper.
75
e. Stick to this list and complete it the night before.
I. Choose to change sleep pattern in order to increase the amount of sleep.
1. Use bright lights in the morning: Your body's clock is "set" by cues like light,
darkness, and when you eat or exercise. Light is the strongest of these cues. It tells
your brain whether it's night or day, and that tells you when to sleep. (NSF, n.d.)
2. Dim the lights in the evening: Too much light at night pushes your sleep time
later (Steward, 2012)
3. Do not nap: napping can interfere with going to sleep at night. (Steward, 2012)
4. Do not sleep in: Getting up at the same time every day is important in maintaining
a functioning sleep schedule.(Steward, 2012)
5. Be strict about your sleep schedule: Once you have reached a workable bedtime,
don’t allow yourself to stray from it. Even one late night can ruin the progress
you’ve made. (Steward, 2012)
J. Be able to develop healthier sleep behaviors
1. Time your meals: (Steward, 2012)
2. Limit technology: watching TV or playing on your cell phone before falling
asleep can interfere with your body’s natural rhythm of falling asleep (NSF, n.d.)
3. Limit Caffeine: You may be tempted to use caffeine to get over the afternoon
hump. Don't. Instead, avoid caffeine after lunch. It can affect your sleep that
night. (NSF, n.d.)
4. Limit your time in bed: If you lie awake when you're in bed, temporarily
restricting your sleep may give you better, deeper sleep. (NSF, n.d.)
5. Sleep on a comfortable mattress and pillows: (Steward, 2012)
76
Sleep Health Evaluation Techniques
By the end of the lesson, the learner will:
1. Be able to describe three health problems associated with inadequate sleep
2. Be able to evaluate how the lack of sleep is associated with poor academic performance
3. Be able to justify reasons on how drowsy driving increases the risk of vehicular accidents
4. Be able to describe two biological processes that link insufficient sleep with Type 2
diabetes
5. Be able to explain how insufficient sleep is associated with obesity by identifying two
physiological mechanisms.
6. Be able to describe two ways in which sufficient sleep can improve the immune system
7. Be able to describe two biological mechanisms that can cause cardiovascular disease with
people who have sleep apnea
8. Be able to identify the side effects of over the counter sleeping aids
9. Be able to identify the side effects of prescribed sleeping aids.
10. Be able to identify three ways insufficient sleep is a risk factor for depression.
11. Be able to list three ways sleepless nights can affect overall mood.
12. Be able to identify methods to eliminate stressors leading to anxiety.
13. Be able to give three examples of different types of mood disorders.
14. Be able to list three types of sleep abnormalities associated with chronic alcoholism.
15. Be able to describe why alcohol use is more prevalent amongst people with poor sleep
habits.
77
16. Be able to identify three symptoms of sleep apnea
17. Be able to explain the association between sleep and epileptic syndromes
18. Describe the prevalence rates of narcolepsy in the U.S.
19. Be able to identify three sleep behavioral patterns associated with insomnia
20. Be able to differentiate between rapid eye movement (REM) sleep and non-rapid eye
movement (non-REM) sleep.
21. Be able to list 3 community resources that improve sleep health
22. Be able to dispute the misconception that the older you get, the fewer hours of sleep you
need.
23. Be able to demonstrate relaxation techniques to fall back asleep
24. Be able to perform three different exercises that will help the learner stay awake during
productive hours
25. Be able to record bedtimes and wake-up times for 7 days.
26. Be able to differentiate the types of food that affect sleep health.
27. Be able to prioritize daily tasks and responsibilities in order to improve time
management and organizational skills.
28. Choose to change sleep pattern in order to increase the amount of sleep.
29. Be able to develop healthier sleep behaviors
78
Evaluation Techniques Checklist
Objective
#
Multiple
Choice
True/
False
Short
Answer
Matching Fill-
in-the
Blank
Anecdotal
Record
Other:
Scavenger
Hunt
1
✔
2 ✔
3 ✔
4 ✔
5 ✔
6 ✔
7 ✔
8
✔
9
✔
10
✔
11 ✔
79
12 ✔
13
✔
14
✔
15 ✔
16 ✔
17 ✔
18
✔
19
✔
20
✔
21
✔
Objective
#
Multiple
Choice
True/
False
Short
Answer
Matching Fill-
in-the
Blank
Anecdotal
Record
Other:
Scavenger
Hunt
22
✔
23
✔
24
✔
80
25
✔
26
✔
27
✔
28
✔
29
✔
30 ✔
81
Sleep Health Written Exam
MULTIPLE CHOICE. Circle the correct response for each question.
