‘Sleep hygiene’ key component to diabetes prevention, management

Issue: September 2016

SAN DIEGO — Too little or too much sleep is associated host of negative health outcomes, especially in patients with chronic conditions, such as type 2 diabetes, according to a speaker here.

“There is a perception, especially in America, that sleep is wasted time,” Terese Hammond, MD, assistant professor of pulmonary, critical care and sleep medicine at the University of Southern California, told Endocrine Today before a presentation at the American Association of Diabetes Educators annual meeting. “Many successful people actually brag about how little they sleep they get and use it as a badge of honor, but the overwhelming body of research suggests that getting adequate quality sleep (between 6 and 9 hours per night) has wide ranging and positive health implications.”

Terese Hammond

Sleep health is extremely important for diabetes management, Hammond said, as prevention and wellness interventions are strongly associated with improvements not only in physical health, but in subjective measures of quality of life.

Metabolic risks

There is ample evidence that adults who chronically get less than 7 hours of sleep nightly experience metabolic and biologic changes, Hammond said. Cortisol and insulin levels increase, while melatonin levels decrease. At the same time, leptin, the hormone associated with satiety, decreases, while gremlin, the hormone associated with hunger, increases.

In a study published in the November 2013 issues of Diabetes Care, suboptimal sleep duration was positively associated with diabetes risk in blacks and whites, although diabetes prevalence was higher at any level of sleep in blacks, Hammond said.

In addition, insufficient sleep is associated with changes in food desirability, increasing the risk for overweight and obesity. Hammond cited a study published in Nature Communications that showed participants who slept less than 7 hours experienced increased desire for high-calorie foods, according to functional MRI analyses.

“In general, people who get less than 7 hours of sleep on a consistent basis consume a little more than 300 extra calories a day, and the majority of those calories are carbohydrates,” Hammond said.

Short sleep, as well as sleep timing, has also been associated with insulin sensitivity, Hammond said, noting that “a patient who goes to bed at 2 a.m. probably isn’t as healthy as a patient who goes to bed at 10 p.m.”

“It’s important to have your radar up for other sleep conditions,” Hammond said. “It’s not just about the time ... but the timing of sleep. It’s important that sleep is built into a normal circadian rhythm.”

“It’s a very primitive process,” Hammond said. “You can’t think yourself to better sleep. You have to act yourself to better sleep.”

Considerable research is underway to strengthen understanding of the association between sleep and long-term diabetes management, Hammond said. The concept of a more biologically active insomnia is being actively investigated. This may be particularly relevant to diabetics since metabolic and hormonal changes associated with insulin resistance may also disrupt the function of proteins, such as orexin, that essentially act as a "sleep switch," Hammond said.

“By differentiating so called phenotypes of insomnia, we will be better equipped to diagnose and treat our patients,” Hammond said. “The vast majority of patients with stage 4 and 5 kidney disease have one or more coexisting sleep disorder, so awareness is key.”

Treatment options

The best way to treat insufficient sleep is through cognitive behavioral therapy, Hammond said.

“[Sleep] is a very primitive function, so behavioral therapies are very high yield,” Hammond said, and added that cognitive behavioral therapy often works as well or better than medication.

“The vast majority of patients with insomnia have it for behavioral reasons,” Hammond said. “Frankly, sleeping pills have some really bad implications, especially long term.”

Cognitive behavioral therapy includes several components, among them what Hammond called “sleep hygiene education,” which stresses the importance of going to sleep and waking at the same time, and other habits such as leaving electronic devices out of the bedroom.

Other components can include sleep restriction therapy, which increases the homeostatic sleep drive with partial sleep deprivation, a systematic reduction of time in bed to the amount of total sleep time from sleep log data, or increasing time in bed by 15 minutes only when sleep efficiency exceeds 90% for 5 nights.

“These things, while they sound simplistic, can be really potent,” Hammond said.

Another option is stimulus control therapy, which assumes there is a learned association between wakefulness and the bedroom. To break the cycle, the patient must not spend time wide awake in the bedroom, go to bed only when sleepy and not use the bedroom for sleep-incompatible activities, Hammond said.

Other options, including relaxation training, progressive muscle relaxation, guided imagery,

biofeedback and self-hypnosis can help some patients with insomnia, Hammond said. – by Regina Schaffer

Reference: Hammond T. F02. Sleep: Implications of Interrupted, Insufficient Sleep on Metabolism, Obesity, Type 2 Diabetes Risk, Glucose Management. Presented at: AADE 2016; Aug. 12-15, 2016; San Diego.

Disclosure: Hammond reports no relevant financial disclosures.