Association between excessive daytime sleepiness and severe hypoglycemia in people with type 2 diabetes: the Edinburgh Type 2 Diabetes Study

Effect of fear of hypoglycaemia on sleep quality of patients with type 2 mellitus diabetes: The mediating role of alexithymia

Background

Patients with type 2 diabetes mellitus (T2DM) commonly experience poor sleep quality. This study aimed to investigate whether alexithymia mediates the association between fear of hypoglycaemia (FoH) and sleep quality in patients with T2DM.

Methods

From September 2021 to November 2021, a cross-sectional survey was conducted on 407 patients with T2DM in China. Data collection was made possible through the administration of the Chinese Version of the Worry Scale, Toronto Alexithymia Scale and Chinese version of the Pittsburgh Sleep Quality Index (CPSQI). Multiple linear regression analyses were also performed.

Results

A total of 65.6% of the participants were male, and 75.7% were aged 18-40 years. FoH showed a moderate and positive correlation with CPSQI scores (r = 0.308, p < 0.001). Alexithymia was weakly and positively correlated with CPSQI scores (r = 0.185, p < 0.001). Meanwhile, FoH exhibited a moderate and positive correlation with alexithymia (r = 0.422, p < 0.001), and difficulty in identifying (r = 0.414, p < 0.001) and describing feelings (r = 0.416, p < 0.001) and a weak and positive correlation with externally oriented thinking (r = 0.221, p < 0.001). The total effect (β = 0.408, p < 0.001) of FoH on CPSQI comprised not only the direct (β = 0.293, 95% confidence interval: 0.174-0.411, p < 0.001) but also the indirect effect (β = 0.115, p < 0.001) of alexithymia.

Conclusions

Alexithymia can mediate the association between FoH and sleep quality. Clinicians should recognize the potential effect of alexithymia and incorporate it in intervention planning and care. Addressing the affective disturbances arising from FoH can enhance emotional expression and sleep quality among T2DM patients.

Louis EK, Chahal AA, Schulte PJ, Mansukhani MP, Xie J, Lipford MC, Li N, Ramar K, Caples SM, Gay PC, Olson EJ, Silber MH, Li J, Somers VK. Sex-specific associations between daytime sleepiness, chronic diseases and mortality in obstructive sleep apnea

Objective

Excessive daytime sleepiness (EDS) is common in obstructive sleep apnea (OSA) and has been linked to adverse outcomes, albeit inconsistently. Furthermore, whether the prognostic impact of EDS differs as a function of sex is unclear. We aimed to assess the associations between EDS and chronic diseases and mortality in men and women with OSA.

Methods

Newly-diagnosed adult OSA patients who underwent sleep evaluation at Mayo Clinic between November 2009 and April 2017 and completed the Epworth Sleepiness Scale (ESS) for assessment of perceived sleepiness (N = 14,823) were included. Multivariable-adjusted regression models were used to investigate the relationships between sleepiness, with ESS modeled as a binary (ESS > 10) and as a continuous variable, and chronic diseases and all-cause mortality.

Results

In cross-sectional analysis, ESS > 10 was independently associated with lower risk of hypertension in male OSA patients (odds ratio [OR], 95% confidence interval [CI]: 0.76, 0.69-0.83) and with higher risk of diabetes mellitus in both OSA men (OR, 1.17, 95% CI 1.05-1.31) and women (OR 1.26, 95% CI 1.10-1.45). Sex-specific curvilinear relations between ESS score and depression and cancer were noted. After a median 6.2 (4.5-8.1) years of follow-up, the hazard ratio for all-cause death in OSA women with ESS > 10 compared to those with ESS ≤ 10 was 1.24 (95% CI 1.05-1.47), after adjusting for demographics, sleep characteristics and comorbidities at baseline. In men, sleepiness was not associated with mortality.

Conclusion

The implications of EDS for morbidity and mortality risk in OSA are sex-dependent, with hypersomnolence being independently associated with greater vulnerability to premature death only in female patients. Efforts to mitigate mortality risk and restore daytime vigilance in women with OSA should be prioritized.

The association between Diabetes and Excessive Daytime Sleepiness among American adults aged 20-79 years: Findings from the 2015-2018 National Health and Nutrition Examination Surveys

PURPOSE

To examine the association between diabetes and EDS.

METHODS

Using the 2015-2018 cycles of the National Health and Nutrition Examination Survey, we applied survey-featured modified Poisson regression to estimate the association between diabetes and EDS among American adults aged 20-79 years, adjusting for confounding demographic, clinical and lifestyle variables. Effect modification by age, sex, race, education, income, sleep apnea and inadequate sleep was assessed. We performed sensitivity analyses using propensity score matched (PS) data and applied ordinal logistic regression using multiple levels of daytime sleepiness. Among people with diabetes, we assessed the association between EDS and diabetes-care variables.

