According to a systemic review of sleep and diabetes outcomes from Diabetes Clinical 2020 Practice, “the prevalence of sleep disorders in adults with diabetes was estimated to be 52%”. This means that more than half of the adults with diabetes suffer from some type of sleep disorder. People with out of control blood sugars in type 2 diabetes experience overall negative sleep patterns. People with diabetes often have difficulty falling and staying asleep. Changing blood sugar levels can cause awakenings during your sleep. Sleep is a basic human need, and it has a strong effect on your physical and mental health.
Dr. Mark Heyman, PhD, Psychologist and ADCES (Diabetes Care and Education Specialist) at The Diabetes and Mental Health Center in California states, “It is very common for people with diabetes to report poor sleep quality. In my experience as a medical person, it is not something we talk about enough or assess enough in people who have diabetes.” Sleep disorders lead to interrupted sleep and eventually can have a negative effect on your blood sugars.
The other side of the equation is unstable, uncontrolled blood glucose levels that are seen with diabetes that can lead to sleep disorders. WebMD notes, “Diabetes is often paired with poor sleeping habits whether it is trying to fall asleep or staying asleep.” Too much sleep or too little sleep is a known factor in making chronic diseases like diabetes and heart disease even worse. Sleep disorders can lead to hypertension, insulin resistance, weight gain, psychological problems including moodiness, anxiety, depression and just being cranky.
What is considered good sleep? Good sleep means “you fall asleep within 30 minutes of hitting the pillow, wake up once or less during the night, feel satisfied with your sleep, spend 85% or more of total sleep in bed and feel rested and alert in the morning”.
What may be the cause of your Sleep Problems?
Sleep is “a cycle of light sleep, slow-wave sleep and REM (rapid eye movement sleep). It occurs in 3-5 cycles per night depending on your age and you, specifically. When the cycle is disrupted, you end up with non-restful sleep and increased fatigue the next day. What is poor sleep? Poor sleep is classified as: “Sleeping less than 6 hours, or more than 10 hours, taking 45 minutes or longer to fall asleep and waking up 3 or more times a night”. These all lead to poor sleep quality nights. Sleep problems are not the same as sleep disorders, but they are connected. Sleep problems are even more common than documented sleep disorders.
Things that create Sleep Problems
- Dementia. Dementia is caused by various forms of brain deterioration occurring more frequently as we age. Aging causes changes in your sleep patterns, sleep needs and quality of your sleep but adding dementia makes restful sleep even more challenging. Medications used for dementia are a possible reason for worse sleep. “Up to 70% of people with cognitive decline impairment or dementia have sleep disturbances.” You may have trouble falling asleep and staying asleep. A specific dementia known as Alzheimer’s can also cause “sundown syndrome”. Sundown syndrome occurs in the evening as the sun starts to set and into the night. This creates more agitation, aggression and anxiety for the patient leading to an inability to fall or stay asleep.
- Pain. Pain is “an unpleasant sensation that we experience when nerve receptors send a signal to the brain telling us something is wrong.” 1 in 5 Americans suffer with chronic pain. Chronic pain can come from peripheral neuropathy in diabetes, rheumatoid arthritis, osteo-arthritis, multiple sclerosis and fibromyalgia. These conditions make it difficult to fall asleep and stay asleep due to the continuous pain cycle. Most of the time your sleep is light and often interrupted. Pain sensitivity increases with bad quality of sleep. Restful sleep can often lessen the daily pain you experience. Chronic pain needs to be treated to regain good sleep.
- Nocturnal Hypoglycemia. Hypoglycemia or low blood sugar can happen anytime of the day but is even more frightening during the night. It is a common cause of the sleep disorder called insomnia. Nocturnal hypoglycemia usually happens to people with diabetes who take insulin but can also occur if you take certain diabetes pills. When your blood sugar drops, your body releases hormones to try to regulate your blood sugars. These hormones tell your brain it is time to eat, so hopefully you wake up. Some common reasons for nocturnal hypoglycemia are:
- Drinking too much alcohol
- Too much daily exercise
- Exercising too close to bedtime
- Taking too much long-acting insulin (basal)
- Skipping dinner
- Skipping bedtime snack
- Deleting carbohydrates at meals or snacks
Low blood sugars during the night can cause screaming, yelling, crying and nightmares during sleep called night terrors. You may wake up drenched in sweat, tired, with a headache, irritable, confused and with a lack of coordination. Discuss this with your health care provider, immediately.
