Risk of type 2 diabetes in patients with insomnia: A population-based historical cohort study

Chronic insomnia, high trait anxiety and their comorbidity as risk factors for incident type 2 diabetes mellitus

The main objective of this study was to evaluate the association of the insomnia-anxiety comorbidity with incident type 2 diabetes (T2D) in a large prospective cohort. We selected adults without diabetes at baseline from the French NutriNet-Santé cohort who had completed the trait anxiety subscale of the Spielberger State-Trait Anxiety Inventory (STAI-T, 2013-2016) and a sleep questionnaire (2014); insomnia was defined according to established criteria. Using multivariable Cox models, we compared T2D risk across 4 groups: no insomnia or anxiety (reference), insomnia alone, anxiety alone (STAI-T ≥ 40), and comorbid anxiety and insomnia. Among 35,014 participants (mean baseline age: 52.4 ± 14.0 years; 76% women), 378 (1.1%) developed T2D over a mean follow-up of 5.9 ± 2.1 years. Overall, 28.5% of the sample had anxiety alone, 7.5%-insomnia alone, and 12.5%-both disorders. In the fully-adjusted model, a higher T2D risk was associated with anxiety-insomnia comorbidity (HR = 1.40; 95% CI 1.01, 1.94), but not with each disorder separately, compared to the group without insomnia or anxiety. The findings supported a positive association between anxiety-insomnia comorbidity and incident T2D among general-population adults. Future research using clinical diagnoses of mental disorders could confirm the findings and guide diabetes prevention programs.

Redefining Comorbid Insomnia and Sleep Apnea: The Association of Sleep Breathing Impairment and Insomnia with Incident Diabetes

Rationale: Obstructive sleep apnea (OSA) is a prevalent sleep disorder that is frequently comorbid with insomnia and often accompanied by metabolic diseases such as type 2 diabetes. Although the apnea-hypopnea index (AHI) is currently the diagnostic criterion for gauging the severity of OSA, the AHI has not consistently predicted incident diabetes. Objectives: To test whether a combined insomnia-OSA (COMISA) phenotype based on comorbid insomnia and sleep breathing impairment index (COMISA-SBII) predicts incident diabetes and to compare the association with an AHI definition of COMISA (COMISA-AHI) in the MrOS (Osteoporotic Fractures in Men) study. Methods: The study samples came from participants in the MrOS sleep study without diabetes at their baseline examination. The SBII was derived as the product of the duration of each respiratory event (apnea and hypopnea) and the accompanying desaturation area from baseline unattended polysomnography. A subgroup of individuals classified as having comorbid insomnia (difficulties falling asleep, waking up in the middle of the night and/or early morning awakenings >15 times per month, and daytime impairments) and sleep breathing impairment (greater than 50th percentile of SBII) were identified at baseline. The primary outcome was incident diabetes during the follow-up visits. Cox proportional models were built to assess the adjusted hazard ratios of COMISA-AHI and COMISA-SBII. Prediction model performances of incident diabetes were compared across different models. Results: A total of 2,365 men (mean age, 76 yr) without diabetes at baseline were included. During a median follow-up of 10.0 years, diabetes developed in 181. After adjusting for demographic characteristics, comorbidities, and behavioral risk factors, participants with COMISA-SBII had a higher risk of incident diabetes (hazard ratio, 1.82; 95% confidence interval, 1.15-2.89) than those without sleep disorders (those with an SBII ⩽13.17 and no insomnia). The result remained significant in the risk competing model. Compared with COMISA-AHI, the addition of COMISA-SBII to a crude model with established risk factors significantly improved the predictive value of incident diabetes. Conclusions: COMISA-SBII, but not COMISA-AHI, predicted incident diabetes after accounting for multiple covariates in a cohort of older men. A comorbid insomnia phenotype based on SBII plus insomnia symptoms may be an important clinical subtype.

Unraveling the associations and causalities between glucose metabolism and multiple sleep traits

Purpose

The aim of our study is to estimate the associations and causalities of glucose metabolism traits of fasting blood glucose (FBG), fasting insulin (FINS), glycosylated hemoglobin (HbA1c), and 2-h glucose post-challenge (2hGlu) with sleep traits consisting of excessive daytime sleepiness (EDS), insomnia, and sleep duration.

Methods

We employed standard quantitative analysis procedures to assess the associations between sleep traits and glucose metabolism. Moreover, we acquired published genome-wide association studies (GWAS) summary statistics for these traits and conducted Mendelian randomization (MR) analyses to estimate their causal directions and effects. Inverse variance weighting (IVW) was employed as the primary approach, followed by sensitivity analyses.

Results

A total of 116 studies with over 840,000 participants were included in the quantitative analysis. Our results revealed that participants with abnormal glucose metabolism had higher risks for EDS (OR [95% CI] = 1.37 [1.10,1.69]), insomnia (OR [95% CI] = 1.65 [1.24,2.20]), and both short and long sleep duration (OR [95% CI] = 1.35 [1.12,1.63]; OR [95% CI] = 1.38 [1.13,1.67] respectively). In addition, individuals with these sleep traits exhibited alterations in several glycemic traits compared with non-affected controls. In MR analysis, the primary analysis demonstrated causal effects of 2hGlu on risks of EDS (OR [95% CI] = 1.022 [1.002,1.042]) and insomnia (OR [95% CI] = 1.020[1.001,1.039]). Furthermore, FINS was associated with short sleep duration (OR [95% CI] = 1.043 [1.018,1.068]), which reversely presented a causal influence on HbA1c (β [95% CI] = 0.131 [0.022,0.239]). These results were confirmed by sensitivity analysis.

Conclusion

Our results suggested mutual risk and causal associations between the sleep traits and glycemic traits, shedding new light on clinical strategies for preventing sleep disorders and regulating glucose metabolism. Future studies targeting these associations may hold a promising prospect for public health.

Associations of meal timing, number of eating occasions and night-time fasting duration with incidence of type 2 diabetes in the NutriNet-Santé cohort

BACKGROUND

Food intake plays a pivotal role in regulating circadian rhythms, which modulate glucose and lipid homeostasis. However, studies investigating the association of meal timing and type 2 diabetes (T2D) incidence are lacking. The objective of this study was to investigate the longitudinal associations of meal timing, number of eating occasions and night-time fasting duration with incidence of T2D.

