dqa focus 2017: sleep and diabetes, an opportunity to treatsleep apnea • sleep apnea and diabetes...

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Sleep and Diabetes, an Opportunity to Treat

Timothy Juergens MD

UW School of Medicine and Public Health, Department of Veterans Affairs‐Madison WI

Objectives

1. Identify impacts of sleep and sleep problems on blood glucose regulation. Include duration of sleep associations.

2. Effects of sleep deprivation on glucose metabolism

3. Discuss adverse effects of diabetes symptoms on sleep.

4. Overlap of primary and comorbid sleep disorders and diabetes, including: SBD, noct movement, pain, nocturia.

5. Identify role and process for optimizing sleep in diabetes management, including factors to address and how, impact of sleep disorders on diabetes care and outcomes, and when to get additional inpt to care.

The TRIUMVIRATE of HEALTH

Health

SLEEP

DIET/NUTRITION

EXERCISE/ACTIVITY

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Normal Adult Sleep

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INSOMNIA/SLEEP DISRUPTION AND CHRONIC MEDICAL CONDITIONS• Diabetes• Depression• Obesity• Heart/Vascular Disease• Congestive Heart Failure• Memory

• COPD (Chronic Obstructive Pulmonary Disorder)

• GI‐Irritable Bowel Syndrome

• Parkinson’s Disease

DIABETES

• Insufficient sleep is linked to an increased risk for the development of Type 2 diabetes.

• Specifically, sleep duration and quality have emerged as predictors of levels of Hemoglobin A1c, an important marker of blood sugar control, representing average blood sugars over time.

• Recent research suggests that optimizing sleep duration and quality may be an important means of improving blood sugar control in persons with Type 2 diabetes.

We are a sleepy country

Less than 7 hrs sleep/n:

1960—15% adults

2000s—40%

Decrease since electricity

Past 40 years decrease further

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How much sleep do we need?

• ~7.5‐8 hours• U shaped curve– problems on either extreme

UPeople reporting consistently sleeping five hours or less per night should be regarded as a higher-risk group for cardiovascular morbidity and mortality; higher odds of having diabetes and insulin resistance

People sleeping nine hours or more per night may represent a useful diagnostic tool for detecting subclinical or undiagnosed comorbidity; higher odds of having diabetes and insulin resistance

Cappucchio et al, 2011, Eur Heart Journal

Effects of Restricted Sleep on Health/Diabetes in Nurses

Rogers, A. 2008 in Patient Safety and Quality: An Evidenced Based Handbook for Nursing 11

Mean (+SE) profiles of glucose and insulin secretion rates (ISR) in a group of 8 normal young men (aged 20–27 yr) studied during a 53-h period including 8 h of nocturnal sleep, followed by 28 h of sleep deprivation including a

period of nocturnal sleep depr...

Karine Spiegel et al. J Appl Physiol 2005;99:2008-2019

©2005 by American Physiological Society

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The first demonstration of a circadian rhythm by Jean Jacques d’Ortous de Mairan in 1729

What other factors?

• Weight is a part of the story.• Sleep loss decreases the hormone leptin, an anorexigenic hormone from adipocytes, and increase in ghrelin (from stomach). –increase appetite

• Other factors likely include:• HPA Axis

• Sympathetic Activity

• Inflammation

• Oxidative Stress

• Adipokine profile (hormone from adiposites‐affect insulin sensitivity)

In type 2 DM patients, sympathetic nerve activity is higher than normal subjects. Anderson et al. reported that acute increase of plasma insulin elevated muscle sympathetic nerve activity (MSNA) in healthy young control. Insulin activates sympathetic nerve activity.

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Figure 8. Putative pathophysiological mechanisms involved in the interactions between obesity, OSA, and hypertension.

Robert Wolk et al. Hypertension. 2003;42:1067-1074

• Chronic sleep loss, whether behavior related (restriction) or sleep disorder related or other, may be a novel risk factor for weight gain, insulin resistance, and type 2 diabetes.

• What is most predictive of disruption of sleep in a person with type 2 diabetes?

Diabetes symptoms impacts on Sleep

• Most predictive of sleep disruption for people with diabetes?