Elevated Blood Sugars
Out of control blood sugars create an elevation in the hormone cortisol, which makes it more difficult to sleep. Lack of decent sleep reduces insulin sensitivity even more creating rebounding high blood sugars. High glucose levels cause inflammation in your body, causing systemic pain and more sleep problems. High blood sugars cause you to urinate more frequently during the night to rid the body of glucose but also disrupts your sleep.
Stress, anxiety and bipolar disorder prevent the brain from shutting off and puts you on a heightened state of alertness while increasing the chance of fragmented and disturbed sleep. It also prevents you from entering deep sleep. You never enter the normal cycles of sleep and rarely feel rested.
Jet lag and shift work plague the operation of our internal clocks. Light exposure and changing time zones are the cause. They confuse your regular sleep cycle making you either too sleepy or unable to sleep at all.
Day time sleepiness happens when you need to take certain Parkinson’s medications. You end up with a poor night’s sleep since your circadian rhythm is affected by brain changes. More than ever your body needs rest and restorative sleep. This cycle needs to be broken for better rest.
If you drink too many fluids or eat a heavy meal before sleep, you will generally experience sleep problems. Add caffeine or alcohol and restful sleep will become impossible. Coffee, tea or chocolate will have the same negative affect since they are all stimulants. High fat foods are difficult to digest prior to sleep. Large dinners or hardy bedtime snacks will cause sleep problems.
Diet pills, opioids, beta blockers and diuretics for blood pressure control, cold medications, decongestants and anti-depressants can affect sleep cycles. Steroids given for breathing problems, pain or inflammation can also prevent you from getting a good night of sleep. Even nicotine from cigarettes will raise heart rates and blood pressure making good sleep difficult.
Allergies, Asthma and Breathing Problems
All these conditions can lead to night- time nasal congestion, sneezing, coughing, shortness of breath, and wheezing problems with the end result of poor sleep. Things like mold, dust mites and animal dander can irritate the lining of your lungs. Strong cleaning products cause lung irritation. Antihistamines and decongestants will stimulate your heart rate and cause sleep loss. Sleep loss increases inflammation and may create more lung damage and irritation.
Irregular Sleep Schedule
According to The Sleep Foundation, “Fluctuating amounts of sleep, irregular bedtimes and wake up times put people at risk for obesity, diabetes and hypertension.” Irregular sleep cycles and patterns elevate blood sugars even in those people without diabetes. Good sleep hygiene with a regular evening schedule helps your body know what and when to expect sleep.
Recognized Sleep Disorders
According to The American Psychiatric Association, “sleep disorders involve problems with the quality, timing and total amount of sleep which results in daytime distress and impairment in functioning.” They are documented disorders. More than 70 million Americans suffer from sleep disorders. It affects women more than men. There are over 80 different types of sleep disorders according to the Cleveland Clinic. Getting an official diagnosis from a sleep physician and sleep center can be most helpful in your treatment. You will be required to do a sleep study test which can be done in a sleep facility or the comfort of your own home. People with diabetes are mostly affected with the following sleep disorders: insomnia, restless leg syndrome and obstructive sleep apnea/bruxism.
Almost 1/3 of adults suffer with insomnia. Common similarities in having insomnia are being a woman, being over 60, having a mental or physical condition or having no regular sleep schedule. Many of the sleep problems listed above can eventually cause insomnia. Short-term insomnia may be created by shift work, a stressful life event, an acute illness or jet lag. Chronic insomnia is when you have a hard time falling asleep or staying asleep for at least one month. Symptoms include: not sleeping even when you are tired or exhausted, never feeling refreshed or alert when you get up in the morning, experiencing restless and interrupted sleep or you constantly wake up too early and can’t fall back to sleep.
