Sleep deprivation has been called “the royal route to obesity”. E.Van Cauter
There is nothing worse than being wide awake for night after night after night. And yet for many of our patients this is a common occurrence. Once you start asking about sleep habits you will find lack of a “refreshing” sleep is a big problem Some of the problems related to sleep include difficulty falling asleep, frequent waking during the night and fatigue and drowsiness the next day.
So, why is there a connection between diabetes and sleep? One study which investigated sleep curtailment in healthy volunteers found a dysregulation of the neuroendocrine control of appetite with a reduction of the satiety factor leptin and an increase in the hunger-promoting hormone ghrelin (1). Low leptin levels have been associated with an increased craving for carbohydrates. Disrupted sleep can result in weight gain, increased insulin resistance and reduced daytime functioning.
There has been an increase in type 2 diabetes, sleep disorders and obesity all at the same time. It may not be possible to lose weight until the sleep problem is corrected. There are other factors which put a person with diabetes at higher risk of sleep problems. These include:
1. Obstructive sleep apnea (OSA)
This can be a common problem in obese patients with diabetes. It is caused by the airway between the tongue and the soft palate collapsing during sleep. This leads to a reduction in the level of oxygen in the blood and the person then wakes up to reopen the airway. The word “apnea” means without breath. Evidence suggests that patients with OSA have a smaller airway that predisposes it to collapse. Patients with OSA can stop breathing hundreds of times during the night and often for a minute or longer. As a result the sleep is extremely fragmented and of poor quality. Loud snoring, broken by periods of silence (the apneas) is typical but not always present. The risks for OSA include excess weight, being male, being over the age of 40, a family history of OSA, having a large neck (17 inches) and a recessed chin, abnormalities in the structure of the upper airway, smoking, alcohol use and ethnicity (African-American, Pacific Islander, and Mexican). Obesity has been considered the most important risk factor as 60-90% of adults with OSA are overweight . One of the reasons for the connection is the reduced pharyngeal lumen size due to the fatty tissue within the airway. Women are less affected by OSA due to a more favourable airway mechanics (2).
Major depressive disorder is present in approximately 15% of patients with diabetes. Sleep problems are very common in this group and have been estimated to be as high as 80%. This can include more time to fall asleep, little or no deep sleep and more frequent awakenings. Alcoholism is also associated with sleep difficulties.
3. Peripheral neuropathy
Peripheral neuropathy can cause tingling, burning and pain in the feet and this can be a major cause of sleep disruption.
4. Restless legs syndrome
This is a sleep disorder that causes an irresistible urge to move your legs resulting in tingling, pulling or pain in the legs. Restless leg syndrome is more common in patients with diabetes.
5. Hypo and hyperglycemia
Fear of hypoglycemia and hypoglycemia itself can disrupt sleeping. Hypoglycemia will awaken the person with symptoms of weakness, shakiness and hunger. In some cases (type 1 diabetes) the patient does not wake up in the middle of the night when experiencing hypoglycaemia.
On the other hand, hyperglycemia can waken a person with poorly controlled diabetes as much as hourly to urinate.
Treatment of insomnia:
- Education about sleep hygiene
- Sleep as much as you need, do not oversleep
- Avoid forcing yourself to sleep – go to bed when you feel sleepy
- Keep a regular sleep schedule – bedtime and awakening
- Avoid caffeine later than the afternoon
- Avoid alcohol prior to going to bed (Alcohol appears to cause one to fall asleep
- Do not smoke especially in the evening. Nicotine is a stimulant
- Check one’s blood sugar before bed and take appropriate action as need be to avoid hypoglycemia
- Keep the room at a comfortable temperature
- Do not watch TV, read, or eat in bed
- If you do not fall asleep 30 minutes after going to bed, get up and go to another room and practice relaxation techniques â€“ Alternately tense and relax your muscles. Breathe deeply. Repeat a phrase such as “I am getting sleepy”
- Avoid long naps in the daytime
- Don’t sleep on a bed that is too hard or too old and replace your mattress every 8-10 years
- Exercise regularly for at least 20 minutes per day and ideally 4 to 5 hours before your bedtime
- Yoga nidra
This is a type of yoga which offers a conscious awareness of the deep sleep state. It has been used with soldiers with PTSD. It puts more emphasis on breathing and relaxation than on invigorating poses and can help with insomnia.