METHODS

In total, 103 312 adults [79% women, mean age at baseline = 42.7 (SD = 14.6)] from the NutriNet-Santé cohort (2009-21) were included. Participants' meal timings and frequency were assessed using repeated 24-h dietary records and averaged from the first 2 years of follow-up (5.7 records/participant). Associations of meal timing, number of eating occasions and night-time fasting duration with incidence of T2D were assessed by using multivariable Cox proportional hazard models adjusted for known risk factors.

RESULTS

During a median follow-up of 7.3 years, 963 new cases of T2D were ascertained. Compared with participants habitually having a first meal before 8AM, those eating after 9AM had a higher incidence of T2D (HR = 1.59, 95% CI 1.30-1.94). Time of last meal was not associated with T2D incidence. Each additional eating episode was associated with a lower incidence of T2D (HR = 0.95, 95% CI 0.90-0.99). Night-time fasting duration was not associated with T2D incidence, except in participants having breakfast before 8AM and fasting for >13 h overnight (HR = 0.47, 95% CI 0.27-0.82).

CONCLUSIONS

In this large prospective study, a later first meal was associated with a higher incidence of T2D. If confirmed in other large-scale studies, an early breakfast should be considered in preventing T2D.

Sleep Patterns, Plasma Metabolome, and Risk of Incident Type 2 Diabetes Mellitus

CONTEXT

A healthy sleep pattern has been related to a lower risk of type 2 diabetes mellitus (T2DM).

OBJECTIVE

We aimed to identify the metabolomic signature for the healthy sleep pattern and assess its potential causality with T2DM.

METHODS

This study included 78 659 participants with complete phenotypic data (sleep information and metabolomic measurements) from the UK Biobank study. Elastic net regularized regression was applied to calculate a metabolomic signature reflecting overall sleep patterns. We also performed genome-wide association analysis of the metabolomic signature and one-sample mendelian randomization (MR) with T2DM risk.

RESULTS

During a median of 8.8 years of follow-up, we documented 1489 incident T2DM cases. Compared with individuals who had an unhealthy sleep pattern, those with a healthy sleep pattern had a 49% lower risk of T2DM (multivariable-adjusted hazard ratio [HR], 0.51; 95% CI, 0.40-0.63). We further constructed a metabolomic signature using elastic net regularized regressions that comprised 153 metabolites, and robustly correlated with sleep pattern (r = 0.19; P = 3×10-325). In multivariable Cox regressions, the metabolomic signature showed a statistically significant inverse association with T2DM risk (HR per SD increment in the signature, 0.56; 95% CI, 0.52-0.60). Additionally, MR analyses indicated a significant causal relation between the genetically predicted metabolomic signature and incident T2DM (P for trend < .001).

CONCLUSION

In this large prospective study, we identified a metabolomic signature for the healthy sleep pattern, and such a signature showed a potential causality with T2DM risk independent of traditional risk factors.

The burden of untreated insomnia disorder in a sample of 1 million adults: a cohort study

BACKGROUND

Insomnia disorder is a highly prevalent, significant public health concern associated with substantial and growing health burden. There are limited real-world data assessing the burden of insomnia disorder on daytime functioning and its association with comorbidities. The objective of this study was to leverage large-scale, real-world data to assess the burden of untreated insomnia disorder in terms of daytime impairment and clinical outcomes.

METHODS

This United States medical claims database study compares patients diagnosed with insomnia disorder but not receiving treatment ('untreated insomnia' cohort) to patients without an insomnia disorder diagnosis and without treatment ('non-insomnia' cohort). International Classification of Disease, Tenth Revision codes were used as a proxy to represent the three symptom domains (Sleepiness, Alert/Cognition, Mood) of the Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ), a newly developed and validated tool used in clinical studies to assess daytime functioning in insomnia disorder. Chronic Fatigue (R53.83) and Other Fatigue (R53.83), Somnolence (R40.0) and Disorientation (R41.0) were selected as categories representing one or more IDSIQ domains. Clinical outcomes included cardiovascular events, psychiatric disorders, cognitive impairment and metabolic disorders.

RESULTS

Approximately 1 million patients were included (untreated insomnia: n = 139,959; non-insomnia: n = 836,975). Compared with the 'non-insomnia' cohort, the 'untreated insomnia' cohort was more likely to experience daytime impairments, with mean differences in occurrences per 100 patient-years for: (a) fatigue, at 27.35 (95% confidence interval [CI] 26.81, 27.77, p < 0.01); (b) dizziness, at 4.66 (95% CI 4.40, 4.90, p < 0.01); (c) somnolence, at 4.18 (95% CI 3.94, 4.43, p < 0.01); and (d) disorientation, at 0.92 (95% CI 0.77, 1.06, p < 0.01). During the 1-year look-back period, patients in the 'untreated insomnia' cohort were also more likely to have been diagnosed with arterial hypertension (40.9% vs. 26.3%), psychiatric comorbidities (40.1% vs. 13.2%), anxiety (29.2% vs. 8.5%), depression (26.1% vs. 8.1%) or obesity (21.3% vs. 11.1%) compared with those in the 'non-insomnia' cohort.

CONCLUSIONS

This large-scale study confirms the substantial burden of insomnia disorder on patients in a real-world setting, with significant daytime impairment and numerous comorbidities. This reinforces the need for timely insomnia disorder diagnosis and treatments that improve both sleep, as well as daytime functioning.

Improving sleep health management in primary care: A potential role for community nurses?

AIMS

To explore community nurses sleep health practices and their perspectives on improving sleep health care provision.

DESIGN

An exploratory study utilizing the qualitative description methodology.

METHODS

Semi-structured interviews were conducted with community nurses from May 2019 - October 2021. Interviews were audio-recorded, transcribed, and subjected to an inductive thematic analysis using a constructivist-interpretive paradigm.

RESULTS

Twenty-three Australian community nurses were interviewed. Participants frequently encountered sleep disturbances/disorders in their patients. Data analysis yielded three main themes: (1) Sleep health in the community serviced, (2) sleep health awareness and management, and (3) community nurses' A to Z of improving sleep health. The most common sleep disorder presentations were insomnia and sleep apnea. Although most community sleep apnea cases were appropriately managed, insomnia was often mismanaged. Participants described their sleep health knowledge as deficient, with the majority advocating for increased sleep-related education tailored to their profession. Other important factors needed for improving sleep health provision were standardized patient treatment/referral pathways, increased interprofessional collaboration, and sufficient time for patient consults.