Obstructive Sleep Apnea (OAS)
Obstructive sleep apnea is a very common sleep disorder in people with diabetes. It can be quite serious since your airway becomes blocked and you can stop breathing. You periodically stop breathing for only a few seconds. The soft tissue in the back of your throat collapses and closes your airway. Symptoms include:
- Loud snoring
- Waking up during the night with a dry throat
- Waking up and gasping for air or choking
- Feeling fatigued, irritable and unrested the next morning
- Frequently falling asleep during the day
- Spouse or partner hearing you stop breathing regularly during the night
Sleep apnea is common in menopausal women due to hormonal changes. It is found in 2/3 of men over 65 who have diabetes. Sleep apnea can worsen existing diabetes and increase the risk of developing diabetes. It makes the heart work harder on less oxygen and increases your risk of coronary heart disease. Sleep apnea can be brought on by obesity, fat deposits around the upper airway, smoking, too much alcohol, nasal congestion and narrow nasal passages. Sleep apnea can affect the quality of your life.
Simple, helpful measures for mild obstructive sleep apnea are losing 5-10% of your body weight and sleeping on your side. Health care providers who treat people with diabetes should be aware and well-versed in obstructive sleep apnea. Once treated, your diabetes will become better controlled. True sleep apnea will require wearing a device called a CPAP through the night. CPAP masks have been updated and are no longer so burdensome. There are other appliances such as mouth guards or surgery if CPAP does not work or can’t be tolerated.
Narcolepsy or sleep paralysis, is a genetic disorder, also associated with auto-immunity. If you are unable to regulate your sleep-wake cycles, you may have it. Narcolepsy is also associated with obesity. Large studies have suggested, “it is related to impaired glucose metabolism.” Narcolepsy makes you fall asleep anytime and anywhere, without warning. You may feel tired all day and hallucinate as you change from being awake to sleeping. Simple changes you can make if you have narcolepsy:
- Watch caffeine and alcohol intake
- Eat small frequent meals instead of large ones
- Eat leafy greens, olive oil, fatty fish and berries for better health
- Avoid simple, processed carbohydrates which will cause a sugar crash
Restless Leg Syndrome (RLS)
RLS is common sleep disorder when you have diabetes. It is “an uncontrollable urge or desire to move your legs while you are resting.” You may feel crawling sensations, tingling or burning especially in your calf muscles. Symptoms seem worse when you are still or inactive, such as during the night. Moving your legs may make you feel better temporarily. Because of constant leg twitching and kicking, it is very disruptive to your sleep. RLS can begin at any age but it usually starts at around 40 and gets worse as you age. Uncontrolled diabetes may lead to peripheral neuropathy and RLS due to nerve damage from high sugars. RLS runs in families and is more common in women.
What can you do to help RLS?
- Take warm baths and get leg massages
- Alternate hot and cold packs on your legs
- Avoid caffeine
- Exercise moderately. Too much exercise may increase RLS symptoms
- Practice good sleep hygiene
- Discuss medications with your health care provider such as Gabapentin, Lyrica (also for peripheral neuropathy), muscle relaxants or sleep medications
Parasomnias are a “catch all” term for unusual behavior that people experience prior to falling asleep, while asleep or between sleep and wakefulness. Something goes wrong with your sleep cycle. They may or may not be seen with diabetes.
The 6 most common types of parasomnias are:
Sleep walking can be a simple or complex form. It is when you get out of bed, walk, urinate and even leave the house while remaining unconscious and still asleep. Sleep walking may be triggered by night-time hypoglycemia (low blood sugar) especially in type 1 diabetes due to too much insulin or type 2 diabetes, when taking high amounts of insulin.
Nightmares are often remembered when you wake up. They may accompany night terrors.
Night terrors are intense episodes of fear and movement during sleep. You can scream, move or flail during a night terror and it is difficult to wake up. “Night terrors are caused by an over-arousal of the central nervous system.” Unlike nightmares, you do not remember night terrors. They can be caused by excess stress, drinking alcohol, fever medications, low blood sugars, obstructive sleep apnea or restless leg syndrome.
REM Sleep behavior disorder
You actually act out your dreams. You shout, scream, talk, hit, pinch and punch.
Nocturnal eating disorder
Nocturnal or nighttime eating is characterized by “excessive eating in the evening and getting up during to sleep, only to eat.” If you have diabetes and have this disorder, it only adds to additional weight gain and out of control blood sugars. The increased eating can be caused by anger, loneliness, sadness, worry or just being upset. People with diabetes who have this parasomnia are more likely to be obese, have multiple diabetes complications and have higher A1Cs.
