Physiology and Epidemiology of Sleep Disruptions in Diabetes

Introduction

My name is Dr. Lori Laffel. I am a Pediatric Endocrinologist and Clinical Investigator at the Joslin Diabetes Center in Boston, Massachusetts. I’m also a Professor of Pediatrics at Harvard Medical School.

We know that managing the care of people with diabetes is complex, and today we’d like to talk about an under-addressed issue — namely sleep. How significant is sleep disruption for adults with diabetes?

Sleep is important for everyone those with and those without diabetes. Sleep disturbances for people with diabetes occur twice as often as sleep disturbances for people without diabetes. Some studies report as many as one out of two adults living with diabetes may experience challenges with sleep, whether with reduced sleep duration, sleep interruptions, or reduced sleep quality. Given how busy health care visits are for people with diabetes, sleep is often an underappreciated area to discuss. Sleep is so important for people with diabetes because there’s a bidirectional impact of sleep and diabetes. Sleep challenges diabetes and metabolic conditions by potentially increasing insulin resistance. It also can change appetite regulation, increasing appetite and reducing satiety. It can also lead to challenges with overall glycaemic control because of the changes in insulin resistance and the changes in satiety leading to overeating and increased weight and therefore, it’s really important that we address sleep, because if one isn’t getting good sleep quality, what it can do during the day is impact diabetes self-care behaviors because one would be too tired to address factors related to self monitoring, medication adherence, as well as exercise.

So in addition, diabetes itself can impact sleep quality for many reasons. In particular, low glucose levels can lead to nightmares, can lead to headaches, and, can lead to, awakenings because of the need to treat a low either due to an alarm awakening someone, or symptoms of hypoglycaemia, which can occasionally be recognised at night. Hyperglycaemia also can lead to sleep disturbances, because elevated glucose levels can lead to thirst, as well as the need to urinate with increase nocturia. Diabetes can also impact sleep because those often with diabetes may experience obstructive sleep apnea due to increases in body weight. We talked about the glycaemic variations of either high or low glucose as over night, but certainly high glucose over time can lead to diabetes complications in those who experience neuropathy may have pain in their feet burning and tingling, which can also disrupt sleep. And just living with a chronic disease such as diabetes leads to stress, anxiety, and even depression. And these, psychological conditions can also lead to inability to fall asleep as well as sleep awakenings.

If we have a look at the physiological mechanisms, can you break down the core issues that fragment sleep in diabetes, particularly focusing on hypoglycaemia and hyperglycaemia?

Sleep and diabetes have bidirectional influences. Let’s start with the impact of disrupted sleep on diabetes. Reduced sleep frequency or disrupted sleep can increase insulin resistance, which can lead to metabolic derangements. In addition, challenges with sleep can lead to disorders of appetite regulation, increasing appetite and decreasing satiety hormones. In addition, overall sleep itself for people with diabetes has been associated with poor glycaemic control. And lastly, if one is having poor sleep quality, inadequate sleep duration, they may be too tired to manage the self-care behaviors needed for diabetes during the day. For example, taking medications, checking glucose levels, attending to a healthful diet, as well as exercising in a timely manner. On the other hand, let’s talk about the other side of that bidirectionality. Diabetes can also impact sleep with high glucoses and low glucoses. High glucose is leading to increased thirst and a nocturia, frequent urination at night, hypoglycaemia leading to nightmares, headaches, and awakenings from alerts and alarms from devices, and the need to treat lows. Those with diabetes may have increased body mass and develop obstructive sleep apnea which can occur in as many as 1 in 2 individuals with type 2 diabetes. Obstructive sleep apnea disrupts sleep with frequent awakenings and poor sleep quality. With frequent hyperglycaemia in the development of diabetes complications, neuropathic pain can lead to tingling, burning, and pain in the feet, also disrupting sleep. And finally, the fact of one living with a chronic disease, such as diabetes, can lead to psychological challenges associated with stress, anxiety, and depression, which in and of themselves may disrupt sleep frequency and quality either challenges falling asleep or challenges staying asleep at night.

In addition to the physiological mechanisms, can you also elaborate on what common lifestyle elements impact nocturnal glucose stability and sleep quality?

It’s important also to think about what happened during the antecedent hours of sleep. For example, was there a late dinner or a late evening snack? Was there afternoon exercise? Was there excessive alcohol intake or potentially other substances that may impact falling asleep at night? and all these factors may lead to additional challenges with glucose regulation overnight because of either extra food in the system, inadequate insulin, or sometimes too much insulin. Caffeine in the evening is another common challenge that may disrupt sleep and can also impact glucose levels.

What is the single most important message you want HCPs to take away regarding the dynamics between sleep and diabetes?

It’s important to recognise and recall the bidirectional nature that sleep and diabetes have upon one another. It’s important to remember to ask about sleep when you’re seeing people living with diabetes because having a restful night of sleep will help their metabolic status and will give everyone the energy needed to manage these self-care behaviors for optimal diabetes outcomes. Checking glucose, taking medications, exercising, paying attention to healthful eating, and feeling refreshed for other activities related to family, leisure, as well as work activities.