- Cognitive control/psychotherapy
This is a process that helps one identify attitudes and beliefs that hinder sleep. The idea is to overcome negative thoughts and promote positive ones. For example, rather than going to bed and worrying about things, one learns to set a “worry time” earlier in the day to deal with this. Guided imagery and visualization can be used.
It is suggested that a combination of sleep education and medication be used.
- A. Herbal sleep aids are available on the internet and include such ingredients as valerian and melatonin. One example is Ambesleep. If your patients use such products they should look for a DIN (drug identification number) or a NPN (Natural Product Number) or a Homeopathic Medicine Number (DIN â€“ HM) indicating that they have been authorized for use in Canada.
- B. Melatonin is sometimes used for certain circadian rhythm disorders such as jet lag and shift work.
- C. Over the counter sleep aids â€“ these usually contain anti-histamines
- D. Prescription drugs â€“ some of the common drugs are: Ambien â€“helps one fall asleep quickly, also available as an extended release form and as an oral spray (Zolpimist) Lunesta â€“ helps one fall asleep quickly Sonata â€“ stays active for the shortest amount of time Benzodiazepines â€“ older sleeping pills such as Halicon and Restoril â€“ stay in your system longer and cause dependence
- Antidepressants â€“ such as Trazodone is used for sleeplessness caused by depression
- More information is available at: www.webmd.org/sleepdisorders
Treatment of OSA
There are many sleep labs across the country which will assess the patient and perform a sleep study. One of the tools used is called a polysomnogram (PSG) and these records the bio-physiological changes that occur during sleep. This is considered the gold standard in sleep studies. There are a minimum of 22 wire attachments to the patient which will measure such things as EEG, airflow, chin movements, leg movements, heart rate and rhythm, oxygen saturation and chest wall movements. The sleep study will determine an Apnea-hypopnea index (AHI) or a respiratory disturbance index (RDI). The AHI is the total number of apneas and hypopneas divided by the total amount of sleep during the study. Hypopneas refer to the episodes of overly shallow breathing. The scoring works as follows:
1-15 = Mild
15-30 = Moderate
30 or more = severe
The device will also show when the patient is in the REM state. There are 4 stages of sleep. They are divided into the non-REM and the REM (rapid eye movement). The amount of REM sleep increases as the night progresses and this is the deepest sleep. REM occurs about four to five times during a normal 8-9 hour sleep period. The non-REM sleep is also known as slow wave sleep and is felt to be the most restorative.
A CPAP (continuous positive airway pressure) is the treatment. The patient wears a face or nasal mask during sleep. The mask is connected to a pump which provides a positive flow of air into the nasal passages in order to keep the airway open. Some patients find the mask uncomfortable and side effects include nasal congestion, sore eyes, headaches and abdominal bloating. It appears to take 2 to 12 weeks to get used to the device. Less than half discontinue the treatment.
One study has found that a 10 kg or more weight loss had the greatest impact on OSA among obese patients with type 2 diabetes (3).
It is important that a sleep problem be diagnosed and treated for the patient with diabetes. It can take over one’s life and make diabetes management much more difficult and significantly reduce quality of life. It is estimated that 85-90% of sufferers still remain undiagnosed. High risks groups for sleep problems include seniors, shift workers and menopausal women. Diabetes educators can be key in asking the right questions and working with the health care team to get patients the help that they need.
- Knutson KL, Van Cauten E. Association between sleep loss and increased risk of obesity and diabetes. Ann NY Acad Sci. 2008;1129:287-304
- Mohsenin V. Gender differences in the expression of sleep-disordered breathing: role of upper airway dimensions.Chest.2001;120(5):1442-7.
- Foster GD et al. A randomized study on the effect of weight loss on obstructive sleep apnea among obese patients with type 2 diabetes: the sleep AHEAD study. Arch Intern Med.2009;169(17):1619-26.