1. Lack of sleep is associated with the inability to concentrate, impaired memory and
physical performance abilities, and ________________________________. (2)
a. increased testosterone levels
b. faster reaction times to external stimuli
c. a reduced ability to carry out math calculations
d. pain in the joints
2. All of the following help improve the immune system by getting a sufficient amount of
sleep EXCEPT: (6)
a. An increase in T helper cell proliferation
b. Facilitation of the migration of naïve T cells to lymph nodes.
c. Increase in glucose levels
d. Promotes the initiation of Th1 immune responses that eventually supports the
formation of long-lasting immunological memories
3. Sleep apnea is associated with cardiovascular disease because the pauses in breathing
indicate low oxygen levels which increases ________________. (7)
a. Cholesterol
b. Testosterone
82
c. Blood pressure
d. Anxiety
4. During the day, individuals who suffer from sleep apnea will experience irritability,
difficulty concentrating, and _____________________ (17)
a. Jitters
b. Sexual dysfunctions
c. Hallucinations
d. Bloating
5. Which of the following behaviors will NOT help with developing better sleep habits?
(30)
a. Limiting caffeine
b. Limiting the use of technology
c. Sleeping on a comfortable mattress
d. Limiting sexual activity
6. Cognitive impairment after approximately 24 hours awake is similar to that of someone
with a blood alcohol content (BAC) of 0.10.%. (3)
a. 0.05%
b. 0.20%
c. 0.10%
d. 0.14%
83
7. A lack of sleep __________ growth hormone levels which leads to ________ glucose
levels increasing the risk of Type 2 diabetes. (4)
a. decreases, low
b. increases, high
c. increases, low
d. decreases, high
8. Select the correct effects of sleeplessness on overall mood. (11,12)
a. Feelings of depression, anxiety, irritability, stress
b. Feeling of suicide
c. Feelings of joy, happiness, positive mood
d. Feelings of satisfaction, content
9. A lack of sleep is associated with lower levels of ___________, a hormone produced by
an adipose tissue hormone that suppresses appetite, and higher levels of ___________, a
peptide that stimulates appetite. (5)
a. testosterone, progesterone
b. melatonin, thyroxine
c. insulin, glucagon
d. leptin, ghrelin
84
10. Which of the following is not a relaxation technique used to fall back asleep? (24)
a. Tai Chi
b. Kegel Exercises
c. Progressive Muscle Relaxation
d. Autogenic Relaxation
TRUE OR FALSE. For each question, write T if the statement is true or F is the statement is
false.
11. Cardiovascular disease, narcolepsy, and type 2 diabetes are chronic illnesses associated
with insufficient amount of sleep. (1) ______
12. Narcolepsy affects mostly males and develops with age. (19) ______
13. Epilepsy patients are often unaware of the seizures that occur while they sleep. (18)
______
14. Dimming the lights prior to going to bed is not an effective change in sleep patterns. (29)
______
15. The older you get, the less sleep you need. (23) ______
16. Alcohol is prevalent amongst people with poor sleep habits. (15,16) ______
85
MATCHING. Match each substance to its appropriate side effects. Answers may be used more
than once. (8, 9)
17. Ambien: ____
18. Melatonin: ____
19. Xananx: ____
20. Unisom Tablets: ____
21. Lunesta: ____
22. Atvian: ____
23. Match the words into the following category: (27)
Contains Tryptophan [A]: Avoid Eating Before Sleeping: [B]
_______________ _______________
_______________ _______________
_______________ _______________
_______________ _______________
A. Headache, fatigue, dizziness, morning grogginess
B. Depression, abnormal slow & shallow breathing,
memory loss
C. Anxiety, abdominal discomfort, irritability
D. Increased chest congestion, dry mouth, nose &
throat, difficulty urinating
Spicy Food[B] Chicken[A] Grapes
Turkey [A] Fish [A] Apples
Banana Fried Food [B] Fatty Food [B]
Eggs[A] Tobacco Alcohol [B]
86
FILL IN THE BLANK.
