Sleep hygiene education can increase sleep quantity, decrease hospital visits
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Although more than half of people with type 2 diabetes report poor sleep, sleep hygiene is often missing from diabetes self-management education, according to two speakers at the Association of Diabetes Care and Education Specialists annual conference.
“When you look on lifestyle, there’s a lot of emphasis on diet, there’s a lot of emphasis on exercise, but there’s not much mentioned on sleep,” Abhishek Pandey, MD, a sleep physician scientist at Enriching Lives Through Medical Physicians PC, told Healio.
Poor sleep can cause changes to hormones, contribute to weight gain and obesity, and cause changes to behavior and lifestyle, Pandey said.
The American Diabetes Association recommends assessing people with diabetes for sleep apnea and sleep-disordered breathing. Although evidence of treatment effect on blood glucose management is mixed, treatment with lifestyle modification or continuous positive airway pressure can improve blood pressure and quality of life, according to the 2020 standards of care guidelines from the organization.
Few diabetes self-management education programs address healthy sleep, according to Kerry Littlewood, PhD, MSW, an instructor in the School of Social Work at the University of South Florida.
“There’s a lot of exposure on factors related to diet and exercise because they’re so connected and widely discussed in terms of diabetes management,” Littlewood said. “It is easy to ask someone, what are you eating, how often are you eating it, when are you eating it. ... [Sleep] is something that is modifiable, just as a diet, just as exercise. It might even be easier to modify.”
Benefits of sleep hygiene
In the Sleep Integrated with Diabetes Education (SLIDE) trial, Littlewood and Pandey integrated four 15-minute presentations on healthy sleep into an existing diabetes self-management education program at a public health department in an urban setting in the South. The trial included 50 underinsured and uninsured participants with type 2 diabetes randomly assigned to either the regular diabetes self-management education classes or the same classes featuring sleep hygiene.
At the start of the program, most participants had obesity (mean BMI, 38.56 kg/m²) and only 11% reported having normal sleep, with 41% reporting short sleep of less than 6 hours and 7% reporting long sleep of 8 hours or more. At the end of the program, participants in the classes highlighting sleep hygiene increased their sleep quantity compared with participants in the regular classes (+2.3 hours mean change vs. –1.2 hours mean change; P < .001) and also had a reduced number of hospital visits (–1.1 mean visits) compared with those who were not in the program (+1.9 mean visits; P < .001). HbA1c improved and was similar for both groups at the end of the study.
The researchers had originally planned for the sleep education presentations to include recorded lectures from experts. However, during the program the researchers realized that the videos were difficult for many of the participants to understand, Pandey said.
“Some of this information is better understood and better taken when it comes from their primary care provider, compared to coming from a renowned expert,” Pandey said.
“What turned out to be the most impactful and helpful was building on that existing relationship the diabetes educator had with their patients and having them step up and actually provide that education through their own style of interaction,” Littlewood said.
Tips for integrating sleep hygiene
“Caregivers recognize sleep as important, but they don’t necessarily prioritize it,” Littlewood said.
She and Pandey outlined how other programs can add sleep hygiene to their sessions. They recommended diabetes care and education specialists use the SATED assessment to measure overall sleep quality in people with diabetes.
“For the initial visit and follow-up visits, they should determine a healthy sleep pattern and duration,” Pandey said. “We should also make sure this happens in follow-up visits every 3 to 6 months. We should individualize to the patient’s sleep duration, sleep quality and the whole, 24-hour circadian cycle.
A regular sleep-wake schedule should be emphasized.
“Whether it’s shift work, whether it’s regular work, whether it’s someone who’s 90 years old, whether it’s someone who’s 10, making sure they’re sticking to a regular sleep-wake schedule can be very beneficial, both for general sleep and also for general health,” Pandey said.
Discussing healthy sleep health practices is also important. People with diabetes can use activities that relax to wind down before sleep; adjust the light, noise and temperature to promote sleep; and use the bedroom for sleep and sex only.
For group sessions, educators can gauge the level of interest the participants have in sleep hygiene and use that feedback to determine the best path forward.
“If it is a group session, ask them and see if there’s some interest,” Pandey said. “Would you like to learn about sleep disorders? Would you like to learn about sleep and how it would affect your diabetes management? If there is a buy-in, spend the time and resources to address that. If there is not a buy-in, what we need to do is what we are doing now — promoting sleep health and helping them understand how things are.”
References:
- American Diabetes Association. Diabetes Care. 2020;doi.org/10.2337/dc20-S004.
- Pandey A, et al. Sleep 2018;doi:10.1093/sleep/zsy061.1051
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Littlewood K, et al. Let’s Talk About Sleep: How to Integrate Healthy Sleep Behaviors Into Your DSMES Curriculum. Presented at: Association of Diabetes Care and Education Specialists Annual Meeting; August 13 - 16, 2020; (virtual meeting).
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