Sleep, Skin and Diabetes - Dr. Elizabeth Aguilar Power Point (& collective student's paper)

Sleep and Diabetes

There are two types of diabetes: Type 1 and Type 2. Type 1 diabetes occurs when the body’s immune system attacks and destroys cells in the pancreas responsible for making insulin; consequently, the pancreas ceases to make insulin. It is usually seen in children and adolescents. On the other hand, Type 2 diabetes is more common than type 1, and occurs when the pancreas does not produce enough insulin or does not use insulin well. Type 2 diabetes (T2DM) usually develops in middle-aged to older populations, however, can occur at any age. It is found that individuals with Type 2 diabetes are associated with a higher incidence of sleep disorders, which may be due to diabetes itself, secondary complications, or diabetes-associated comorbidities. Further, higher rates of insomnia, low quality sleep, excessive daytime sleepiness, and higher use of sleeping medications are prominent in the diabetic population. Pain associated with peripheral neuropathy, restless leg syndrome, nocturnal hyper or hypoglycemic episodes, nocturia, and associated depression are all factors that affect sleep quality, and may result in insomnia. Moreover, diabetes affects the central nervous system that in turn, influences neurobehavioral and neurotransmitter functioning, autonomic function, and endocrine function, all of which disturb sleep. Moreover, the reverse also holds true— lack of sleep can increase an individual’s risk of developing type 2 diabetes. According to the American Academy of Sleep Medicine and the Sleep Research Society, it is recommended that adults receive at least 7 hours of sleep per night. Consequences of lack of sleep include increased insulin resistance, difficulty losing weight, increased blood pressure, increased risk of depression and anxiety, and weakened immune system thereby increasing susceptibility to infection.

There is a correlation between individuals who receive less than 5 to 6 hours of sleep a night, those who receive poor sleep quality, and those with excessive sleep (9 hours or more a day) and an increased risk of obesity and T2DM. According to analyzed data from the Massachusetts Male Aging Study, borderline diabetic male patients between 1987-1989 were followed until 2004. Male participants were divided based on how many hours of sleep they received: those who slept less than 5h, 6h, 7h, 8h, and those who slept above 8 hours. It was found that those who slept less than 5 hours a night were twice as likely to develop diabetes and those who slept above 8 hours were thrice as likely to develop diabetes in comparison to those that slept 7 hours a day. Thus, there is a relationship between shorter duration of sleep and excessive amounts of sleep and the risk of diabetes. Likewise, there exists a relationship between interrupted sleep and dysregulation of the neuroendocrine control of appetite. When deprived of sleep, the orexin system becomes hyperactive. Orexin is a neuropeptide responsible for the regulation of arousal, wakefulness, and appetite. Orexin-releasing neurons are most active during the day, and in order to maintain wakefulness, orexin neuropeptides stimulate other neurons to release the neurotransmitters, dopamine serotonin, and norepinephrine, to promote alertness. Overactivity of the orexin system during sleep deprivation results in overfeeding. In addition, circulating levels of ghrelin, a hunger-promoting hormone, increases, while leptin, a satiating-promoting hormone, decreases.

One particular sleep disorder that diabetics experience is obstructive sleep apnea (OSA), and it is prevalent in 23% of T2D populations. In fact, according to the Action for Health in Diabetes (Look AHEAD) trial, the prevalence of sleep-disordered breathing was over 80% in obese, T2D individuals. OSA is characterized by loud snoring, frequent cessation of breathing during sleep, and choking or gasping episodes. As a result of inadequate sleep, an individual experiencing sleep apnea may feel drowsy or sleepy during the daytime, rapid weight gain, and cognitive deficits. Sleep apnea can lead to insulin resistance, hypertension, and cardiovascular disease. Hypoxia and oxidative stress, increased levels of interleukin-6 (an inflammatory marker), overactivity of the sympathetic nervous system, and lipid metabolism dysregulation are OSA-induced processes that increase one’s risk of developing cardiovascular disease.

