Sleep disorders associated with diabetes: an introduction
Good sleep is a basic human need. Our health depends on getting an adequate amount of quality sleep on a daily basis and sleep deprivation has been shown to contribute to a long list of health problems. Researchers have shown that people with diabetes are more likely to experience insomnia and short sleep duration has been shown to increase risk for developing type 2 diabetes. Additionally, elevated blood sugar, whether it occurs in a person with or without diabetes, has been shown to contribute to short sleep duration1
Other research has shown that lack of sleep aggravates insulin resistance and is related to other factors associated with diabetes risk, including high blood pressure, high blood lipids, and obesity.1
People with type 2 diabetes appear to especially prone to insomnia and sleep problems. For instance, in the Look AHEAD Study, a 4-year randomized, controlled trial conducted in 4,503 adults with type 2 diabetes who had a body mass index (BMI) of 25 or higher found that obstructive sleep apnea affected 86% of a subgroup of participants at baseline.3 Therefore, it is important to know the causes of insomnia, how it impacts diabetes, and what your treatment options are.
Potential consequences of insomnia
|Decreased quality of life|
|Daytime fatigue or sleepiness|
|Diminished performance on cognitive testing|
|Increased absenteeism from work|
|Higher likelihood of requiring disability benefits or medical leave|
|Higher risk of developing depression|
|Higher risk for hypertension and cardiovascular disease|
Reproduced from Deak MC, Winkelman JW. Insomnia. Neurol Clin 2012;30:1045-66.
Reasons to take sleep disorders seriously
Insomnia and other sleep disorders can be linked to a range of negative consequences. Daytime drowsiness resulting from interrupted sleep or difficulty getting to sleep can be potentially dangerous when it interferes with performance on the job or with our ability to operate a vehicle. Additionally, having insomnia has been shown to double the risk for development of depression and increase the risk for development of cardiovascular disease. One study conducted in people who had experienced a heart attack found that subjects who had the symptoms of insomnia (difficulty falling asleep, difficulty staying asleep, or having nonrestorative sleep) were significantly more likely to experience a second heart attack at some point over the next decade.2
For a person with diabetes, insomnia and other sleep disturbances can be particularly dangerous. Research has shown that people who don’t get an adequate amount of sleep eat differently from those who do. In one study, healthy subjects were allowed to sleep only half of their usual sleep time for several days. The response was that these subjects began to consume more food overall compared to a well-rested group of people. The sleep-deprived group tended to eat more calorie-dense food, such as what we call “junk food”, compared to the control group. This is a significant research finding if you have diabetes, because one of the most important ways you have of controlling your blood sugar is to eat a healthfully.2
What are the sleep problems I should be aware of?
IInsomnia is one of the most common sleep problems. It involves one or a combination of the following: difficulty falling asleep, difficulty staying asleep, and poor quality of (nonrestorative) sleep. Another sleep problem called restless leg syndrome (RLS) can also cause sleep deprivation. This problem has been shown to respond well to treatment with medication. Another common sleep problem is sleep apnea, a condition in which a person stops breathing and is awakened by the need for oxygen. Awakenings due to sleep apnea and heavy snoring can happen numerous times during the night and leave a person extremely sleep deprived during the day.
The most common type of sleep apnea is obstructive sleep apnea (OSA). This form of apnea results from a physical obstruction in the airway during sleep. OSA tends to occur more frequently in men, overweight or obese individuals, and the elderly. One study found that 6 out of 10 men with type 2 diabetes who were over the age of 65 years had OSA. Interestingly, several studies have shown that successfully treating OSA in individuals with diabetes can lower blood glucose more effectively than any oral diabetes medication.2
Important sleep history information used in diagnosis4
|When symptoms began and how long they have lasted|
|Type of sleep disturbance (difficulty initiating sleep, difficulty maintaining sleep, early morning waking)|
|Factors that may be causing sleep problem|
|Factors that may be contributing to sleep problem|
|Prior treatments used|
|Sleep habits and practices and beliefs regarding sleep|
|Existing health conditions|
How are sleep problems diagnosed?
Diagnosis of sleep problems, including insomnia (difficulty initiating or maintaining sleep), RLS, and OSA, begins with a careful history of the problem. This should cover information including when the symptoms started, what the daytime consequences are (such as daytime sleepiness and difficulty functioning), what seems to improve or worsen symptoms, and previous treatments tried. Additionally, factors that might play a role causing sleep problems, such as stress, psychiatric disorders, medication use, and other health conditions, should be considered. A thorough assessment of current sleep practices and habits should also be made.4
There are a range of assessment tools that can be useful in diagnosing sleep problems, including sleep questionnaires that can be completed during an office visit, a sleep diary that can be kept by an individual over a period of time to record sleep habits, total sleep time, number waking episodes, and other important sleep-related information.Assessment tools such as actigraphy and polysomnography are also used to obtain objective information (that is information not recorded by a person).4
Actigraphy is a method of monitoring rest and activity cycles during sleep and can be useful in detecting sleep disturbance and circadian rhythms patterns. An actimetry sensor is worn during sleep to measure movement of limbs. The sensor transmits data to an actigraph unit, which records a record of limb movements. Actigraphy is also useful in determining total sleep time, time to sleep onset, the number of waking episodes (last more than 5 minutes) during the night.4
Polysomonography (sometimes also called a sleep study) is used in a sleep laboratory setting as an assessment tool for OSA. A polysomnography unit is used to measure changes in various parameters during sleep that suggest specific sleep problems, including brain waves, blood oxygen level, heart rate, breathing, and eye and leg movements.4
Recommendations for good sleep hygiene4
|Avoid napping during the day||
|Go to bed and get up at the same time every day (including on weekends)||
|Avoid stimulants close to bedtime||
|Don’t eat too close to bedtime||
|Get enough natural light||
|Get regular exercise||
|Develop a relaxation routine before going to bed||
|Use your bed only for sleep and sex||
|Make sure your sleep environment is conducive to sleep||
How are sleep disorders treated?
Treatment options for sleep disorders depend on the specific disorder. As mentioned above, RLS can be treated quite successfully with medication. OSA is more difficult to treat successfully. A device that supplies continuous positive airway pressure (CPAP) during sleep has been shown to be effective in some individuals with OSA. Other treatment options for OSA include weight loss (the majority of people with OSA are overweight or obese), nasal decongestant treatment, position therapy (this is a type of behavioral intervention that promotes sleeping on the side instead of the back), surgery, and wearing an oral appliance that looks like a mouth guard worn by a football player.
When it comes to insomnia, there are many simple steps that you can take to improve your sleep. These steps are designed to promote good sleep hygiene. We usually think of good hygiene in terms of washing our hands or keeping kitchen surfaces clean, but hygiene applies to sleep, as well. If we practice good sleep habits, we can improve our ability to get a full night’s rest.
Good sleep hygiene recommendations include establishing a regular time for getting to bed and getting up in the morning, making sure that your bed is comfortable and that your bedroom is dark and quiet, making sure that you use your bed for sleep and sex only, getting regular exercise, avoiding caffeine or other stimulants during the evening, and putting aside time before going to bed to get relaxed and ready for sleep.5
If good sleep hygiene is not enough to improve your insomnia, a range of medications, including selected antidepressant medications and benzodiazepines, are available for treatment of insomnia. A doctor who specializes in treating sleep problems can recommend which of these option may be of benefit to you.