• Nocturia• Pain

• Lamond et el 2000

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Ways sleep gets disrupted in diabetes

• Hyperglycemia

• Polyneuropathy• Cardiovascular disease• Congestive heart failure• Apnea

• Restless leg synd/PLMs• Depression• medications

• Nocturia

• Pain, thermal regulation off• Pain• Central apnea, nocturia• Poor quality/quantity sleep, day sleepiness

• Poor sleep quality• Circadian Rhythms (others too)• Various. Nightmares (b‐blkr), shorter sleep (Ca ch blkrs‐some)

Common primary sleep disorders

• Sleep Apnea• Focus on OBSTRUCTIVE

• ‐decreased/stopped airflow when sleeping, often with subsequent decline in oxygen saturation.

• Can occur many times a night

• AHI= apnea hypopnea index (number of events/hour of sleep).

• RLS/PLMS‐restless leg syndrome, periodic limb movements of sleep

• Strong urge to move legs when they are still, more at night (circadian part), relieved with moving.

• PLMS‐ 0.5 to 10 second long leg movements in sleep, some with associated EEG(brain arousal)

SLEEP APNEA

• Sleep apnea and diabetes are well‐tied, with sleep apnea impairing insulin sensitivity. Additionally often both have obesity as a part.

• Sleep apnea is an independent risk factor for stroke.

• Sleep apnea is tied with some hypertension.

• Sleep apnea and depression are linked, with improvement in mood for some with treatment of comorbid sleep apnea.

• CPAP treatment—role in glucose control and hypertension

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• OSA RISK FACTORS• Obesity• Male• Neck circumference >44 cm• Age• Narrowed airway• Family history• Hypertension• Alcohol or sedatives• Smoking

Figure. Superimposed recordings of the electrooculogram (EOG), electroencephalogram (EEG), electromyogram (EMG), ECG (EKG), sympathetic nerve activity (SNA), respiration (RESP), and blood pressure (BP) during REM sleep

in a patient with OSA. (From Somers et al.14 Copyright © 1995.


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Figure. Recordings of sympathetic nerve activity (SNA) during wakefulness in patients with OSA and matched control subjects showing high levels of SNA in patients with OSA. (From Somers et al. 1995).


POLYSOMNOGRAPHY OF OSA‐ Obstructive Sleep Apnea

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SE = 98%

SE = 63%

AHI = 1.4

AHI = 57.3

OSA ‐ Insomnia

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PERIODIC LIMB MOVEMENTS and RESTLESS LEG SYNDROME• More common with age

• More common if neuropathic injury (such as from diabetes or chronic alcohol use).

• Many medications can worsen (most antidepressants).

• Medical conditions (renal problems‐increased creatinine, low iron, low thyroid can all worsen)

• ‐‐role‐‐‐ can disrupt sleep, decrease sleep quality.

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Link of sleep, diet, diabetes

• Obesity, sleep, stress, diet, and exercise

• One study: if not enough sleep, you wake up with greater hunger

• Proper amounts of sleep and exercise decrease appetite and obesity

• For some people, it’s easier to obtain proper sleep and treat sleep apnea than to diet

• (one of many tools/areas to address in overall diabetes management)

Sleep Apnea & Diabetes

• Sleep Apnea has an independent association for developing glucose intolerance and progressing to diabetes. Treating shows impacts at this stage.

• There are fewer associations shown between glycemic control and OSA in people with established diabetes at moderate level.

• 2 RCT looking at did not bear out with people with moderate elevations in HgA1C.

• Observational uncontrolled studies have shown. • Some details: time CPAP was used in studies, durations, severity of diabetes.

• Sleep deprivation in normal young people leads to looking like a diabetic state

Independent Association Between Obstructive Sleep Apnea Severity and Glycated Hemoglobin in Adults Without Diabetes

• HbA1c measured in whole-blood samples from 2,139 patients undergoing nocturnal recording for suspected OSA

• Participants with self-reported diabetes, use of diabetes medication, or HbA1c value ≥6.5% excluded from study

• Final sample size comprised 1,599 patients

• CONCLUSION: increased OSA severity is independently associated with increased impaired glucose metabolism.

• Oxygen desaturations (#) and duration low also were associated with impaired glucose metabolism.