CONCLUSION

Community nurses service a patient population that requires increased sleep health care. However, they are currently underequipped to do so, leading to suboptimal treatment provision. Providing community nurses with the appropriate resources, such as increased sleep-related education and standardized treatment frameworks, could enable them to better manage sleep disturbance/disorder presentations, such as insomnia.

IMPACT

Little is known about how community nurses care for patients with sleep disturbance/sleep disorders. This study found that contemporary sleep health care was lacking due to knowledge deficits, competing challenges, and a need for standardized care pathways. These findings can inform the development of targeted education/training and standardized guidelines for community nurses providing sleep health care to patients as well as the design of future practice models of care provision.

PATIENT OR PUBLIC CONTRIBUTION

Previous research by authors has involved extensive engagement with patients and health professionals, such as community pharmacists, general practitioners, and naturopaths who play a role in sleep health in the primary health care sector. These previous research projects built a significant understanding of the patient and health practitioner experience and have provided the background to the concept and design of this study.

The interrelationship between sleep, diet, and glucose metabolism

Obesity and type 2 diabetes (T2D) are increasingly common worldwide. While these disorders have increased in prevalence over the past several decades, there has been a concomitant reduction in sleep duration. Short sleep duration has been associated with higher rates of obesity and T2D, and the causality of these associations and their directionality, continue to necessitate evaluation. In this review we consider the evidence that sleep is an intrinsic factor in the development of obesity and chronic metabolic disorders, such as insulin resistance and T2D, while evaluating a potential bi-directional association. We consider the evidence that diet and meal composition, which are known to impact glycemic control, may have both chronic and acute impact upon sleep. Moreover, we consider that postprandial nocturnal metabolism and peripheral glycemia may affect sleep quality. We propose putative mechanisms whereby acute effects of nighttime glucose excursions may lead to increased sleep fragmentation. We conclude that dietary manipulations, particularly with respect to carbohydrate quality, may confer sleep benefits. Future research may seek to evaluate the effectiveness of synergistic nutrient strategies to promote sleep quality, with particular attention to carbohydrate quality, quantity, and availability as well as carbohydrate to protein ratio.

Causal association between sleep traits and the risk of coronary artery disease in patients with diabetes

Background and aims

The association between sleep traits and coronary artery disease (CAD) in patients with diabetes has been reported in previous observational studies. However, whether these potential relationships are causal remains unclear. We aim to assess the causal relationship between sleep traits and CAD in diabetic.

Methods

Genetic instrumental variables associated with five sleep-related traits (insomnia, sleep duration, ease of getting up, morningness and snoring) were extracted from corresponding genome-wide association studies (GWAS). The associations of genetic variants with CAD were based on 15,666 individuals with diabetes (3,968 CAD cases and 11,696 controls). The primary analysis was derived using the inverse variance weighting method. Further sensitivity analysis was conducted to confirm the robustness and consistency of the main results.

Results

Genetic liability to insomnia was significantly related to the increased risk of CAD in individuals with diabetes [odds ratio (OR): 1.163; 95% CI: 1.072-1.254; p = 0.001]. Suggestive evidence was found for the borderline associations between both sleep duration (OR: 0.629; 95% CI: 0.380-1.042, p = 0.072) and snoring (OR: 1.010, 95% CI: 1.000-1.020, p = 0.050) with CAD risk. However, no consistent evidence was found for the association between ease of getting up and morningness with the risk of CAD in diabetic. Similar results can be verified in most sensitivity analyses.

Conclusions

We provide consistent evidence for the causal effect of insomnia on the increased risk of CAD in individuals with diabetes. The management of sleep health should be emphasized to prevent CAD in diabetic patients.

Diet, Lifestyle Behaviours and Other Risk Factors Associated With Type 2 Diabetes Beyond Body Mass Index: A Mendelian Randomization Study

OBJECTIVES

Our aim in this study was to identify promising targets for the prevention of type 2 diabetes in addition to weight loss. We conducted a Mendelian randomization (MR) study to investigate the body mass index (BMI)-independent associations of 16 risk factors, including diet, lifestyle behaviours and others, with type 2 diabetes.

METHODS

We selected genetic variants as instrumental variables for diet, sleep traits, smoking, physical activity, education and blood pressure (BP) from European-descent genome-wide association studies (GWASs). Summary statistics for type 2 diabetes were derived from a recent GWAS with 74,124 European cases and 824,006 European controls. The inverse-variance weighted MR method was used to assess the associations of the risk factors with type 2 diabetes, followed by validation of robustness using different MR methods in sensitivity analyses.

RESULTS

Genetically predicted insomnia (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.06 to 1.15), smoking initiation (OR, 1.14; 95% CI, 1.06 to 1.21), educational level (OR, 0.69; 95% CI, 0.65 to 0.74), hypertension (OR, 6.50; 95% CI, 3.13 to 13.50), systolic BP (OR, 1.02; 95% CI, 1.02 to 1.03) and diastolic BP (OR, 1.03; 95% CI, 1.02 to 1.03) had BMI-independent effects on type 2 diabetes risk. In addition, alcohol dependence (OR, 1.10; 95% CI, 1.05 to 1.16; BMI-adjusted OR, 1.04; 95% CI, 0.98 to 1.09) and vegetarian diet (OR, 0.50; 95% CI, 0.33 to 0.74; BMI-adjusted OR, 0.78; 95% CI, 0.57 to 1.06) appeared to be correlated with type 2 diabetes via a BMI-mediated pathway. Sensitivity analyses further confirmed the relationship between these factors and type 2 diabetes.

CONCLUSIONS

In this systematic MR study, insomnia, smoking, education and BP had BMI-independent causal effects on the risk of type 2 diabetes, whereas alcohol dependence and vegetarian diet were associated with type 2 diabetes through BMI.

