Sleep complaints are very common in the diabetic patient. For example, patients with Type 2 diabetes have higher rates of insomnia than nondiabetic people, and often this is associated with other complications, such as restless legs syndrome (1). The Sleep Heart Health Study reported that diabetes is often associated with both obstructive and central sleep apnea (2). This paper discusses insomnia and sleep apnea, their respective impacts on diabetes and related diseases, and their treatments.

Consequences of Insomnia

Insomnia affects 33% of our population at some point during their lifetime and has been associated with several diseases. Multiple studies (3, 4) have consistently shown a U-shaped curve relating sleep time to the development and/or worsening of diabetes, metabolic syndrome, and hypertension. Individuals who get fewer than 6 hours or more than 8 hours of sleep per night develop these three conditions much more often than individuals who sleep 7–7.5 hours per night.

Short sleep duration, therefore, may be a significant risk factor for diabetes (5). The mechanism proposed is an increase in activity of the sympathetic nervous system that raises evening cortisol levels and decreases cerebral glucose utilization, leading to insulin resistance and later to diabetes. Chronic sleep deprivation is thought to decrease leptin levels and increase ghrelin levels, leading to increased hunger and weight gain. Poor sleep maintenance (i.e., frequent micro-arousals) that suppresses slow-wave sleep is thought to cause a decrease in insulin sensitivity and an increase in daytime sympathetic activity (6). Long sleep duration (>8 hours) has also been associated with diabetes, but the mechanisms have not been clarified. Poor sleep duration—both too short and too long—may also affect the suprachiasmic nucleus, which organizes the autonomic rhythms of the body.

Like diabetes, metabolic syndrome has been associated with both short and long sleep duration. The odds of developing metabolic syndrome were found to increase by more than 45% in short and long sleepers as compared with individuals who slept 7–8 hours per night (7). One component of metabolic syndrome, hypertension, has been associated with sleeping less than 5 hours per night (8).These poor sleepers were also at least 1.6 times more likely to meet the criteria for abdominal obesity. Another U-shaped association was found between sleep duration and both high triglycerides and low levels of high-density lipoprotein cholesterol among women, but not men (9). Considering this information, it is not surprising that carotid intima-media thickness was reportedly greater among those with short or long sleep duration (10).

Sleep disturbances have been associated with other types of morbidity and even mortality. Shift workers, who are typically short sleepers, have been found to have more diseases than non-shift workers. The World Health Organization’s International Agency for Research on Cancer and the National Cancer Institute implicated the graveyard shift as a “probable”cause of cancer, based on higher incidence of breast cancer and prostate cancer among women and men who work during the night(11). Finally, the Whitehall II cohort study was“the first study to show that both a decrease in sleep duration and an increase in sleep duration are associated with an increase in mortality via effects on cardiovascular death and non-cardiovascular death respectively” (12).

Treatment of Insomnia

The treatment prescribed by non–sleep professionals has been very inconsistent and can be harmful to patients. Insomnia is best treated with a combination of behavioral therapy and medication. In my experience during 25 years of sleep-medicine work, I have found that the need for sleep medication decreases as proper sleep hygiene increases. Ledet’s Four Cardinal Rules of Insomnia Management, described below, combine many behavioral modalities that have proved useful when dealing with insomnia patients. These and other sleep-hygiene measures are given to patients in written form before they leave their first office visit.

Cardinal rule 1. Patients should wake up at the same time each morning (while allowing 30 minutes longer on weekends). This is very important to keep the sleep–wake cycle consistent.

Cardinal rule 2. Eight hours before wake-uptime is bedroom time, but not yet bedtime. Persons with insomnia must prepare for sleep in order to avoid “fearing bedtime.” I recommend that after bathroom time, the patient sit in a chair next to the bed, not in the bed, in order to “take your foot off the accelerator and put it on the brake.” In other words, this practice should stop the brain’s racing thoughts (accelerator) and teach the brain that it is time to stop working (brake). Sometimes it helps the patient to write down these racing thoughts to train the brain to save them until the morning. Next, it is time to turn off the lights and relax with music, meditation, and/or prayer. Only after becoming sleepy should the patient get into bed. Sleep medications, ifneeded, can be taken at this time. The only over-the-counter sleep medication I allow is melatonin, if it helps. Other over-the-counter medications simply disrupt sleep quantity and quality and eventually cause worsening insomnia, weight gain, loss of memory, and poor cognition. This disruption of sleep is also known to occur with alcohol and benzodiazepines.