Priou P et al. Diabetes Care 2012;35:1902-1906

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Results

• Dose‐response relationship observed between apnea‐hypopneaindex (AHI) and the percentage of patients with HbA1c >6.0%, ranging from 10.8% for AHI <5 to 34.2% for AHI ≥50

• After adjusting for age, sex, smoking habits, BMI, waist circumference, cardiovascular morbidity, daytime sleepiness, depression, insomnia, sleep duration, and study site, odds ratios (95% CIs) for HbA1c >6.0% were as follows:

o 1 (reference) for AHI values <5o 1.40 (0.84–2.32) for values 5 to <15o 1.80 (1.19–2.72) for values 15 to <30o 2.02 (1.31–3.14) for values 30 to <50o 2.96 (1.58–5.54) for values ≥50

• Increasing hypoxemia during sleep was independently associated with the odds of HbA1c >6.0%



Obesity

• Obesity, Sleep Apnea promote each other

• Hormonal links: leptin decreases and ghrelin increases hunger, while having opposite effects on sleep (sleep deprivation decreases leptin)

• Unfortunately medical trials with leptin have not been fruitful

• Body is programmed: if not sleeping then eat more, in particular CHO and fat

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Obesity & Sleep Apnea

• Sleep apnea and obesity promote each other

• BMI: Body Mass Index

• Underweight: <19

• Normal : 19 – 24

• Overweight : 25 – 29

• Obese : 30 – 39

• Morbidly Obese: 40 or above

• If obese RISK of Sleep Apnea increases with increased BMI

Obesity and Sleep Deprivation

• Direct link with avoiding sleep and obesity

• Risk of obesity rises with sleep deprivation

• Less than 4 hours : 73% risk

• Five hours : 50% risk

• Six hours : 23% risk

• Less sleep: then lower leptin levels

• Obese persons sleep less

1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2008

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2008

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

CDC

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Prevalence¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011--- change in how measured in 2011.

¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.

Prevalence¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2012



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Prevalence of Self-Reported Obesity Among Hispanic Adults, by State and Territory, BRFSS, 2014-2016


Prevalence of Self-Reported Obesity Among Non-Hispanic Black Adults, by State and Territory, BRFSS, 2014-2016


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Control Sleep Apnea: Better Diabetes Control

• Improve insulin sensitivity

• Lower blood sugars

• Lower HbA1‐c in some populations

• Lower dosages of oral hypoglycemic agents or less medicines

TREATMENT

• Treat underlying condition that may impact sleep.

• Identify and treat primary sleep disorders, especially sleep breathing disorders, as well as limb movement disorders and insomnia.

• Treat diabetes directly at the same time.

• Goal is to end/slow the downward spiral of these various conditions worsening each other. These are BIDIRECTIONAL.

• Pain, nighttime urination, COPD, smoking, alcohol, depression.

Other Interventions

• 1. Work to really strengthen to degree possible the circadiancomponent of sleep at sleep time. Associations/cues too.

• Light exposure timing

• Scheduled timing of social activities/interactions

• Scheduled timing of meals in relation to sleep time

• ?temperature manipulation/?melatonin

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Other Interventions

• 2. To degree possible, increase homeostatic drive to sleep at night (sleep deprivation component we each have each day).

• Timing and duration of daytime naps

• Physical activity

• Mental activity/stimulation/learning• Naps– pros/cons recommendations

• Earlier/shorter

• + Can decrease evening behavioral outbursts

• ‐ Takes off some of sleep debt drive to sleep at night

Good Sleep Hygiene: Basics

• Regular times for sleeping and awakening

• Similar amount of sleep (8hr)/night

• Associate bed with sleep, not other things

• If napping, nap strategically (not too late, not too long)

• Maintain bedroom dark, quiet, comfortable

• Avoid at night: alcohol, caffeine, nicotine

• Exercise

• Diet

Others

• 1. Ensure sufficient opportunity (time) and environment (bed, temperature, noise, light) to sleep.

• 2. consider sleeping well at night as:• Something that occurs when you set everything up for it to ‘happen’ rather than trying to ‘force’ sleep.

• A 24 hour a day issue, not only something to consider once it gets dark.

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Conclusions/Summary

• 1. Sleep disorders and diabetes are very common together.

• 2. People with diabetes endorse more sleep disruption.

• 2. Disrupted sleep adversely affects glucose regulation.• 3. Clinically, disruptions are multifactorial but can include increased arousals/sleep fragmentation, oxygen desaturations/resaturations, and potential circadian components.

• 4. Treatment of sleep disruptions can positively affect symptoms, and also glucose regulation in some. There is more evidence of treatment impacting the development of diabetes, so a worthy place to focus in prevention.

The TRIUMVIRATE of HEALTH

Health

SLEEP

DIET/NUTRITION

EXERCISE/ACTIVITY

dqa focus 2017: sleep and diabetes, an opportunity to treatsleep apnea • sleep apnea and diabetes...

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