24. REM sleep occurs _______% of the night, whereas non-REM happens _______% of the
night. REM has _______ stage(s), whereas non-REM has ______stage(s). The cycles
repeat every _______ minutes. (21)
SHORT ANSWER. Describe your answer in at least 2-3 sentences for each question.
25. Describe three symptoms that individuals with insomnia experience. (10,12, 20)
26. List and discuss 2 ways in which you can increase your time management skills and
reduce stress. (13, 28)
27. Name 3 different types of mood disorders. (14)
87
Sleep Health Written Exam Answer Key
Multiple Choice
1. C
2. C
3. C
4. B
5. D
6. C
7. C
8. A
9. D
10. B
True or False
11. T
12. F
13. T
14. F
15. F
16. T
Matching
17. A
18. C
19. B
88
20. D
21. A
22. B
23. Section [A]:
turkey
eggs
chicken
fish
Section [B]:
alcohol
fatty foods
spicy foods
fried foods
Fill in the Blank
24. 25, 75, 1, 4, and 90
Short Answers
25. Difficulty falling asleep
Difficulty staying asleep (waking up during the night and having trouble returning to
sleep)
Waking up too early in the morning
Unrefreshing sleep (also called "non-restorative sleep")
Fatigue or low energy
Cognitive impairment, such as difficulty concentrating
89
Mood disturbance, such as irritability
Behavior problems, such as feeling impulsive or aggression
Difficulty at work or school
Difficulty in personal relationships, including family, friends and caregiver
26. Set a precise bedtime every night.
Use a planner/ calendar to help with scheduling.
Measure travel times prior to leaving.
Prioritize tasks
27. Major Depression
Dysthymia
Manic Bipolar
Substance induced
90
Evaluation Technique #2
Sleep Diary
(ANECDOTAL RECORD)
Unit IV Objective: Upon completion of this unit, the learner will synthesize a weekly plan to
increase the amount of sleep.
Enabling Objectives:
At the end of the lesson, the learner will demonstrate relaxation techniques to fall back asleep.
(24)
At the end of the lesson, the learner will perform three different exercises that will help the
learner stay awake during productive hours. (25)
Implementation:
For seven days, the learner must attempt at least one relaxation technique before bedtime in the
evening and one exercise that will help the learner stay awake during the daytime/afternoon. The
learner will record the exercises and techniques in a journal as well as a summary of their
reactions for each exercise or technique.
Criteria: The learner will be evaluated according to the following criteria:
Must have a total of a 7 journal entries with at least 2 exercises/techniques listed
Each journal entry must indicate at least one relaxation technique before bedtime and one
exercise that will help the learner stay awake during the daytime/afternoon.
Each journal entry must have the dates and times each technique or exercise was
performed
Each exercise/technique must be performed for at least 5 minutes
- The learner will record the start time and end time for each one
91
For each exercise/technique, the learner must complete the following writing prompt:
- One paragraph describing how they performed the exercise/technique
- Their immediate reaction
- Advantages
- Disadvantages
- Recommendations or suggestions
Example of Journal Entry:
Journal Entry #1/Day#1
Date: December 2, 2014
Morning Exercise/Technique: Short Walk
Time Exercise/Technique was performed: 7:30am – 7:50am
[writing prompt]
Bedtime Exercise/Technique: Tai Chi
Time Exercise/Technique was performed: 9:30pm – 10:00pm
[writing prompt]
92
Evaluation Technique #3
Sleep Health Scavenger Hunt
(OTHER: SCAVENGER HUNT)
Unit IV Objective: Upon completion of this unit, the learner will synthesize a weekly plan to
increase the amount of sleep.
Enabling Objectives:
At the end of the lesson, the learner will be able to list 3 community resources that improve sleep
health. (22)
Implementation:
As a homework assignment, the learner will be given a scavenger hunt worksheet to complete.
The learner can use all types of resources including the Internet to find the community resources.
Criteria: The learner will be evaluated according to the following criteria:
Must have three community resources listed
For one of the community resources, the learner must include a copy of one of the
following documents:
- Brochure
- Pamphlet
- Business card
- Fliers
- Sample products or equipment
All community resources must have:
- Name
93
- Address
- Phone Number
- Contact Person
- E-Mail Address
- Website
- Services & treatments provided by organization
- Would you visit this location? Explain why or why not.
- How was resource located?
Web? Magazine? Newspaper? Referral?