The Efficacy and Safety of Zaoren Anshen Capsule in Combination with Zolpidem for Insomnia: A Multicentre, Randomized, Double-Blinded, Placebo-Controlled Trial

Purpose. Insomnia is the most common sleep disorder with high rate of prevalence, persistence, and leads to negative consequences. The mainstays of insomnia treatment have limitations due to either the side effects of hypnotics or limited accessibility to cognitive behavioral therapy. This study aims to compare the efficacy and safety of the traditional Chinese medicine (TCM) Zaoren Anshen capsule alone or as an adjunct treatment with different doses of the nonbenzodiazepine medication zolpidem tartrate in treating insomnia. Method. This randomized, double-blind, multicentre placebo control trial was conducted in 131 patients with chronic insomnia. The patients were randomly assigned to one of the following four regimen groups: Group ZA + Z5 : Zaoren Anshen capsule and 5 mg zolpidem tartrate (n = 32); Group Z5: 5 mg zolpidem tartrate and placebo capsule (n = 35); Group Z10 : 10 mg zolpidem tartrate and placebo capsule (n = 32); Group ZA : Zaoren Anshen capsule and placebo pill (n = 32). The drugs were administered for 4 weeks. All patients were evaluated by the Insomnia Severity Index (ISI) at 0, 2, 4, 5, and 6 weeks, and adverse events were recorded. Result. There are significant differences in the comparison between the four groups at each treatment stage ( $P<0.05$ ). Repeated measurement analysis of variance (ANOVA) of ISI scores in each treatment stage of the four groups exhibits significant differences in time effect, intergroup effect, and interaction effect ( $P<0.05$ ). After four weeks of drug administration, the treatment efficacy is similar in Groups ZA + Z5 and Z10 (93%) and in Groups Z5 and ZA (62% and 65%, respectively). Groups ZA + Z5 and Z10 present significantly lower ISI scores compared with Groups Z5 and ZA ( $P<0.05$ ), which indicates better treatment response of Groups ZA + Z5 and Z10. No significant difference was observed in the incidence of adverse events between the groups. Conclusion. Zaoren Anshen capsule can effectively treat insomnia disorder either alone or in combination with zolpidem tartrate. A preferred combination of TCM Zaoren Anshen capsule with zolpidem can provide a magnified therapeutic efficacy with fewer side effects than zolpidem-only management, clinical trial registration number: Chinese Clinical Trial Registry ChiCTR-IPR-1600969.

The association between subjective-objective discrepancies in sleep duration and mortality in older men

A discrepancy in subjective and objective estimations of sleep duration, which often diverge, could have long-term adverse effects on health outcomes in older adults. Using data from 2674 older adult men (≥ 65 years of age) of the Osteoporotic Fractures in Men Sleep Study, we assessed the longitudinal association between misperception index (MI), calculated as MI = (objective sleep duration - subjective sleep duration)/objective sleep duration, and all-cause mortality. During the follow-up with a mean (standard deviation) of 10.8 (4.2) years, 1596 deaths were observed. As a continuous variable, MI showed a linear relationship with all-cause mortality after adjusting for multiple covariates, including polysomnography-measured objective sleep duration [fully adjusted hazard ratio (HR), 0.69; 95% confidence interval [CI], 0.56-0.84]. As a categorical variable, the lowest MI quartile (vs. the interquartile MI range) was associated with increased mortality (fully adjusted HR, 1.28; 95% CI, 1.12-1.46), whereas the highest MI quartile was not associated with mortality (fully adjusted HR, 0.97; 95% CI, 0.85-1.11). The subjective overestimation of sleep duration may be a risk factor for all-cause mortality in older men. Future studies should examine why subjective overestimation of sleep duration is associated with all-cause mortality from a physiological perspective.

Sleep duration predicts subsequent long-term mortality in patients with type 2 diabetes: a large single-center cohort study

Background

Sleep duration is associated with mortality. However, prior studies exploring whether sleep duration predicts subsequent long-term mortality in patients with diabetes are limited. This study aims to examine whether metabolic factors affect the associations between baseline sleep duration and subsequent risks of all-cause, expanded, and non-expanded cardiovascular disease (CVD) mortalities among patients with type 2 diabetes (T2D).

Methods

A total of 12,526 T2D patients aged 30 years and older, with a follow-up period ≥ 3 years, were identified from the Diabetes Case Management Program of a medical center in Taiwan. Sleep duration was measured using computerized questionnaires by case managers, and the time frame for this question was 1 month prior to the interview date. Sleep duration in relation to subsequent mortality from all causes, expanded CVD, and non-expanded CVD was examined using Cox proportional hazard models.

Results

Within 10 years of follow-up, 2918 deaths (1328 CVD deaths and 1590 non-CVD deaths) were recorded. A J-shaped association was observed for all-cause, expanded CVD, and non-expanded CVD mortalities, and the lowest risks were observed for patients with 5–7 h of sleep. The significant joint effects included sleep duration of more or less than 7 h with age ≥ 65 years [adjusted HRs: 4.00 (3.49–4.60)], diabetes duration ≥ 5 years [1.60 (1.40–1.84)], age at diabetes diagnosis ≤ 45 years [1.69 (1.38–2.07)], insulin use [1.76 (1.54–2.03)], systolic blood pressure/diastolic blood pressure > 130/85 mmHg [1.24 (1.07–1.43)], triglyceride ≥ 150 mg/dL [1.38 (1.22–1.56)], HbA1c ≥ 7% [1.31 (1.13–1.52)], and body mass index < 27 kg/m² [1.31 (1.17–1.45)] for all-cause mortality.

Conclusion

A J-shaped association was observed between sleep duration and all-cause and expanded CVD mortality, and a sleep duration of 5–7 h had the lowest mortality risk. Sleep duration also showed significant synergistic interactions with diabetes duration but shared an antagonistic interaction with age and obesity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01500-0.

Network Mendelian randomization study: exploring the causal pathway from insomnia to type 2 diabetes

INTRODUCTION

Insomnia is a novel pathogen for type 2 diabetes mellitus (T2DM). However, mechanisms linking insomnia and T2DM are poorly understood. In this study, we apply a network Mendelian randomization (MR) framework to determine the causal association between insomnia and T2DM and identify the potential mediators, including overweight (body mass index (BMI), waist-to-hip ratio, and body fat percentage) and glycometabolism (HbA1c, fasting blood glucose, and fasting blood insulin).