Cardinal rule 3. Only positive things should happen in bed, meaning either intimacy or sleep. No negative issues should occur in bed. If the patient can’t sleep after 10 or 20 minutes of relaxation, then he or she should go back to the “ritual chair” and begin the process again. Too many chronic insomniacs teach themselves how not to sleep, thus perpetuating their insomnia.

Cardinal rule 4. No napping! Any sleep that occurs between wake-up time and bedroom time is considered napping. Napping only further disrupts the sleep–wake cycle and continues the vicious cycle of insomnia. Some medical problems necessitate resting during the day. If this is the case, a 30-minute rest after lunch may be necessary.

Consequences of Sleep Apnea

Obstructive sleep apnea (OSA), although not as common as insomnia, is estimated to occur in 15 million Americans and lately has received an increasing amount of attention. This sleep disorder may cause “environmental insomnia” for the bed partner and others in the home because of loud snoring. Like OSA, its precursor, snoring itself has been reported to cause several health problems. Some studies suggest that snoring is associated with hypertension, ischemic heart disease, and stroke, although other studies do not support this finding (13). Lee and colleagues found that “heavy snoring significantly increases the risk of carotid atherosclerosis, and the increase is independent of… nocturnal hypoxemia and obstructive sleep apnea severity” (14). They suggested that the transmission of vibrations during snoring is one of the pathophysiologic mechanisms associated with the development of carotid disease. Another study found that heavy snoring was associated with case fatality and short-term mortality after a first acute myocardial infraction (15). Snoring was not associated with long-term mortality rates.

OSA has been associated with a worse long-term prognosis, although there are conflicting reports regarding this association. OSA with hypoxia leads to ischemia and arrhythmia, and it directly depresses cardiac contractility (13). OSA may also be involved in the generation of oxygen free radicals. Sleep-disordered breathing is associated with a rise in circulating levels of other inflammatory cytokines as well as vascular adhesion molecules, all of which damage the cardiovascular system. Endothelial dysfunction has been associated with OSA (16). A consensus document on sleep apnea and cardiovascular disease stated that OSA is associated with hypertension, coronary artery disease, stroke, and atrial fibrillation (17). Central sleep apnea, in which the brain temporarily stops sending signals to the muscles that control breathing, occurs mainly in patients with heart failure, but also in patients using high doses of narcotics. A meta-analysis of sleep apnea in patients with stroke and transient ischemic attack (TIA) found a common association, regardless of the type of stroke, and the authors concluded that sleep studies should be considered in all patients after stroke or TIA (18).

The American Diabetes Association recommends that all diabetic patients be screened for OSA. Sleep-disordered breathing is associated with increased sympathetic nerve activity and catecholamine (adrenaline) release, which may promote hyperinsulinemia. This association between OSA and insulin resistance was seen in both obese and non-obese subjects. Each additional episode of apnea or hypopnea per sleep hour increased the fasting insulin level and insulin resistance (measured by the homeostasis model assessment of insulin resistance; HOMA-IR) by about 0.5%(19). Several studies also noted a dose-response relationship between the severity of nocturnal hypoxemia caused by sleep-disordered breathing and the degree of insulin resistance (20, 21).

In my experience, any patient who snores and is sleepy during the day deserves a sleep study to evaluate the possibility of OSA. Recent studies have evaluated screening nocturnal oximetry with oxygen desaturation index as a powerful screening tool (22). A ResMed ApneaLink apparatus is also available for home screening use. Typical physical findings in OSA patients include a crowded posterior airway space caused by an elongated palate, enlarged tonsils, a large tongue, and/or an overbite. Retrognathia is a common finding in non-obese patients with significant OSA.

Treatment of Sleep Apnea

The only treatment proved effective for this disorder is continuous positive airway pressure (CPAP). Surgical correction of the crowded posterior airway space usually gives less impressive results. Compliance with CPAP is a common problem but can be overcome with instruction from an experienced sleep specialist. One of the most common adverse effects with CPAP use is nasal obstruction caused by vasomotor rhinitis and/ordeviation of the nasal septum. Vasomotorrhinitis can be treated with nasal antihistamines and the proper use of CPAP humidification. Surgery may be needed to repair adeviated septum. In addition, the use of a nasal pillow apparatus instead of the CPAP mask may also help with CPAP compliance.