RESULTS

Of the 6,289 participants, 895 (10%) had diabetes. The estimated prevalence of EDS was higher among adults with diabetes (30.6%) than counterparts without diabetes (26.3%). After adjusting for confounding variables, diabetes remained associated with EDS (aPR:1.20; 95%CI:1.06 1.36). There was no statistically significant effect modification. Sensitivity analyses confirmed our main results. Among people with diabetes, there was limited evidence that the diabetes-care variables were related to EDS.

CONCLUSIONS

Among American adults, diabetes is associated with EDS after controlling for confounding variables. Although the cross-sectional design is a limitation, our findings support further exploration of the role of diabetes in EDS.

Can a sleep disorder intervention-embedded self-management programme contribute to improve management of diabetes? A pilot single-arm pretest and post-test study

OBJECTIVE

To investigate the efficacy and feasibility of a self-management programme incorporating a sleep intervention for improving diabetes outcomes.

DESIGN

A single-arm pre-test and post-test study was conducted within a community setting in Hiroshima, Japan.

PARTICIPANTS

Participants were aged 52-74 years and diagnosed with type 2 diabetic nephropathy stages 1-3.

INTERVENTIONS

Participants received self-management education from nurses for 6 months. First, the nurses assessed their sleep conditions using insomnia scales and a sleep metre. Then, the participants learnt self-management to increase their physical activity and improve their sleep condition. They also implemented diet therapy and medication adherence.

OUTCOME MEASURES

Physiological indicators, subjective and objective indicators of sleep quality, self-management indicators, quality of life (QOL) and feasibility were evaluated. To confirm the efficacy of intervention, Freidman tests, analysis of variance, Wilcoxon signed-rank test and t-test were performed. Pearson's correlations were analysed between activities and sleep condition.

RESULTS

Of the 26 enrolled participants, 24 completed the programme and were analysed. Among them, 15 participants (62.5%) had sleep disorders caused by multiple factors, such as an inappropriate lifestyle and physical factors that interfere with good sleep. Although insomnia scales did not change for the sleep disorders, their subjective health status improved. Regarding indicators related to diabetes management, lifestyles improved significantly. Haemoglobin A1c, body mass index, systolic blood pressure, non-high-density lipoprotein-cholesterol and QOL also improved. All participants except one were satisfied with the programme. However, use of the sleep metre and nurses' consultation about sleep disturbance were not well evaluated.

CONCLUSIONS

This programme was effective in improving diabetes status, lifestyle and behaviour changes. However, its effect on sleep condition was limited because of its complexity. A simple and novel approach is needed to strengthen the motivation for sleep behaviour change and to increase programme efficacy and feasibility.

TRIAL REGISTRATION NUMBER

UMIN000025906.

Sleep Disorders in Pregnancy, Influencing Factors and Quality of Life

AIM

In our study, the frequency of sleep disturbances in pregnancy, the reasons underlying the low quality of sleep, clinical factors, and the effects on quality of life were investigated.

METHODS

The study was planned as a prospective study and included 189 pregnant women. Clinical features, laboratory results, socio-demographic status, obstetric and medical anamnesis were evaluated. The Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, the Berlin Questionnaire, Beck Depression Inventory, SF-36 quality-of-life questionnaire, and restless leg syndrome (RLS) diagnosis criteria were used for data collection.

RESULTS

We investigated sleep disorders in 110 pregnant women (58.2%). A history of premenstrual syndrome and patients with hyperemesis gravidarum, obstructive sleep apnea syndrome, Vitamin B12 deficiency, and higher TSH levels in the laboratory were found to be associated with sleep disorders. Sleep disorders and daytime sleepiness were associated with depression, physical and social functioning, pain, and disturbance in general health perception. The number of pregnant women who had two or more RLS complaints was 84 (44%).

CONCLUSION

The results of our study show that sleep disorders in pregnancy can be managed with easily applicable methods according to the risk factors and related problems.

Predicting and preventing diabetes: Translational potential of Ayurveda information on pre-diabetes

Continued rise in incidence and prevalence of diabetes globally warrants an effective strategy for its prevention and control. Prevention of diabetes seems more logical to attempt seeing its health care burden, long dormancy, systemic affliction and poor general awareness.