RESEARCH DESIGN AND METHODS

We use the MR framework to detect effect estimates of the insomnia-T2DM, insomnia-mediator, and mediator-T2DM associations. A mediator between insomnia and T2DM is established if MR studies in all 3 steps prove causal associations.

RESULTS

In the Inverse variance weighted method, the results show that insomnia will increase the T2DM risk (OR 1.142; 95% CI 1.072 to 1.216; p=0.000), without heterogeneity nor horizontal pleiotropy, strongly suggesting that genetically predicted insomnia has a causal association with T2DM. Besides, our MR analysis provides strong evidence that insomnia is causally associated with BMI and body fat percentage. There is also suggestive evidence of an association between insomnia and the waist-to-hip ratio. At the same time, our results indicate that insomnia is not causally associated with glycometabolism. Higher BMI, waist-to-hip ratio, and body fat percentage levels are strongly associated with increased risk of T2DM.

CONCLUSIONS

Genetically predicted insomnia has a causal association with T2DM. Being overweight (especially BMI and body fat percentage) mediates the causal pathway from insomnia to T2DM.

Insomnia symptoms are associated with an increased risk of type 2 diabetes mellitus among adults aged 50 and older

PURPOSE

To evaluate the association of the different degrees of insomnia symptoms with subsequent incidence of type 2 diabetes mellitus (T2DM).

METHODS

The data were extracted from Health and Retirement Study 2006-2014 waves. The association of insomnia symptoms with T2DM incidence was evaluated by the competing risk model with cumulative incidence function (death was considered a competing event) and Cox proportional hazard model with the Kaplan-Meier method. Population attributable fraction (PAF) was calculated. All analyses related to our study were conducted between November 2020 and January 2021.

RESULTS

A total of 14,112 patients were included in this study, with an average follow-up of 6.4 years, and the incidence density was 17.9 per 1000 person-years. Insomnia symptoms were positively associated with T2DM incidence compared with those with no insomnia symptoms, regardless of competing risk model (≥ 1 symptoms: sub-distribution hazard ratio (SHR) 1.13; 95% confidence interval (CI) 1.02-1.26; P-trend = 0.012) and Cox proportional hazard model (≥ 1 symptoms: hazard ratio (HR) 1.13; 95% CI 1.02-1.26; P-trend = 0.013). The cumulative incidence function (Gray's test, p < 0.001) and Kaplan-Meier estimate (log-rank test, p < 0.001) also presented this positive relationship. This positive association was more apparent in women and participants with ages from 50 to 65 years. The PAF was 4.1% with 95% CI (0.7-7.9%).

CONCLUSIONS

Insomnia symptoms may be an important risk factor for the development of T2DM, which is unbiased by the death competing risk. These findings suggest that management of sleep problems may be an important part of strategies to prevent T2DM.

Effect of Acupuncture on Cognitive Function of Insomnia Patients Compared with Drugs: A Protocol for Meta-analysis and Systematic Review

Insomnia, one of the most common sleep disorders, is thought to have an adverse effect on cognitive function. At the same time, people with cognitive dysfunction are more prone to insomnia. At present, pharmacotherapy is the main treatment for insomnia, but there are some shortcomings such as poor long-term efficacy and potential dependence. There is some evidence that acupuncture has some advantages in alleviating insomnia and improving cognitive function. This study is aimed at investigating the effects of acupuncture and drugs on cognitive function in patients with insomnia and evaluating the efficacy and safety of these two interventions, providing strong evidence for clinical decision-making. The study will retrieve eight major databases: China National Knowledge Infrastructure, Wanfang Database, VIP Database for Chinese Technical Periodicals, SinoMed, PubMed, Web of Science, Embase, and Cochrane Library. Dissertations, conference papers, and ongoing experiments will also be retrieved for supplement. Literature screening and data extraction will be completed by two authors independently (JJ and X-QW). If there were any disagreements, they would be discussed or referred to a third person for adjudication (W-ZW). Authors will use Cochrane risk of bias tool to assess the included studies. The Review Manager Statistical (RevMan) software is used to conduct the statistical process of meta-analysis, and funnel plot is used to evaluate reporting biases. The Grading of Recommendations Assessment Development and Evaluation (GRADE) Profiler can be used to be aware of the quality of evidence.

Understanding insomnia as systemic disease

Sleep plays a critical role in homeostasis of the body and mind. Insomnia is a disease that causes disturbances in the initiation and maintenance of sleep. Insomnia is known to affect not only the sleep process itself but also an individual’s cognitive function and emotional regulation during the daytime. It increases the risk of various neuropsychiatric diseases such as depression, anxiety disorder, and dementia. Although it might appear that insomnia only affects the nervous system, it is also a systemic disease that affects several aspects of the body, such as the cardiovascular, endocrine, and immune systems; therefore, it increases the risk of various diseases such as hypertension, diabetes mellitus, and infection. Insomnia has a wide range of effects on our bodies because sleep is a complex and active process. However, a high proportion of patients with insomnia do not seek treatment, which results in high direct and indirect costs. This is attributed to the disregard of many of the negative effects of insomnia. Therefore, we expect that understanding insomnia as a systemic disease will provide an opportunity to understand the condition better and help prevent secondary impairment due to insomnia.

Relationships of coping styles and psychological distress among patients with insomnia disorder

BACKGROUND

Insomnia appears to be one of the most frequent sleep complaints in the general population. It has significant negative impact on daily functioning. However, there has been little research that described the effect of coping style in insomnia disorder.

METHODS

The Simplified Coping Style Questionnaire (SCSQ) was used to evaluate 79 adult patients with insomnia disorder alongside 80 healthy controls. Additionally, sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), and Symptom Checklist-90-Revised (SCL-90R) was utilized to determine the status of depression, anxiety and other psychological symptoms.

RESULTS

Positive coping style score was significantly lower, whereas negative coping style score and nine symptomatic dimensions of SCL-90R were significantly higher in insomnia patients than in controls. Positive coping style score was adversely related to PSQI score, obsessive-compulsive, depression, anxiety and phobic anxiety, whereas negative coping style score was positively related to PSQI score, somatization and interpersonal sensitivity. Further multiple stepwise regression analysis showed that PSQI total score was independently and positively correlated with negative coping style score.