94
Evaluation Technique #4
Sleep Health Management 101
(ANECDOTAL RECORD)
Unit IV Objective: Upon completion of this unit, the learner will synthesize a weekly plan to
increase the amount of sleep.
Enabling Objectives:
At the end of the lesson, the learner will record bedtimes and wake-up times for 7 days. (26)
Implementation:
As a homework assignment, the learner will be given a worksheet to complete. All seven days
must be recorded in order to complete the assignment.
Criteria: The learner will be evaluated according to the following criteria:
- Include all nap times
Time went to sleep: Time woke up: Scale (1-10) felt waking up:
Monday 11:35 pm 6:15 am 7
Tuesday 10:53 pm
4:30pm
6:25 am
4:50pm
8
7
Wednesday 11:03 pm 7:02 am 6
Thursday 11:47 pm
4:30pm
6:18 am
4:50pm
5
6
Friday 12:35 pm 7:15 am 8
95
Time went to sleep: Time woke up: Scale (1-10) felt waking up:
Saturday 10:15 pm
1:00pm
9:43 am
2:00pm
6
8
Sunday 1:09 am 12:04 pm 9
96
Reference List
Ackermann, K., Revell, V., Lao, O., Rombouts, E., & Skene, D. (2012, July 1). Diurnal rhythms
in blood cell populations and the effect of acute sleep deprivation in healthy young men.
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22754039.
Baptist Health South Florida: Continuing Medical Education. (2013). Sleep center symposium
2013 objectives. Retrieved from
http://cme.baptisthealth.net/sleepcenter/pages/objectives.aspx
Besedovsky, L., Lange, T., Born, J. (2012). Sleep and immune function. Pflugers Archiv
European Journal of Physiology, 463, 121-137. doi: 10.1007/s00424-011-1044-0
Blackwell, T., Yaffe, K., Acoli-Isreal, S., Schnieder, J., Cauley, J., & Hiller, T. (2007, April 1).
Poor sleep is associated with impaired cognitive function in older women. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/16611709.
Boergers, J., Koinis-Mitchell, D. (2010). Sleep and culture in children with medical conditions.
Journal of Pediatric Psychology, 35 (9), 915-926. doi: 10.1093/jpepsy/jsq016
Centers for Disease Control and Prevention. (2011). Insufficient sleep among California adults.
Retrieved from
http://www.cdc.gov/sleep/pdf/states/Insufficient_Sleep_Fact_Sheet_2011_CA.pdf
Centers for Disease Control and Prevention. (2013, July 1). Key sleep disorders. Retrieved from
http://www.cdc.gov/sleep/about_sleep/key_disorders.htm (CDC, 2013a).
Centers for Disease Control and Prevention. (2013, Jul 1). Sleep and sleep disorders: data and
statistics. Retrieved from http://www.cdc.gov/sleep/data_statistics.htm (CDC, 2013b)
Centers for Disease Control and Prevention (2014, Jan 6). Drowsy driving: asleep at the wheel.
Retrieved from http://www.cdc.gov/Features/dsDrowsyDriving/index.html
97
Centers for Disease Control and Prevention (2014, Apr 14). Are you getting enough sleep?
Retrieved from http://www.cdc.gov/features/sleep/
Centers for Disease Control and Prevention (2014, Sept 3). Childhood obesity facts. Retrieved
from http://www.cdc.gov/obesity/data/childhood.html
Centers for Disease Control and Prevention (2014, Sept 9). Adult obesity facts. Retrieved from
http://www.cdc.gov/obesity/data/adult.html
Colten, H. (2007). Extent and health consequences of chronic sleep loss and sleep
disorders. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK19961/
Colten, H. R., & Altevogt, B. M. (2006). Sleep disorders and sleep deprivation: an unmet public
health problem. Retrieved from http://www.nap.edu/catalog/11617.html
Division of Sleep Medicine Harvard Medical School. (2007, Dec 18). Sleep and disease risk.
Retrieved from
http://healthysleep.med.harvard.edu/healthy/matters/consequences/sleep-and-
disease-risk
Drug and Alcohol Related Sleep Disorders. (2010, January 28). Retrieved November 20, 2014,
http://my.clevelandclinic.org/services/neurological_institute/sleep-disorders-
center/disorders-conditions/hic-drug-and-alcohol-related-sleep-disorders
Drowsy Driving: Asleep at the Wheel. (2014). Retrieved from
http://www.cdc.gov/features/dsdrowsydriving/.