Promoting and practicing healthy sleeping habits and routines may help ensure a quality night’s rest and improve health outcomes in the prevention of type 2 diabetes or in diabetic patients. It is strongly recommended that individuals go to bed and wake up at the same time every day to maintain consistency. Methods to promote sleep include keeping the bedroom dark and quiet and ensuring that the individual is in a relaxed environment. Removing electronic distractions, such as turning off the TVs and silencing one’s phones are another way to induce sleep. Avoiding nocturnal physical exercise, large evening meals, and caffeine intake at night can ensure that the body is able to wind down and rest.

References

Chattu, Vijay Kumar, et al. “The Interlinked Rising Epidemic of Insufficient Sleep and Diabetes Mellitus.” Healthcare (Basel, Switzerland), 5 Mar. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6473416/.

Khandelwal, Deepak, et al. “Sleep Disorders in Type 2 Diabetes.” Indian Journal of Endocrinology and Metabolism, 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5628550/.

“Sleep for a Good Cause.” Centers for Disease Control and Prevention, 28 July 2022, www.cdc.gov/diabetes/library/features/diabetes-sleep.html.

When people think about diabetes, they often do not consider the many aspects of life that living with diabetes can affect. Studies have been done to determine the association between poor sleep and diabetes. Sleep is an extremely important factor of everyday life and health that has been decreasing throughout the years in the adult population. Insomnia has become more and more prevalent and some trials have been done to look into metabolic effects correlating with sleep restriction. Self-reported sleep times of less than 6 hours a night or 9 or more hours were associated with impaired glucose tolerance and diabetes mellitus. However, older age, greater waist girth, women, and minorities were factors more associated. Hormones like leptin and ghrelin are affected by lack of sleep, and there are hormones that are associated with diabetes because they antagonize the action of insulin and can result in impaired glucose tolerance as well. Hormones like cortisol and insulin are involved in sleep disturbances, pre-diabetes and diabetes, and stress.

It is estimated that half of patients living with diabetes have sleep problems due to hormonal imbalance and unstable blood sugar levels. Both high and low blood sugar during the night can lead to insomnia and next-day fatigue. The symptoms related to these two conditions can cause disruptions during sleep or make sleep next to impossible. In the same way that blood sugar imbalance can affect sleep, poor sleep hygiene can also affect blood sugar levels. Poor sleep can increase blood sugar even in non-diabetics. Sleep deprivation raises levels of ghrelin, the hunger hormone, and decreases levels of leptin, the hormone that makes people feel full. To compensate for lower energy levels, people who sleep poorly may be more likely to seek relief in foods that raise blood sugar and put them at risk of obesity, which is a risk factor for diabetes.

Individuals with diabetes are also more likely to develop sleep apnea or restless legs syndrome. RLS can develop as a result of diabetic neuropathy which can also include numbness, tingling and pain in the extremities. Both of these conditions can make it difficult to fall asleep. Obstructive sleep apnea is common in people who are obese, which is a large population of diabetic patients. Sleep apnea can interfere with slow-wave sleep, but it also periodically cuts off the body’s oxygen supply. The effects can lead to insulin resistance and impaired metabolism of glucose.

Pharmacists can counsel their patients living with diabetes to have good sleep hygiene and good nonpharmacologic efforts to manage their diabetes. This can include adhering to a healthy diet, getting regular exercise, having a sleep schedule, avoiding caffeine or cigarettes especially before bed, and keeping the bedroom a relaxing environment for sleep and relaxation.

Danielle Pacheco. Lack of Sleep and Diabetes. Sleep Foundation, Nov 2020. Retrieved from https://www.sleepfoundation.org/physical-health/lack-of-sleep-and-diabetes#:~:text=It's%20estimated%20that%20one%20in,insomnia%20and%20next%2Dday%20fatigue