CONCLUSIONS

Insomniacs use more negative coping styles and less positive ones. Positive coping is adversely associated with insomnia symptoms and psychological distress, whereas negative coping is positively related to those symptoms. And negative coping has a negative effect on sleep quality. we should attach importance to coping styles of insomniacs in clinical practice, which may help to develop more targeted prevention and intervention strategies.

Cost-effectiveness of digital cognitive behavioral therapy (Sleepio) for insomnia: a Markov simulation model in the United States

STUDY OBJECTIVES

To examine the cost-effectiveness and potential net monetary benefit (NMB) of a fully automated digital cognitive behavioral therapy (CBT) intervention for insomnia compared with no insomnia treatment in the United States (US). Similar relative comparisons were made for pharmacotherapy and clinician-delivered CBT (individual and group).

METHODS

We simulated a Markov model of 100,000 individuals using parameters calibrated from the literature including direct (treatment) and indirect costs (e.g. insomnia-related healthcare expenditure and lost workplace productivity). Health utility estimates were converted into quality-adjusted life years (QALYs) and one QALY was worth $50,000. Simulated individuals were randomized equally to one of five arms (digital CBT, pharmacotherapy, individual CBT, group CBT, or no insomnia treatment). Sensitivity was assessed by bootstrapping the calibrated parameters. Cost estimates were expressed in 2019 US dollars.

RESULTS

Digital CBT was cost beneficial when compared with no insomnia treatment and had a positive NMB of $681.06 (per individual over 6 months). Bootstrap sensitivity analysis demonstrated that the NMB was positive in 94.7% of simulations. Relative to other insomnia treatments, digital CBT was the most cost-effective treatment because it generated the smallest incremental cost-effectiveness ratio (-$3,124.73).

CONCLUSIONS

Digital CBT was the most cost-effective insomnia treatment followed by group CBT, pharmacotherapy, and individual CBT. It is financially prudent and beneficial from a societal perspective to utilize automated digital CBT to treat insomnia at a population scale.

Association between Depression, Antidepression Medications, and the Risk of Developing Type 2 Diabetes Mellitus: A Nationwide Population-Based Retrospective Cohort Study in Taiwan

The relationship between depression, antidepressant medications (ADMs), and the risk of subsequent type 2 diabetes mellitus (T2DM) development remains controversial. Thus, we investigated this aspect by a population-based retrospective cohort study using the Longitudinal Health Insurance Database 2000 available in Taiwan. This large, observational study included 46,201 patients with depression and a 1 : 1 age- and sex-matched nondepression cohort enrolled between January 1, 2000, and December 31, 2013, and the newly diagnosed T2DM incidence rates were determined. We estimated the effects of depression on T2DM and the cumulative incidence curves by Cox proportional regression hazard models and Kaplan-Meier methods, respectively. We found that 47.97% of the patients with depression did not receive ADM. Among patients with depression who received ADM, 29.71%, 6.29%, 0.05%, 9.65%, and 6.32% received selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), heterocyclic antidepressants, and other medications, respectively. Patients without ADM treatment had a 39% higher risk of developing T2DM. However, those who received ADM treatment had a significantly lower risk of T2DM development in every treatment category. Depressive disorder treated with ADMs, especially with long-term use, was associated with an 11–48% decrease in the risk of T2DM in all ADM groups; however, heterocyclic antidepressant treatment for shorter periods (<80 days) was not significantly associated with a decreased risk of T2DM. The incidence of T2DM in Taiwan was found to be associated with an a priori history of depression and was inversely correlated with ADM treatment.

Sleep Disturbances and Cognitive Impairment in the Course of Type 2 Diabetes-A Possible Link

There is an increasing number of patients worldwide with sleep disturbances and diabetes. Various sleep disorders, including long or short sleep duration and poor sleep quality of numerous causes, may increase the risk of diabetes. Some symptoms of diabetes, such as painful peripheral neuropathy and nocturia, or associated other sleep disorders, such as sleep breathing disorders or sleep movement disorders, may influence sleep quality and quantity. Both sleep disorders and diabetes may lead to cognitive impairment. The risk of development of cognitive impairment in diabetic patients may be related to vascular and non-vascular and other factors, such as hypoglycemia, hyperglycemia, central insulin resistance, amyloid and tau deposits and other causes. Numerous sleep disorders, e.g., sleep apnea, restless legs syndrome, insomnia, and poor sleep quality are most likely are also associated with cognitive impairment. Adequate functioning of the system of clearance of the brain from toxic substances, such as amyloid β, i.e. glymphatic system, is related to undisturbed sleep and prevents cognitive impairment. In the case of coexistence, sleep disturbances and diabetes either independently lead to and/or mutually aggravate cognitive impairment.

Investigating Causal Relations Between Sleep-Related Traits and Risk of Type 2 Diabetes Mellitus: A Mendelian Randomization Study

Objective

Extensive literature put forward the link between sleep and type 2 diabetes mellitus (T2DM), however, little is known about the underlying causality of the associations. Here we aim to assess the causal relationships between five major sleep-related traits and T2DM.

Design, Setting, and Participants

Two-sample Mendelian randomization (MR) was utilized to investigate the potential causal relations. Independent genetic variants associated with five sleep-related phenotypes—insomnia, sleep duration, short sleep duration, long sleep duration, and morningness—were chosen as instrumental variables to estimate the causal associations with T2DM. Summary statistics were acquired from the genome-wide association studies of UK Biobank and 23andMe (for sleep-related measures), the DIAbetes Genetics Replication And Meta-analysis and the FinnGen (for T2DM).

Main Methods

Individual Cochran’s Q statistic was applied to remove the pleiotropic instruments, global Q statistics and MR-Egger regression were adopted to test for the global heterogeneity and horizontal pleiotropy of the screened instruments, respectively. Two T2DM cohorts were selected to analyze their associations with sleep traits. A modified inverse variance weighted (IVW) estimate was performed to combine the ratio estimators from each instrument and acquire the causal estimate, alternative methods including IVW with first-order weights, simple and weighted median estimations, and MR-Egger regression were conducted as sensitivity analyses, to ensure the robustness and solidity of the findings.

