Subjective sleep impairment in adults with type 1 or type 2 diabetes: Results from Diabetes MILES—The Netherlands
Introduction
Humans spend approximately one-third of their lives asleep. The exact function of sleep remains an unresolved mystery, but the main theories focus on energy metabolism and neural plasticity [1]. Emerging evidence suggests that poor sleep can have adverse health consequences. Meta-analysis of longitudinal studies shows that both quantity and quality of sleep predict the risk of development of type 2 diabetes [2]. Short duration of sleep (≤5–6 h per night) increases the risk by 28%, while long duration of sleep (>8–9 h per night) increases this risk by 48% [2]. Furthermore, quality indicators such as difficulties in initiating and maintaining sleep increase the risk for type 2 diabetes onset by 57% and 84%, respectively [2]. The rate of self-reported poor sleep quality in adults with diagnosed type 2 diabetes generally ranges between 45% and 70% (e.g., [3], [4], [5]), compared to 10–30% in the general population and elderly without diabetes [6], [7], [8]. However, most estimates in type 2 diabetes are based on studies with small sample sizes (typically, N < 150). Studies that focus on the prevalence of sleep problems in adults with type 1 diabetes are scarce. One recent study among 99 adults with type 1 diabetes and 99 matched adults without this condition reported that subjective poor sleep quality was significantly more common in the diabetes group compared to the control group (35% versus 20%), while subjective sleep duration did not differ [9]. Whether these findings are representative of adults with type 1 diabetes in general and how they relate to estimates in adults with type 2 diabetes has yet to be established.
Experimental manipulations that reduce sleep duration impair glucose metabolism in healthy volunteers [10], [11]. These findings are consistent with epidemiological studies showing that poor sleep quality and both short and long sleep duration are associated with higher glycated haemoglobin (HbA1c) levels in adults with type 2 diabetes [3], [5], [12], [13]. Also in adults with type 1 diabetes, experimental partial sleep restriction lowers insulin sensitivity [14]. In another study, short sleep duration measured by wrist actimetry has been shown to be associated with a 0.64% (7 mmol/mol) increase in HbA1c level in adults with type 1 diabetes [15], while self-reported sleep duration and sleep quality showed no relation with HbA1c [9]. Apart from direct effects on glucose metabolism, sleep disturbances may also indirectly influence glycaemic control through suboptimal diabetes self-care. While sleep disturbances are known to have a negative impact on physical activity and eating behaviours [16], [17], only one study has examined the association between impaired sleep and self-care in people with diabetes. In that study of 107 adults with type 2 diabetes, poor sleep quality was associated with suboptimal (self-reported) diabetes self-care (including diet, medication taking and exercise) and problems with glycaemic control [18]. However, this small sample consisted of a highly select group of insulin-naive individuals who reported daytime sleepiness. Preliminary data in adults with type 2 diabetes suggest that sleep disturbances may also affect other aspects of daytime functioning, including daytime sleepiness, fatigue and mood [19], [20], [21], [22]. However, these studies also had small sample sizes or focused on select groups only, i.e., adults from specialised clinics or participants in a randomised trial. One study found no difference in self-reported daytime sleepiness between adults with and without type 1 diabetes [9].
Despite the growing recognition of the impact of sleep on diabetes and its management, a clear profile of people with type 1 or type 2 diabetes with disturbed sleep has yet to be established. Factors that may be implicated include being female, older and having a higher number of comorbidities, suboptimal glycaemic control, higher body mass index, depressive symptoms, alcohol use and hypoglycaemia [4], [5], [9], [13], [15], [21], [23], [24]. However, these potential risk markers for poor sleep quality have not been studied comprehensively in a large number (N > 200) of adults with type 1 or type 2 diabetes, nor is it clear whether the same risk markers exist across diabetes types.
Given the current knowledge gaps, the aims of the present study are to examine: (1) subjective sleep characteristics in adults with type 1 and type 2 diabetes; (2) the association between poor subjective sleep quality and glycaemic control, self-care activities and daytime functioning; and (3) possible risk markers for poor subjective sleep quality.
Section snippets
Participants and procedure
The rationale, design and procedure of Diabetes MILES (Management and Impact for Long-term Empowerment and Success)—The Netherlands have been described in detail elsewhere [25]. The primary aim of this national, online, cross-sectional observational study was to examine the psychosocial aspects of living with diabetes among adults with this condition in The Netherlands. From September to October 2011, all Dutch adults (aged ≥19 years, no upper age limit) with self-reported diabetes of any type
Sample characteristics
The total sample consisted of 628 people, of whom 43% (n = 267) had type 1 diabetes and 57% (n = 361) had type 2 diabetes. Table 1 describes the sociodemographic, clinical, self-care and psychological characteristics of these groups. Of the adults with type 1 diabetes, 59% were women, the mean age was 47 ± 16 years and 19% had a low education level. Of those with type 2 diabetes, 46% were women, the mean age was 62 ± 9 years and 31% had a low education level.
Subjective sleep characteristics
Subjective sleep characteristics of adults
Key findings
In this large sample of adults with diabetes, 31% of those with type 1 diabetes and 42% of those with type 2 diabetes reported poor sleep quality. Participants with good sleep quality did not differ from those with poor sleep quality with respect to self-reported HbA1c or the frequency of meeting several self-care recommendations. However, they did report a significantly higher burden of meeting dietary and exercise recommendations, as well as higher levels of daytime sleepiness, fatigue,
Conflict of interest
None
Acknowledgements
We thank all people with diabetes who participated in Diabetes MILES—The Netherlands. We also thank the Dutch Diabetes Association and the Dutch Diabetes Research Foundation for their kind and very valuable assistance in the recruitment of participants.
All authors contributed to the conception and design of the study, analysis and interpretation of the data. GN, ED and FP drafted the first version of the manuscript. All authors critically revised the manuscript for important intellectual
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