When used consistently, CPAP improves glycemic control. Diabetic patients who used CPAP nightly for at least 4 hours had significant decreases in fasting and postprandial blood sugar levels averaging 50–80 mg/dl(23). Use of CPAP for more than 4 hours also resulted in better control of blood sugar level sand fewer days with elevated levels, which in turn resulted in lower glycosylated hemoglobin and metabolic improvement in diabetic patients. CPAP is thought to reverse the impairment in glucose homeostasis caused by OSA. Another study noted that CPAP treatment rapidly improved insulin sensitivity in patients with OSA (24).

Conclusions

Sleep disorders, particularly insomnia and OSA, are associated with many metabolic disorders, cardiovascular disease, and diabetes. Therefore, sleep disorders must be addressed when taking a patient’s history and a review of systems. Simply ask a few questions such as the following:

• Do you have difficulty sleeping, getting to sleep, or staying asleep?
• Do you snore? Are you sleepy during the day?
• Do your legs bother you while trying to rest during the evening?

By asking these simple questions and further evaluating those with a positive response, we may eliminate the need for additional anti-hypertensive and/or anti diabetic medications. We may also decrease the frequency of conditions that are possibly caused by untreated OSA, such as nocturnal sinus pauses requiring the placement of pacemakers and recurrent atrial fibrillation. In addition, if an underlying sleep disorder is discovered and treated, expensive evaluations for memory loss may not be necessary. Remember, memory is worsened by poor sleep, and better sleep leads to a better day!

Dr. Ledet is the Director of Preventive Care & Sleep Medicine in Mobile and in Daphne, Alabama. He is board certified in Family Medicine and Clinical Lipidology. He serves as the Medical Director of the Southeastern Regional Sleep/Wake Disorders Center at Springhill Medical Center in Mobile, Alabama; and he serves as an Assistant Clinical Professor in the Department of Family Medicine at the University of South Alabama College of Medicine. He is on the speaker’s bureau of Abbott, Atherotech, Cephalon, GlaxoSmithKline, Sanofi-Aventis, Sepracor, and Takeda Pharmaceuticals.

References

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4. Gottlieb DJ, Punjabi NM, Newman AB, et al: Association of sleep time with diabetes mellitus and impaired glucose tolerance. Arch Intern Med165(8):863–867, 2005.
5. Gangwisch JE, Heymsfield SB, Boden-Albala B, et al: Sleep duration as a risk factor for diabetes incidence in a large U.S.sample. Sleep30(12):1667–1673, 2007.
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It important to understand multiple medications can affect our sleep both quality and quantity. Most over the counter sleep medications that contain Benadryl and Benadryl-like medication decrease both deep and dream sleep so they may help quantity of sleep, but they worsen the quality of our sleep; they also lose effectiveness the longer they are used and require higher doses which only makes the quality of sleep worsen more. If these products are used chronically, they can adversely affect men’s prostate function and lessen both gender’s memory recall and cognition.

Multiple studies continue to prove that Cognitive Behavior Therapy for Insomnia (CBTi) works better than medication, but I believe the two working together works faster for patients who always want an immediate fix. Now over 30 years helping patients with their insomnia, it is quite apparent to me that CBTi is necessary for patients to continue achieving adequate sleep quantity and quality of sleep. Good sleep medications lose their effectiveness if CBTi is not maintained. Maintaining good sleep hygiene and following the rules of CBTi help patients transition off sleep medications sooner and result in better long-term sleep improvement.

CBTi is not commonly covered by insurance companies and usually difficult to find someone who offers this therapy. It can be obtained online through various websites. Over the years I’ve incorporated the multiple modalities of CBTi into my everyday practice working with patients using 5 simple rules. I always guarantee my patients they will be sleeping better over time working with me but the sooner they master my 5 rules, the sooner they will be sleep better with or without medication.

Before discussing my 5 rules of better sleep management, I review the patient’s health history and medications because both can adversely affect their sleep as noted later in this article. Then I ask what 8 hours they want to be in the bedroom preparing for sleep and sleeping in the bed. Typically, it is 10pm to 6am.