Results

Two-sample MR supported findings for an adverse effect of genetically predicted insomnia on T2DM risk (odds ratio [OR] = 1.14, 95% confidence interval [CI]: 1.09–1.19, p = 1.29E–08) at the Bonferroni-adjusted level of significance (p < 0.005). We further investigated the causal role of T2DM on insomnia but obtained a non-significant estimation. There was also little evidence for the causal effect of other sleep-related measures on T2DM. Results were largely consistent when leveraging two different T2DM cohorts, and were robust among various sensitivity analyses.

Conclusion

Findings provide significant evidence for an adverse effect of insomnia on T2DM risk. The study extends fundamental knowledge to further understanding of the pathophysiological mechanisms of T2DM, and points out the non-negligible role of insomnia on epidemiologic intervention and clinical therapeutics of T2DM.

Association of bedtime with the risk of non-alcoholic fatty liver disease among middle-aged and elderly Chinese adults with pre-diabetes and diabetes

BACKGROUND

Emerging evidence indicated that sleep characteristics may play important roles in the development of metabolic disorders. However, little is known as to the association between bedtime and the risk of non-alcoholic fatty liver disease (NAFLD) in individuals with pre-diabetes and diabetes.

METHODS

In a prospective cohort of 10 375 adults aged ≥40 years, 1960 of 3484 eligible pre-diabetic and diabetic individuals were identified for the current study. NAFLD was diagnosed using liver ultrasonography at baseline and at follow-up. Information on bedtime was obtained at baseline using a standard questionnaire.

RESULTS

We documented 433 incident cases of NAFLD among this study population. In multivariable-adjusted logistic regression model, later bedtime was associated with increased risk of NAFLD (29% increased risk per hour of later bedtime). Compared to individuals with bedtime ≤20:00, the odds ratios (95% confidence intervals) of NAFLD for bedtime of 20:00-22:00 and ≥22:00 were 1.56 (1.04-2.34) and 2.05 (1.31-3.20), respectively. In the subgroup analysis, significant associations were observed among those who were overweight or physically inactive, or those with metabolic syndrome or elevated 10-year risks for atherosclerotic cardiovascular disease. When estimating the joint effect of bedtime and other sleep characteristics, higher risk of incident NAFLD was observed in groups of late bed/early rise, late bed/napping (yes), late bed/bad sleeper, or late bed/shorter sleep durations.

CONCLUSIONS

Later bedtime was significantly associated with an increased risk of incident NAFLD in adults with pre-diabetes and diabetes, underscoring the importance of sleep behaviour management in the prevention of NAFLD.

Sleep disturbances: one of the culprits of obesity-related cardiovascular risk?

Growing evidence suggested that Sleep Disorders (SD) could increase the risk of developing obesity and could contribute to worsen obesity-related cardiovascular risk. Further, obesity per se has been reported to blunt sleep homeostasis. This happens through several mechanisms. First of all, the excessive adipose tissue at neck and chest levels could represent a mechanical obstacle to breathe. Moreover, the visceral adipose tissue is known to release cytokines contributing to low-grade chronic inflammation that could impair the circadian rhythm. Also, nutrition plays an important role in sleep homeostasis. High fat and/or high carbohydrate diets are known to have a negative impact on both sleep quality and duration. In addition, obesity predisposes to a condition called "obstructive sleep apnea" that has a detrimental effect on sleep. SD could increase the risk and/or could contribute to worsen cardiovascular risk usually associated with obesity. The chronic low grade inflammation associated with obesity has been reported to increase the risk of developing hypertension, type 2 diabetes and dyslipidemia. In turn, improving quality of sleep has been reported to improve the management of these cardiovascular risk factors. Thus, the aim of this manuscript is to provide evidence on the association of obesity and SD and on how they could contribute to the risk of developing cardiovascular risk factors such as hypertension, dyslipidemia and type 2 diabetes in obesity.

Efficacy and safety of TCM Yangxin Anshen Therapy for insomnia: A systematic review and meta-analysis

BACKGROUND

Traditional Chinese Medicine (TCM) has gradually drawn the attention of clinicians as an alternative choice for insomniacs and TCM Yangxin Anshen Therapy (TYAT) is a crucial therapy of treating insomniacs. The purpose of this study was to evaluate the efficacy and safety of TYAT for insomnia.

METHODS

Seven electronic databases were searched from inception to July 2019. Two authors independently identified Randomized Controlled Trials (RCTs), extracted data and assessed risk of bias by Cochrane risk bias assessment tool. Comprehensive meta-analysis was conducted with the Review Manager for eligible and appropriate studies.

RESULTS

Fourteen trials (1549 participants) were finally included in this study. The included studies were of moderate-to-high quality. Twelve trials reported the specific methods of random sequence generation, and 4 of them used the allocation concealment. Blinding of participants and personnel were used in 7 studies, and blinding of outcome assessment was performed in 3 studies. The main meta-analysis showed: CONCLUSION:: TYAT is an effective alternative therapy for insomnia, and its clinical application appears safe. The conclusions of this paper have a certain reference value for further research and clinical practice.

TRIAL REGISTRATION NUMBER

PROSPERO CRD 42019135115.

Effect of repetitive transcranial magnetic stimulation (rTMS) for insomnia: a protocol for a systematic review

INTRODUCTION

Repetitive transcranial magnetic stimulation (rTMS), a non-invasive brain stimulation approach, might be a promising technique in the management of insomnia. A systematic review of the available literature on this topic is warranted. The systematic review described in this protocol aims to investigate the efficacy of rTMS as a physical therapy in patients with insomnia.

METHODS AND ANALYSIS

This protocol was developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. We will retrieve relevant literatures across the following electronic bibliographic databases: CENTRAL, PubMed, EMBASE, PsycINFO, CINAHL, PEDro, CBM, CNKI, WANFANG and VIP. A manual search of the reference lists of all relevant articles will be performed for any additional studies. We will include randomised controlled trials published in English and Chinese examining efficacy of rTMS on patients with insomnia. Two reviewers will independently complete the article selection, data extraction and rating. PEDro scale will be used to assess the methodological quality of the included studies. Narrative and quantitative synthesis will be done accordingly.

ETHICS AND DISSEMINATION

Ethical approval will not be required for this review. The results of this review will be disseminated in a peer-review journal.

PROSPERO REGISTRATION NUMBER

CRD42018115033.