Pre-diabetes is the intermediate state of erratic glucose metabolism without overt features of diabetes. This state seems to be a crossroad having a possibility to either convert into clinical diabetes, remain dormant or return to normal glucose control depending upon the efforts made. Unfortunately, due to the paucity of apparent clinical symptoms, this state embedded with reversal possibility, remains unexplored. Ayurveda account of prameha purvarupa (subclinical features of diabetes) may be proposed as the foundation upon which clinic-based pre-diabetes identification and subsequent prevention may be explored. Knowing the symptoms for their reliable proximity with upcoming diabetes may turn to be sensible sensitizers prompting the people to abort the disease process in an effective and timely manner. Considering diabetes from its purvarupa to complications as disease continuum and exploring the opportunities to intervene in order to prevent, or manage the disease on the basis of shada kriyaa kaala therefore, has a huge translational potential warrants an urgent exploration.

Excessive daytime sleepiness and its impact on quality of life in de novo Parkinson's disease

Excessive daytime sleepiness (EDS) is one of the most common sleep problems in patients with Parkinson's disease (PD); however, its clinical implications are not clear, especially in early stage, non-medicated PD patients. This study investigated EDS in Korean patients with de novo PD and its impact on quality of life. This cross-sectional study was carried out with 198 PD patients who underwent a structured clinical interview and examination based on common and conventional scales. Motor and nonmotor symptoms were assessed by the Unified Parkinson's Disease Rating Scale (UPDRS) and Non-Motor Symptoms Scale (NMSS). EDS was evaluated with the Epworth Sleepiness Scale (ESS), the nocturnal disabilities and nighttime sleep problems were assessed with Parkinson's Disease Sleep Scale 2nd version, and quality of life was measured with the Parkinson's Disease Quality of Life 39 (PDQ-39). The relationships between ESS score and each scale were investigated. Among the patients studied, 42 patients had EDS defined as ESS > 10. Patients with EDS had a higher motor burden, greater nocturnal disabilities, more severe non-motor symptoms, and lower quality of life than did patients without EDS. Partial correlations revealed that ESS score was related to PDQ-39 summary index, irrespective of age, body mass index, or disease duration. These results show that EDS can have an immense negative impact on quality of life. The causes of EDS are multifactorial, which complicates its treatment. Further investigations are required to determine the safety and efficacy of potential EDS therapies and to develop novel EDS treatments in PD.

Relationship between depression, sleep quality, and hypoglycemia among persons with type 2 diabetes

Objective

We analyzed two cohorts of people with type 2 diabetes to evaluate the relationships between depression, sleep quality, and history of hypoglycemia.

Research design and methods

Two adult cohorts from Chicago (n = 193) and Bangkok, Thailand (n = 282) with type 2 diabetes completed questionnaires to assess sleep quality, depressive symptoms, and hypoglycemia frequency. Proportional odds logistic regression models for each cohort adjusted for duration of therapy, insulin and sulfonylurea management, and other factors.

Results

Those with hypoglycemia in both cohorts had a longer duration of diabetes, greater use of insulin, and worse sleep quality. The Chicago cohort used less sulfonylureas but had higher depressive symptom scores. The Thailand cohort had greater sulfonylurea use. In the final Thailand regression model, depressive symptoms were independently associated with hypoglycemia frequency. In both final Chicago and Thailand models, sleep quality was not associated with hypoglycemia frequency.

Conclusions

In the Thailand cohort, depressive symptoms were associated with hypoglycemia frequency.

Risk factors for unstable blood glucose level: integrative review of the risk factors related to the nursing diagnosis

Objective

to identify evidence in the literature on the possible risk factors for the risk of unstable blood glucose diagnosis in individuals with type 2 diabetes mellitus, and to compare them with the risk factors described by NANDA International.

Method

an integrative literature review guided by the question: what are the risk factors for unstable blood glucose level in people with type 2 diabetes mellitus? Primary studies were included whose outcomes were variations in glycemic levels, published in English, Portuguese or Spanish, in PubMed or CINAHL between 2010 and 2015.

Results

altered levels of glycated hemoglobin, body mass index>31 kg/m2, previous history of hypoglycemia, cognitive deficit/dementia, autonomic cardiovascular neuropathy, comorbidities and weight loss corresponded to risk factors described in NANDA International. Other risk factors identified were: advanced age, black skin color, longer length of diabetes diagnosis, daytime sleepiness, macroalbuminuria, genetic polymorphisms, insulin therapy, use of oral antidiabetics, and use of metoclopramide, inadequate physical activity and low fasting glycemia.

