Is iatrogenic sleep disturbance worth the effort in Type 1 diabetes?

Identifying the deficiencies of currently available CGM to improve uptake and benefit

BACKGROUND AND AIMS

The use of diabetes technologies is increasing worldwide, with health systems facilitating improved access to devices. Continuous glucose monitoring is a complex intervention that provides information on glucose concentration, rate and direction of change, historical data and alerts and alarms for extremes of glucose. These data do not themselves change glycaemia and require translation to a meaningful action for impact. It is, therefore, crucial that such systems advance to better meet the needs of individuals using them.

METHODS

Narrative review of the use of, engagement with, limitations and unmet needs of continuous glucose monitoring systems.

RESULTS

CGM devices have made a significant contribution to the self-management of diabetes; however, challenges with access and user experience persist, with multiple limitations to uptake and benefit. These limitations include physical size and implementation, with associated stigma, alarm fatigue, sleep disturbance and the challenge of addressing large volumes of real-time data. Greater personalisation throughout the continuous glucose monitoring journey, with a focus on usability, may improve the benefits derived from the device and reduce the burden of self-management. Healthcare professionals may have unconscious biases that affect the provision of continuous glucose monitors due to deprivation, education, age, ethnicity and other characteristics.

CONCLUSIONS

Continuous glucose monitoring exerts a dose-dependent response; the more it is used, the more effective it is. For optimal use, continuous glucose monitors must not just reduce the burden of management in one dimension but facilitate net improvement in all domains of self-management for all users.

Relationship between sleep disturbances, lipid profile and insulin sensitivity in type 1 diabetic patients: a cross-sectional study

Objective The consequences of sleep deprivation in type 1 diabetes (T1D) patients are poorly understood. Our aim was to determine how sleep disorders influence lipid profile and insulin sensitivity in T1D patients. Materials and methods This was a cross-sectional study at a public university hospital. Demographic information and medical histories were obtained during regular scheduled visit of T1D patients to the outpatient clinic. Insulin sensitivity was obtained using the estimated glucose disposal rate (eGDR) formula. Sleep quality was assessed using the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale and Berlin Questionnaire. Results The adult participants (n = 66, 62% women) had a median age of 28.0 years (interquartile range 21.8-33.0). Six patients (9%) had metabolic syndrome according to the International Diabetes Federation criteria. Thirty patients (46%) were considered poor sleepers according to the Pittsburgh Sleep Quality Index. The LDL-c and total cholesterol levels of poor sleepers were higher than those of good sleepers (103 v. 81; p = 0.003 and 178.0 v. 159.5 mg/dL; p = 0.009, respectively). Three patients (4%) were at high risk of obstructive sleep apnea syndrome (OSAS) according to the Berlin Questionnaire. The eGDR was lower in the group of patients with high probability of having OSAS (6.0 v. 9.1 mg.kg-1.min-1;p = .03). Conclusions Poor subjective quality of sleep and higher risk of OSAS were correlated with a worsened lipid profile and decreased insulin sensitivity, respectively. Therefore, T1D patients with sleep disturbances might have an increased cardiovascular risk in the future.

Effect of predicted low suspend pump treatment on improving glycaemic control and quality of sleep in children with type 1 diabetes and their caregivers: the QUEST randomized crossover study

Background

In attempting to achieve optimal metabolic control, the day-to-day management is challenging for a child with type 1 diabetes (T1D) and his family and can have a major negative impact on their quality of life. Augmenting an insulin pump with glucose sensor information leads to improved outcomes: decreased haemoglobin A1c levels, increased time in glucose target and less hypoglycaemia. Fear of nocturnal hypoglycaemia remains pervasive amongst parents, leading to chronic sleep interruption and lack of sleep for the parents and their children.

The QUEST study, an open-label, single-centre randomized crossover study, aims to evaluate the impact on time in target, in hypoglycaemia and hyperglycaemia and the effect on sleep and quality of life in children with T1D, comparing a sensor-augmented pump (SAP) with predictive low glucose suspend and alerts to the use of the same insulin pump with a flash glucose measurement (FGM) device not interacting with the pump.

Methods/design

Subjects meeting the inclusion criteria are randomized to treatment with the SAP or treatment with an insulin pump and independent FGM for 5 weeks. Following a 3-week washout period, the subjects cross over to the other study arm for 5 weeks. During the week before and in the last week of treatment, the subjects and one of their caregivers wear a sleep monitor in order to obtain sleep data. The primary endpoint is the between-arm difference in percentage of time in glucose target during the final 6 days of each treatment arm, measured by a blinded continuous glucose measurement (CGM).

Additional endpoints include comparison of quantity and quality of sleep as well as quality of life perception of the subjects and one of their caregivers in the two different treatment arms.

Recruitment started in February 2017. A total of 36 patients are planned to be randomized. The study recruitment was completed in April 2018.

Discussion

With this study we will provide more information on whether insulin pump treatment combined with more technology (SmartGuard® feature and alerts) leads to better metabolic control. The inclusion of indicators on quality of sleep with less sleep interruption, less lack of sleep and perception of quality of life in both children and their primary caregivers is essential for this study and might help to guide us to further treatment improvement.

Trial registration

ClinicalTrials.gov, NCT03103867. Registered on 6 April 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3034-4) contains supplementary material, which is available to authorized users.

Impact of Chronic Sleep Disturbance for People Living With T1 Diabetes

AIM

The aim was to explore personal experiences and to determine the impact of impaired sleep on well-being and diabetes-related activities/decision making among a cohort of people living with T1D.

METHOD

Adults with T1D over the age of 18 and parents/carers of children with T1D were invited to complete an online questionnaire about their quality and quantity of sleep. Questions included impact of sleep on diabetes-related decision making, effective calculation of bolus doses, important aspects of psychosocial functioning, and frequency of waking. Diasend download data were used to objectively determine frequency of nocturnal blood glucose testing in children.

RESULTS

A total of 258 parent/carer participants (n = 221 female, 85.6%) and 192 adults with T1D (n = 145, 75.5% female, age range 19 to 89 years) took part. In all, 239 parents/carers and 160 adults believed waking in the night has an impact on their usual daily functioning. Of these, 236 parents/carers and 151 (64%) adults reported the impact as negative. Chronic sleep interruption was associated with detrimental impact on mood, work, family relationships, ability to exercise regularly, ability to eat healthily, and happiness.

CONCLUSION

Chronic sleep interruption is highly prevalent in adults with T1D and parents/carers of children with T1D with negative effects on daily functioning and well-being. Appropriate interventions are required to alleviate this burden of T1D, address modifiable risk factors for nocturnal hypoglycemia, and reduce the (perceived) need for nocturnal waking.