Subjective sleep impairment in adults with type 1 or type 2 diabetes: Results from Diabetes MILES—The Netherlands

doi:10.1016/j.diabres.2015.07.008

Diabetes Research and Clinical Practice

Volume 109, Issue 3, September 2015, Pages 466-475

https://doi.org/10.1016/j.diabres.2015.07.008 Get rights and content

Abstract

Aims

Despite growing recognition of the impact of sleep on diabetes, a clear profile of people with diabetes regarding subjective sleep impairment has yet to be established. This study examines: (1) subjective sleep characteristics in adults with type 1 and type 2 diabetes; (2) the relationship of poor subjective sleep quality with glycaemic control, self-care and daytime functioning; (3) possible risk markers for poor sleep quality.

Methods

In a cross-sectional study, Dutch adults with type 1 (n = 267) or type 2 diabetes (n = 361) completed an online survey, including the Pittsburgh Sleep Quality Index (PSQI), socio-demographic, clinical, self-care and psychological measures.

Results

Poor sleep quality (PSQI-score >5) was reported by 31% of adults with type 1 and 42% of adults with type 2 diabetes. Participants with good and poor sleep quality did not differ in self-reported HbA_1c or the frequency of meeting lifestyle recommendations. Poor sleep quality was related to a higher self-care burden and higher levels of daytime sleepiness, fatigue, depressive and anxiety symptoms, and diabetes-specific distress. In multivariable logistic regression analyses examining risk markers, poor sleep quality was associated with depressive symptoms in adults with type 1 (OR = 1.39, 95% CI 1.25–1.54) and type 2 diabetes (OR = 1.31, 1.16–1.47), and with being female in those with type 2 diabetes (OR = 2.72, 1.42–5.20).

Conclusions

Poor subjective sleep quality is prevalent both in adults with type 1 and type 2 diabetes, and is related to poor daytime functioning and higher self-care burden. The temporal relation with depression and merits of therapy should be explored.

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 (HbA_1c) 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 HbA_1c level in adults with type 1 diabetes [15], while self-reported sleep duration and sleep quality showed no relation with HbA_1c [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 HbA_1c 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

References (48)

M. Chennaoui et al.
Sleep and exercise: a reciprocal issue?
Sleep Med Rev
(2015)
R.P. Skomro et al.
Sleep complaints and restless legs syndrome in adult type 2 diabetics
Sleep Med
(2001)
K. Jauch-Chara et al.
Sleep and the response to hypoglycaemia
Best Pract Res Clin Endocrinol Metab
(2010)
D.J. Buysse et al.
The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research
Psychiatry Res
(1989)
G. Nefs et al.
Type D (distressed) personality in primary care patients with type 2 diabetes: validation and clinical correlates of the DS14 assessment
J Psychosom Res
(2012)
P.M. Becker
Pharmacologic and nonpharmacologic treatments of insomnia
Neurol Clin
(2005)
K.A. Babson et al.
Cognitive behavioral therapy for sleep disorders
Psychiatr Clin N Am
(2010)
C.M. van der Feltz-Cornelis et al.
Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis
Gen Hosp Psychiatry
(2010)
T. Porkka-Heiskanen et al.
Sleep, its regulation and possible mechanisms of sleep disturbances
Acta Physiol (Oxf)
(2013)
F.P. Cappuccio et al.
Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis
Diabetes Care
(2010)

K.L. Knutson et al.

Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus

Arch Intern Med

(2006)

Y. Song et al.

Disturbed subjective sleep in Chinese females with type 2 diabetes on insulin therapy

PLoS One

(2013)

W.A. Wan Mahmood et al.

Association between sleep disruption and levels of lipids in Caucasians with type 2 diabetes

Int J Endocrinol

(2013)

D.J. Buysse et al.

Quantification of subjective sleep quality in healthy elderly men and women using the Pittsburgh Sleep Quality Index (PSQI)

Sleep

(1991)

Y. Doi et al.

Subjective sleep quality and sleep problems in the general Japanese adult population

Psychiatry Clin Neurosci

(2001)

N. Okubo et al.

Relationship between self-reported sleep quality and metabolic syndrome in general population

BMC Public Health

(2014)

M. van Dijk et al.

Disturbed subjective sleep characteristics in adult patients with long-standing type 1 diabetes mellitus

Diabetologia

(2011)

E. Donga et al.

A single night of partial sleep deprivation induces insulin resistance in multiple metabolic pathways in healthy subjects

J Clin Endocrinol Metab

(2010)

S. Reutrakul et al.

Interactions between sleep, circadian function, and glucose metabolism: implications for risk and severity of diabetes

Ann N Y Acad Sci

(2014)

Y.W. Tsai et al.

Impact of subjective sleep quality on glycemic control in type 2 diabetes mellitus

Fam Pract

(2012)

T. Ohkuma et al.

Impact of sleep duration on obesity and the glycemic level in patients with type 2 diabetes: the Fukuoka Diabetes Registry

Diabetes Care

(2013)

E. Donga et al.

Partial sleep restriction decreases insulin sensitivity in type 1 diabetes

Diabetes Care

(2010)

A.L. Borel et al.

Short sleep duration measured by wrist actimetry is associated with deteriorated glycemic control in type 1 diabetes

Diabetes Care

(2013)

M.P. St-Onge

The role of sleep duration in the regulation of energy balance: effects on energy intakes and expenditure

J Clin Sleep Med

(2013)

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Subjective sleep impairment in adults with type 1 or type 2 diabetes: Results from Diabetes MILES—The Netherlands

Abstract

Aims

Methods

Results

Conclusions

Introduction

Section snippets

Participants and procedure

Sample characteristics

Subjective sleep characteristics

Key findings

Conflict of interest

Acknowledgements

Sleep Med Rev

Sleep Med

Best Pract Res Clin Endocrinol Metab

Psychiatry Res

J Psychosom Res

Neurol Clin

Psychiatr Clin N Am

Gen Hosp Psychiatry

Sleep, its regulation and possible mechanisms of sleep disturbances

Acta Physiol (Oxf)

Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis

Diabetes Care

Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus

Arch Intern Med

Disturbed subjective sleep in Chinese females with type 2 diabetes on insulin therapy

PLoS One

Association between sleep disruption and levels of lipids in Caucasians with type 2 diabetes

Int J Endocrinol

Quantification of subjective sleep quality in healthy elderly men and women using the Pittsburgh Sleep Quality Index (PSQI)

Sleep

Subjective sleep quality and sleep problems in the general Japanese adult population

Psychiatry Clin Neurosci

Relationship between self-reported sleep quality and metabolic syndrome in general population

BMC Public Health

Disturbed subjective sleep characteristics in adult patients with long-standing type 1 diabetes mellitus

Diabetologia

A single night of partial sleep deprivation induces insulin resistance in multiple metabolic pathways in healthy subjects

J Clin Endocrinol Metab

Interactions between sleep, circadian function, and glucose metabolism: implications for risk and severity of diabetes

Ann N Y Acad Sci

Impact of subjective sleep quality on glycemic control in type 2 diabetes mellitus

Fam Pract

Impact of sleep duration on obesity and the glycemic level in patients with type 2 diabetes: the Fukuoka Diabetes Registry

Diabetes Care

Partial sleep restriction decreases insulin sensitivity in type 1 diabetes

Diabetes Care

Short sleep duration measured by wrist actimetry is associated with deteriorated glycemic control in type 1 diabetes

Diabetes Care

The role of sleep duration in the regulation of energy balance: effects on energy intakes and expenditure

J Clin Sleep Med