Conclusions

risk factors for the diagnosis, risk for unstable blood glucose level, for persons with type 2 diabetes mellitus were identified, and 42% of them corresponded to those of NANDA International. These findings may contribute to the practice of clinical nurses in preventing the deleterious effects of glycemic variation.

Non-linear associations of risk factors with mild hypoglycemia among Chinese patients with type 2 diabetes

AIMS

The present study aimed to examine the nonlinear associations between risk factors and mild hypoglycemia in Chinese patients with type 2 diabetes mellitus (T2DM).

METHODS

From May 2013 to August 2013, we conducted a cross sectional survey of 6633 inpatients with T2DM and without severe hypoglycemia, aged 21-77 years, from 81 top tertiary hospitals in China. Mild hypoglycemia was defined as having hypoglycemia with symptoms in one month. Binary logistic regression analysis with restricted cubic splines was used to estimate odds ratio curves of non-linear risk factors for mild hypoglycemia.

RESULTS

Increasing body mass index was associated with decreasing risk of mild hypoglycemia in a linear manner while age, duration of diabetes, glycated hemoglobin (HbA1c), mean artery pressure and lipids were associated with mild hypoglycemia in non-linear manners. Age ≥40 years, duration ≥2 years, HbA1c ≥7.0-<11.5% (≥53-<102 mmol/mol), triglyceride ≥1.7-<3.6 mmol/L, low-density lipoprotein cholesterol (LDL-C) ≥2.6-<4.8 mmol/L, and high-density lipoprotein cholesterol (HDL-C) ≥1.2-<4.8 mmol/L were associated with increased risks of mild hypoglycemia.

CONCLUSIONS

Chinese T2DM patients with age≥40 years, duration of diabetes ≥2-<6 years, HbA1c ≥7.0-<11.5% (≥53-<102 mmol/mol), LDL-C ≥2.6-<4.8mmol/L, HDL-C ≥1.2-<4.8 mmol/L or triglyceride ≥1.7-<3.6 mmol/L were at particularly high risk for mild hypoglycemia.

An association between liraglutide treatment and reduction in excessive daytime sleepiness in obese subjects with type 2 diabetes

BACKGROUND

The main purpose of the present study is to evaluate whether treatment with long-acting human glucagon-like peptide-1 liraglutide was associated with an improvement of excessive daytime sleepiness (EDS) in obese subjects with type-2 diabetes.

METHODS

This single-centre retrospective study included 158 obese (body mass index [BMI] ≥ 30 kg/m(2)) adult subjects with type-2 diabetes who were initiated with liraglutide treatment at least 3 months before study inclusion. Data of the Epworth Sleepiness Scale (ESS), anthropometric parameters, glucose-control and metabolic parameters were collected at liraglutide initiation (baseline) and at months 1 and 3 after liraglutide initiation.

RESULTS

Significant reductions in ESS score were achieved at months 1 (-1.3 ± 2.8, p < 0.001) and 3 (-1.5 ± 3.0, p < 0.001) after liraglutide introduction. After 3 months of treatment with liraglutide, significant changes in body weight (p < 0.001), BMI (p < 0.001), waist (p < 0.001) and neck circumferences (p < 0.005), HbA1c (p < 0.001), mean blood glucose (p < 0.001), fasting plasma glucose (p < 0.001), triglycerides (p < 0.01) and total cholesterol (p < 0.001) were achieved.

CONCLUSIONS

After 3 months of treatment with liraglutide a significant reduction in EDS was observed in obese subjects with type-2 diabetes. Besides this, significant changes in body weight and metabolic parameters of diabetes control were also accomplished. Further investigation is required to determine whether liraglutide could improve other abnormal sleep patterns and obstructive sleep apnoea.

Prevalence of self-reported sleep duration and sleep habits in type 2 diabetes patients in South Trinidad

The present study aims to determine the prevalence of self-reported sleep duration and sleep habits and their associated factors in patients with type 2 diabetes in Trinidad. This was a cross-sectional multicenter study. There were 291 patients with type 2 diabetes studied. Sleep habits were assessed using the Epworth Sleepiness Scale (ESS) and the National Health and Nutrition Examination Survey sleep disorder questionnaire. Demographic, anthropometric and biochemical data were also collected. The sample had a mean age of 58.8 years; 66.7% were female. The mean BMI was 28.9 kg/m(2). The prevalence of Excessive Daytime Sleepiness (EDS) was 11.3%. The prevalence of patients with short sleep (⩽6h) was 28.5%. The prevalence of patients with poor sleep was 63.9%. Poor sleep was associated with age, intensive anti-diabetic treatment and longer duration of diabetes. Short sleep was associated with intensive anti-diabetic treatment and BMI, while EDS was associated with increased BMI. In a sample of patients with type 2 diabetes, a high prevalence of self-reported sleep duration and unhealthy sleep habits was found. There needs to be an increased awareness of sleep conditions in adults with type 2 diabetes by doctors caring for these patients.