The Association Between Sleep Disorders and the Risk of Colorectal Cancer in Patients: A Population-based Nested Case-Control Study

AIM

To investigate the risk of colorectal cancer in patients with sleep disorders.

MATERIALS AND METHODS

We identified 7,355 participants with colorectal cancer between January 1, 2000, and December 31, 2013, from the Longitudinal Health Insurance Database 2005 of the Taiwan National Health Insurance Research Database; 29,420 controls were also identified from the same database based on frequency matching on age, sex, and index date of the cases. Diagnoses of sleep disorders by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) in the cases and controls prior to the index date were assessed. The risk of colorectal cancer in patients with sleep disorders was estimated with multivariate logistic regression analyses.

RESULTS

The mean age of the 36,775 patients was 63.05 years, and 56% of them were males. The risk of colorectal cancer was higher in patients with sleep disorders compared to those without [adjusted odds ratio (OR)=1.29, 95% confidence interval (CI)=1.13-1.47]. The risk of colorectal cancer was higher in patients having sleep disorders with depression compared to those without the condition (adjusted OR=5.69, 95% CI=4.01-6.98).

CONCLUSION

The risk of colorectal cancer in patients with sleep disorders was found to be significantly higher by case-control study and particularly pronounced among those with sleep disorders with depression, exhibiting a joint effect on colorectal cancer risk.

Complementary and Alternative Medicine for the Treatment of Insomnia: An Overview of Scientific Evidence from 2008 to 2018

Insomnia is a widespread sleep disorder in the general population, and it is a risk factor for impaired function, the development of other medical and mental disorders, and causes an increase in health care costs. In view of the health hazards of insomnia and the shortcomings of western medicine, Complementary and Alternative Medicine (CAM) should be considered in the management of insomnia. The present overview reports the potential role of herbal medicine and non-pharmacological therapies in the treatment of insomnia and summarizes the scientific evidence reported from 2008 to 2018. PubMed and Web of Science databases were searched for studies published from 2008 to 2018. 17 randomized controlled trials and 22 non-pharmacological therapies were included in this review, and the results showed that CAM had certain advantages in the treatment of insomnia. The safety of CAM for insomnia was acceptable. Meanwhile, based on pre-clinical trial, the possible mechanisms of CAM for insomnia were modulation of circadian rhythm, GABA receptor activation, antagonisms of 5-HT receptors, inhibition of glutamate-mediated pathways, and attenuation of inflammation. CAM for insomnia has made some progress, but high quality evidence-based medical evidence is still needed to provide guidance for clinical application.

Gender differences in the associations between insomnia and glycemic control in patients with type 2 diabetes: a cross-sectional study

STUDY OBJECTIVES

Insomnia is associated with insulin resistance and type 2 diabetes (T2D) in the general population. However, the associations between insomnia and glycemic control in T2D population are not consistently reported. In this study, we aimed to examine the associations between insomnia and glycemic control, and gender differences in these associations among Hong Kong Chinese patients with T2D.

METHODS

This was a cross-sectional study involving T2D patients recruited from the Hong Kong Diabetes Registry between July 2010 and June 2015. Glycemic control was estimated by fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c). Participants with the Insomnia Severity Index score > 14 were considered as having insomnia.

RESULTS

A total of 3753 patients were recruited. Compared with patients without insomnia, patients with insomnia had higher levels of FPG and HbA1c. After adjustment for potential confounding factors, insomnia was associated with higher FPG and HbA1c in the entire cohort. There were significant interactions between insomnia and gender for FPG (p = 0.001) and HbA1c (p = 0.025) in the full model. Subgroup analyses found that men with insomnia had higher FPG [8.23 (7.85-8.61) mmol/L versus 7.50 (7.39-7.61) mmol/L, p < 0.001] and HbA1c [7.79 (7.57-8.02)% versus 7.45 (7.39-7.52)%, p = 0.005] than men without insomnia after adjusted for confounding factors, whereas such difference was not observed in women.

CONCLUSIONS

T2D patients with insomnia had worse glycemic control than the patients without insomnia. The associations were particularly pronounced in men.

The Epidemiology of Sleep and Diabetes

PURPOSE OF REVIEW

To provide an overview of the mechanistic and epidemiologic evidence linking sleep-related exposures, such as short sleep duration, obstructive sleep apnea, shift work, and insomnia, with type 2 diabetes risk in adults.

RECENT FINDINGS

Both poor sleep habits and sleep disorders are highly prevalent among adults with type 2 diabetes. In observational studies, short sleep duration, obstructive sleep apnea, shift work, and insomnia are all associated with higher risk of incident type 2 diabetes and may predict worse outcomes in those with existing diabetes. However, interventional studies addressing sleep abnormalities in populations with or at high risk for type 2 diabetes are scarce. Although common sleep abnormalities are associated with risk of incident type 2 diabetes and worse prognosis in those with established diabetes, there are few randomized trials evaluating the impact of sleep-focused interventions on diabetes, making it difficult to determine whether the relationship is causal.

Association between insomnia and type 2 diabetes mellitus in Han Chinese individuals in Shandong Province, China

PURPOSE

Diabetes and sleep disorders are public health threats worldwide, but the potential association between them is still unclear.

METHODS

We conducted a community-based cross-sectional study including 5078 participants (2665, 52.5% male) to determine the association between insomnia and diabetes mellitus prevalence.

RESULTS

In patients with type 2 diabetes mellitus (T2DM) and nondiabetic controls, the prevalence of insomnia was 20.2% (68/377) and 12.2% (578/4741), respectively. The results showed that insomnia was associated with T2DM after adjusting for age, sex, BMI, smoking, alcohol consumption, presence of disease history (hypertension, dyslipidemia, stroke, cardiovascular diseases, cancers), and depression (odds ratio [OR] = 1.31, 95% confidence interval [CI] 1.03-1.66). After stratifying by age and sex, insomnia was significantly associated with diabetes mellitus only in the subgroup of middle-aged participants (40-59 years) (OR = 1.61, 95% CI 1.16-2.23) and males (OR = 1.48, 95% CI 1.08-2.03) after controlling for the above covariates.

CONCLUSIONS

This study suggests that insomnia is independently and significantly associated with diabetes mellitus in the northern Chinese population, especially in the 40-59-year-old age group and in males.