Rule #1: Always wake up the same time in the morning and get out of bedroom and start your day no matter how little sleep you have received during the night

Rule #2: No Napping during the day between wake-up time and bedroom time. Napping in the late afternoon is the worst thing a patient can do to get a good night sleep

Rule #3: Only 2 good things in the bed: sleep and intimacy! If not doing either, then get out of the bed but not the bedroom and proceed to Rule #4.

Rule #4: If not doing either of the 2 things mentioned in #3, then leave lights off and get into a comfortable chair in the bedroom and focus on 3 things: music without words, listening prayer, and meditation.

Rule #5: And finally, for the mind racing patients and ones that worry too much, they need a processing time some time before bedroom time. I encourage writing down their “to do list”, what made them angry or upset during the day, and/or simply journaling about the issues on their mind so this is less likely to occur while trying to go to sleep. So many patients do their processing time in bed and wonder why they can’t go to sleep.

We have two receptors in our brain, the GABA and Orexin, acting like the brake and accelerator in our car. If one accelerates the Orexin receptor, while trying the brake the GABA receptor, the car/brain doesn’t work very well. You can use multiple brakes (sleep medications) but if you leave your foot on the accelerator (mind race/worry), the car (brain) will have a difficulty stopping (getting to sleep) and maintaining the brake (sleep) through the night.

Studies have consistently shown worsening health conditions occur when proper sleep quality and quantity are not achieved. Even people who are getting adequate hours of sleep may suffer other medical problems because of unknown sleep apnea, restless legs syndrome/periodic movements of sleep, and other sleep disorders. Here is a list of some medical problems made worse with poor sleep and vice versa:

• Obesity has become epidemic and poor sleep causes an increase secretion in the hunger hormone, ghrelin from the stomach. At the same time there is decrease in the satiety hormone, leptin secreted from the fat cells. One study suggests for every extra hour of sleep towards the daily goal is associated with a 50% reduction in the risk of obesity. Poor sleep also leads to slower metabolism perhaps because of less growth hormone secreted in deep sleep.
• Blood Pressure is affected by poor sleep, elevation is more common in short sleepers getting less than 5 hours of sleep. The lack of physiologic blood pressure drop that normally occurs during the night that is not present in poor sleep can lead to worsening cardiovascular disease. Multiple awakenings during the night from insomnia, sleep apnea, and other sleep disorders increase our adrenaline and is associated with higher blood pressure. Untreated sleep apnea not only elevates blood pressure but is associated with stroke, heart attacks, atrial fibrillation, heart failure, diabetes, lower testosterone, erectile dysfunction, more urination during the night, and more GI reflux at night.
• Diabetes develops from genetic penetration, obesity from poor eating, sleep apnea, and simply from poor sleep. Getting proper sleep quantity and quality improves blood sugar control by enabling your own insulin to work more efficiently. Using CPAP for sleep apnea lowers blood sugar.
• Cholesterol problems particularly elevated triglycerides and low HDL (good cholesterol) can occur from poor sleep.
• Gastrointestinal reflux can cause insomnia and sleep apnea can worsen reflux. Eating too close to bedtime magnifies this problem as well.
• Asthma, uncontrolled, can worsen sleep and untreated sleep apnea can worsen asthma.
• Testosterone production is lowered in poor sleep particularly sleep apnea and replacement of this hormone can worsen sleep apnea.
• Cognitive dysfunction (brain fog) is greatly affected by all types of sleep disorders. Attention Deficit Disorder (ADD) is made worse in poor sleepers and sometimes misdiagnosed when the person may have a sleep disorder.
• Chronic pain, for example fibromyalgia, is worsened by poor sleep and proper sleep management is one of the few consistent modalities that improves this disorder. Chronic muscle pain is helped with proper sleep, particularly REM (dream) sleep because our skeletal muscles are paralyzed during this sleep stage helping our muscles relax.
• Bedwetting and frequent urination at night can be a symptom of sleep apnea and needs to part of the evaluation of these symptoms.

Insomnia is the most common sleep disorder in the United States affecting 30% of our population sometime during their lifetime. Sleep problems should be discussed during the evaluation of multiple medical problems and complaints, some listed above. It is important for patients to volunteer their sleep problems/complaints to their care providers to enable them to obtain the best information to solve their problem.

Michael Ledet, M.D. has practiced Sleep Disorders Medicine and Lipidology in Mobile Alabama for over 30 years. He is Board Certified in these disciplines as well as Family Medicine.

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