Ehrlich, S. D. (2012, Jan 1). Melatonin. Retrieved from
http://umm.edu/health/medical/altmed/supplement/melatonin
Ehrlich, S. D. (2011, May 4). Valerian. Retrieved from
http://umm.edu/health/medical/altmed/herb/valerian
98
Ellison, C. G., Bradshaw, M., Storch, J., Marcum, J. P., Hill, T. D. (2011). Religious doubts and
sleep quality: findings from a nationwide study of presbyterians. Review of Religious
Research, 53 (2), 119-136. doi: 10.1007/s13644-011-0019-0
Good Samaritan Hospital. (2014). Comprehensive Sleep Center. Retrieved from
http://goodsam.org/clinical/sleep-center.php
Grandner, M., & Pack, A. (2011, December 21). Sleep Disorders, Public Health, and Public
Safety. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3685138/.
Hershner, S. D., Chervin, R.D. (2014). Causes and consequences of sleepiness among college
students. Nature and Science of Sleep, 6, 73-84. doi: 10.2147/NSS.S62907
Hussain, A. (2007). Wide Awake with Acupressure. Retrieved from
http://www.psychologytoday.com/articles/200512/wide-awake-acupressure
Kenney, S. R., Lac, A., LaBrie, J. W., Hummer, J. F., Pham, A. (2012). Mental health, sleep
quality, drinking motives, and alcohol-related consequences: a path-analytic model.
Journal of Studies on Alcohol and Drugs, 6 (74), 841-851. Retrieved from
http://www.jsad.com/jsad/downloadarticle/Mental_Health_Sleep_Quality_Drinking_Mot
ives_and_AlcoholRelated_Consequ/5202.pdf .
Key Sleep Disorders. (2013).Centers for Disease Control and Prevention. Retrieved October 8,
2014, from http://www.cdc.gov/sleep/about_sleep/key_disorders.htm
Knowlden, A. P., & Sharma, M. (2014). Health belief structural equation model predicting sleep
behavior of employed college students. Family & Community Health, 1-8. doi:
10.1097/FCH.0000000000000043
Liu, Y., Croft, J. B., Wheaton, A. G., Perry, G. S., Chapman, D. P., Strine, T. W., McKnight-
Eily, L. R., Presley-Cantrell, L. (2013). Association between perceived insufficient sleep,
99
frequent mental distress, obesity and chronic diseases among US adults, 2009 behavioral
risk factor surveillance system. BMC Public Health 13, 84. doi: 10.1186/1471-2458-13-
84
Longstreth, W., Koepsell, T., Ton, T., Hendrickson, A., & Belle, G. (2007). The epidemiology of
narcolepsy. SLEEP, 30. Retrieved from http://www.journalsleep.org/Articles/300102.pdf
Martiniuk A. C., Senserrick T., Lo S., Williamson, A., Du, W., Grunstein, R. R., Woodward, M.,
Glozier, N., Stevenson, M., Norton, R., Ivers, R. Q. (2013). Sleep-deprived young drivers
and the risk for crash: the DRIVE prospective cohort study. JAMA Pediatrics, 167 (7),
647-655. doi:10.1001/jamapediatrics.2013.1429
Mayo Clinic (2014). Stress management. Retrieved from http://www.mayoclinic.org/healthy-
living/stress-management/in-depth/relaxation-technique/art-20045368?pg=2
MedlinePlus. (2014, Feb 10). Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000694.htm
MemorialCare Health System. (2014). Memorialcare sleep disorder center. Retrieved from
http://www.memorialcare.org/services/sleep-disorders-care/sleep-disorders-care- long-
beach-memorial
Merikanto, I., Lahti, T., Puusniekka, R., Partonen, T. (2013). Late bedtimes weaken school
performance and predispose adolescents to health hazards. Sleep Medicine, 14 (11),
1105-1011. doi: 10.1016/j.sleep.2013.06.009
Moseley, L., & Gradisar, M. (2009). Evaluation of a School-Based Intervention for Adolescent
Sleep Problems. SLEEP, 32(3), 334-341. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647787/pdf/aasm.32.3.334.pdf
100
Mullington, J. (2007). Healthy Sleep. Healthy Sleep. Retrieved from
http://healthysleep.med.harvard.edu/health/
Mullington, J. (2007). Sleep and Disease Risk. Healthy Sleep. Retrieved from
http://healthysleep.med.harvard.edu/healthy/matters/consequences/sleep-and-disease-risk.