Sleep Optimization and Diabetes Control: A Review of the Literature

Pre-diabetes and diabetes occur secondary to a constellation of pathophysiological abnormalities that culminate in insulin resistance, which results in reduced cellular glucose uptake and increased glucose production. Although pre-diabetes and diabetes have a strong genetic basis, they are largely environmentally driven through lifestyle factors. Traditional lifestyle factors such as diet and physical activity do not fully explain the dramatic rise in the incidence and prevalence of diabetes mellitus. Sleep has emerged as an additional lifestyle behavior, important for metabolic health and energy homeostasis. In this article, we review the current evidence surrounding the sleep-diabetes association.

The Impact of Nocturnal Hypoglycemia on Sleep in Subjects With Type 2 Diabetes

OBJECTIVE

The aim of this trial was to investigate the impact of nocturnal hypoglycemia on sleep patterns (assessed by polysomnography) and counterregulatory hormones.

RESEARCH DESIGN AND METHODS

In this single-blinded, crossover trial, 26 subjects with type 2 diabetes attended two experimental night visits (one normoglycemic and one hypoglycemic) in randomized order. Plasma glucose (PG) levels were controlled by hyperinsulinemic glucose clamping. On the hypoglycemic night, hypoglycemia was induced after reaching sleep stage N2 by turning off glucose infusion until the PG target of 2.7-2.8 mmol/L was reached and maintained for 15 min. Thereafter, subjects were brought back to normoglycemia for the rest of the night. On the normoglycemic night, PG was maintained at 5.0-7.0 mmol/L throughout the night.

RESULTS

During the first 4 h of sleep (0-4 h; after reaching sleep stage N2), no difference between experimental nights was observed in the rate of electroencephalography-identified arousals or awakenings, but the rate of awakenings was 27% lower during 4-8 h and 20% lower during 0-8 h on the hypoglycemic night than on the normoglycemic night (both statistically significant). Total sleep time tended to be longer on the hypoglycemic night (observed means 366 vs. 349 min, P nonsignificant). Statistically significantly higher counterregulatory hormonal responses (adrenaline, growth hormone, and cortisol) to hypoglycemia were observed compared with normoglycemia.

CONCLUSIONS

Nocturnal hypoglycemia in patients with type 2 diabetes caused a decrease in awakening response in the 4-8-h period following the event. These findings underscore the risks associated with nocturnal hypoglycemia because nocturnal hypoglycemia potentially affects the patient's ability to wake up and respond with an adequate intake of carbohydrates.

Hypoglycaemic episodes in patients with type 2 diabetes--risk factors and associations with patient-reported outcomes: The PANORAMA Study

AIM

To explore the frequency of hypoglycaemic episodes, their risk factors, and associations with patient-reported outcomes in patients with type 2 diabetes enrolled in the PANORAMA cross-sectional study.

METHODS

Five thousand seven hundred and eighty-three patients aged ≥ 40 years with type 2 diabetes duration ≥ 1 year were recruited in nine European countries. Patients reported severe and non-severe hypoglycaemic episodes during the past year at a single study visit. Patient-reported outcomes were measured by the Audit of Diabetes-Dependent Quality of Life, Diabetes Treatment Satisfaction Questionnaires, Hypoglycaemia Fear Survey-II, and EQ-5D Visual Analog Scale.

RESULTS

During the previous year, 4.4% of the patients experienced ≥ 1 severe hypoglycaemic episode; among those without severe hypoglycaemia, 15.7% experienced ≥ 1 non-severe episode. Patients experiencing any hypoglycaemic episode reported a greater negative impact of diabetes on quality of life, greater fear of hypoglycaemia, less treatment satisfaction and worse health status than those with no episodes. In multivariate analyses hypoglycaemia was significantly associated with longer diabetes duration; presence of microvascular and, to a lesser extent, macrovascular complications; treatment with insulin, glinides or sulfonylureas; and use of self-monitoring blood glucose.

CONCLUSION

In patients with type 2 diabetes, severe hypoglycaemic episodes were not uncommon and one in five experienced some form of hypoglycaemia during the previous year. Hypoglycaemia was associated with more negative patient-reported outcomes. The risk of hypoglycaemia increased with diabetes duration, presence of diabetes-related complications, use of self-monitoring blood glucose, insulin secretagogues, and insulin treatment.