Myths - and Facts - About Sleep. (2014). Retrieved from
http://sleepfoundation.org/how-sleep-works/myths-and-facts-about-sleep
National Institute of Neurological Disorders and Stroke. (2013). Narcolepsy. [Brochure].
Bethedsa, MD: National Institutes of Health.
National Conference of State Legislatures. (2014, July). Summaries of current drowsy driving
laws. Retrieved from http://www.ncsl.org/research/transportation/summaries-of-current-
drowsy-driving-laws.aspx
National Heart, Lung, and Blood Institute. (2012, July 12). What is sleep apnea? Retrieved from
http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/
National Institute of Neurological Disorders and Stroke. (2014, July 25). Brain basics:
understanding sleep. Retrieved from
http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm#dynamic_acti
vity
National Sleep Foundation. (n.d.). Healthy sleep tips. Retrieved from
http://sleepfoundation.org/sleep-tools-tips/healthy-sleep-tips
National Sleep Foundation (n.d.).What happens when you sleep? Retrieved from
http://sleepfoundation.org/how-sleep-works/what-happens-when-you-sleep
National Sleep Foundation. (2012). Taste. Retrieved from
http://sleepfoundation.org/bedroom/taste.php
101
National Sleep Foundation. (2014). Facts and stats. Retrieved from
http://drowsydriving.org/about/facts-and-stats/
National Sleep Foundation. (2014). Sleep apnea. Retrieved from
http://sleepfoundation.org/sleep-disorders-problems/sleep-apnea
National Sleep Foundation. (2014). Warning signs. Retrieved from
http://drowsydriving.org/about/warning-signs/
National Sleep Foundation (n.d.). Healthy Sleep Tips. Retrieved from
http://sleepfoundation.org/sleep-tools-tips/healthy-sleep-tips
National Sleep Foundation (n.d.).What Happens When You Sleep? Retrieved November from
http://sleepfoundation.org/how-sleep-works/what-happens-when-you-sleep
Neurosciences Institute Orange County. (2014). Retrieved from
http://www.hoag.org/Specialty/neurosciences/Pages/Sleep-Disorders/Sleep-
Disorders.aspx
National Institute of Health. (2014). Any anxiety disorder among adults. Retrieved from
http://www.nimh.nih.gov/statistics/1ANYANX_ADULT.shtml
Neurosciences Institute Orange County. (2014). Retrieved from
http://www.hoag.org/Specialty/neurosciences/Pages/Sleep-Disorders/Sleep-
Disorders.aspx
Overview of Mood Disorders. (n.d.). Retrieved November 20, 2014, from
http://www.hopkinsmedicine.org/healthlibrary/conditions/mental_health_disorders/overvi
ew_of_mood_disorders_85,P00759/
Parvaneh, K., Poh, B. K., Hajifaraji, M., Ismail, M.N. (2014). Sleep deprivation is related to
obesity and low intake of energy and carbohydrates among working Iranian adults: a
102
cross sectional study. Asia Pacific Journal of Clinical Nutrition 23 (1), 84-90. Retrieved
from http://apjcn.nhri.org.tw/server/APJCN/23/1/84.pdf
Patel, S. R., Hu, F. B. (2008). Short sleep duration and weight gain: a systematic review. Obesity,
16 (3), 643-653. doi: 10.1038/oby.2007.118
Reader's Digest. (n.d.). 24 Ways to Brighten Your Morning. Retrieved from
http://www.rd.com/health/wellness/24-ways-to-brighten-your-morning/
Reader's Digest. (n.d.). 24 Ways to Brighten Your Morning. Retrieved from
http://www.rd.com/health/wellness/24-ways-to-brighten-your-morning/
Richardson, B. (2010). Sleep basics for health promotion. [PowerPoint slides]. Retrieved from
http://www.pitt.edu/~super1/lecture/lec39321/index.htm
Robinson, Lawrence, Segal, Robert, Segal, Jeanne, Smith, Melinda (2014). Help Guide.
Relaxation Techniques for Stress Relief. Retrieved from
http://www.helpguide.org/articles/stress/relaxation-techniques-for-stress-relief.htm
Robinson, Lawrence, Segal, Robert, Segal, Jeanne, Smith, Melinda (2014). Help Guide.
Relaxation Techniques for Stress Relief. Retrieved from
http://www.helpguide.org/articles/stress/relaxation-techniques-for-stress-relief.htm
Schoenborn, C. A., Adams, P. F. (2010). Sleep duration as a correlation of smoking, alcohol use,
leisure-time physical inactivity, and obesity among adults: united states, 2004-2006.
Retrieved from http://www.cdc.gov/nchs/data/hestat/sleep04-06/sleep04-06.htm#F2
Sharpless, B. A., & Barber, J. P. (2011). Lifetime prevalence rates of sleep paralysis: a Sleep
Center of California (2009). Retrieved from
http://www.sleepdiagnosticcentersite.com/index.htmlsystematic review. Sleep Medicine
Reviews, 15(5), 311-315. doi: 10.1016/j.smrv.2011.01.007
103
Short, M. A., Gradisar M., Lack, L. C., Wright, H. R., Dewald, J. F., Wolfson, A. R., Carskadon,
M. A. (2013). A cross-cultural comparison of sleep duration between US and Australian
adolescents: the effect of school start time, parent-set bedtimes, and extracurricular load.
Health Education and Behavior, 40 (3), 323-330. doi: 10.1177/1090198112451266
Sleep and Depression. (n.d.). Retrieved November 20, 2014, from
http://www.depressiontoolkit.org/aboutyourdiagnosis/sleep_and_depression.asp
Sleep Apnea. (2014, September 1). Retrieved from
Sleep Diagnostic Center. (n.d.). Welcome to sleep diagnostic centers. Retrieved from
http://www.sleepdiagnosticcentersite.com/index.html
Sleep Center Orange County. (n.d.). Sleep center orange county. Retrieved from
http://www.sleepcenteroc.com/index.html
Simon, H. (2012, Sep 10). Insomnia. Retrieved from
http://umm.edu/health/medical/reports/articles/insomnia
Steward, K. (2012). 10 tips to reset your internal clock. Retrieved from
http://www.everydayhealth.com/sleep/insomnia/resetting-your-clock.aspx
St. Joseph Health. (2014). Sleep disorders center. Retrieved from http://www.sjo.org/Our-
Services/Sleep-Disorders-Center.aspx
Steward, K. (2012). 10 tips to reset your internal clock. Retrieved from
http://www.everydayhealth.com/sleep/insomnia/resetting-your-clock.aspx
Strohl, K. P., Veasey, S., Harding, S., Skatrud, J., Berger, H. A., Papp, K. K., Dunagan, D.,
Guilleminault, C. (2003). Competency-based goals for sleep and chronobiology in
undergraduate medical education. SLEEP, 26, 333-336. Retrieved from
http://www.journalsleep.org/Articles/260313.pdf
104
Touma, C. T., & Pannain, S. (2011). Does lack of sleep cause diabetes? Cleveland Clinic Journal
of Medicine, 78 (8), 549-558. doi: 10.3949/ccjm.78a.10165
UCLA Health. (n. d.). UCLA sleep disorders center. Retrieved from
http://www.sleepcenter.ucla.edu
United States Department of Health and Human Services. Office of Disease Prevention and
Health Promotion. Health People 2020. (2014). Sleep health. Retrieved from
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=38
Van Drongelen, A., Boot, C. R. .L., Hlobil, H., Twisk, J. W. R., Smid, T., van der Beek, A. J.
(2014) Evaluation of an mhealth intervention aiming to improve health-related
behavior and sleep and reduce fatigue among airline pilots. Scandinavian Journal of
Work, Environment & Health 1-12. doi: 10.5271/sjweh.3447
Weingarten, J., & Chowdhuri, S. (2012 Aug). Obstructive sleep apnea and heart disease.
Retrieved from http://patients.thoracic.org/?p=221
Wheaton, A. G., Perry, G. S., McKnight-Eily, L. R., Chapman, D. P., & Croft, J B. (2011).
Relationship between body mass index and perceived insufficient sleep among U.S.
adults. BMC Public Health, 11, 1-8. doi: 10.1186/1471-2458-11-295
World Health Organization (2003). Who definition of health. Retrieved from
http://who.int/about/definition/en/print.html
World Health Organization (2007). WHO releases report on youth and road safety ahead of first
UN global road safety week. Retrieved from
http://www.who.int/violence_injury_preverevention/publications/road_traffic/youth_road
safety/en/
105