Bruxism is a term used for teeth grinding during sleep. Your teeth become flat and worn down. It can also lead to broken, missing or chipped teeth if left untreated. Bruxism is more common if you are highly stressed or have obstructive sleep apnea. Your jaw joint is inflamed, painful and can be swollen. The treatment would be to wear a protective night guard and attend stress management sessions.
Things to Encourage a Better Night’s Sleep
Here are tips to improve your sleep hygiene which will help your over-all health including your diabetes control.
Get your Activity during the Day
The more fresh air, sunlight and activity you incorporate into your day the better your sleep will be. Do not leave your activity for the evening hours since this will cause over-stimulation. You can still take a gentle walk 30 minutes after dinner for your blood sugar control without disturbing your sleep. Try to exercise 5-6 days a week. Just a 30-minute daily walk will work wonders. You can break the walk down into 10 minute intervals if you can’t walk for 30 minutes all at once.
Review all Medications with your Physician
You may be taking stimulants or water pills which are keeping you up at night. These medications must be taken in the early hours of the day so your sleep is undisturbed. Always bring your entire list of medications, vitamins and supplements to your MD visit so it can be frequently reviewed. You may be able to switch medication times for improved sleep.
Reduce Bedroom Allergens
Wash bedding regularly and vacuum weekly. Allow fresh air into your room as often as you can. Keep the ceiling fan on. Consider purchasing pillow covers and mattress covers that reduce allergens. Reduce clutter in your bedroom and dust objects at least weekly. Pets should remain outside your bedroom to reduce loose pet hair and dander where you sleep. Purchase an air filter tower and place near your bed. Remember to clean and change filters as needed.
Turn your Clock Around
The blue light emitting from your clock can be disruptive to your sleep. There are “clock watchers” who keep checking their clock to see how much sleep they have already missed. This begins a chronic cycle of dread, anxiety and poor sleep habits. Only check the clock if you are awake for more than 30 minutes. Leave your bedroom and return 20 minutes later. Try to deep breathe or read. Retry sleeping when returning to your bed.
Each person likes to personalize their sleep environment but here are some standard suggestions for better sleep quality. Invest in a decent mattress. Some of you like soft mattresses while others prefer hard ones. Test them out before you purchase, which is now a common practice. Online mattresses come with excellent return policies. Decide if you are a side-sleeper or back-sleeper when purchasing a pillow. Also know if you prefer down or foam pillows. There are also memory foam pillows which adapt to the curve of your neck.
Which type of sheets do you prefer? There are percale, different thread counts and different fiber contents such as bamboo. Find a sheet that keeps you cool. You may need a lighter weight blanket or comforter during the warmer months. If you loved the bedding during your last hotel visit, try buying the entire set online. Consider getting a weighted blanket which is a new trend similar to “swaddling a baby.” The weighted blanket makes you feel safe and secure. Do you keep you room temperature at 68-70 degrees or less?
Keeping the room dark helps you sleep but you should be able to catch natural light in the morning which helps your circadian rhythm stay on track. Blackout shades may prevent all natural morning light so consider wearing eye masks. These allow a bit of morning light in from the sides. You may want to use ear plugs to block out unwanted noise. No TV, phone, computer or iPad use in bed. No eating or drinking, except water, in bed.
You can read, meditate, deep breathe or listen to soft music immediately before bedtime. Think about buying a noise machine if you prefer a “droning and continuous noise.” There are white noise machines that play sounds offering static noise such as a running fan or brown noise machines sounds that may feature a running river, steady rainfall or strong winds. Brown noise is associated with deeper and stronger sounds giving you more relaxation, focus and better sleep.
20/20/20 Rule – 60 minutes before Bed
The hour before sleep can be divided into 3 different sections.
- 20 minutes: Get ready for tomorrow. Get clothing ready for tomorrow, pack lunch, organize papers, make lists or answer final emails.
- 20 minutes: Get ready for bed. Put on your pajamas and take care of your personal hygiene.
- 20 minutes: Relax, meditate, breathe, read or listen to soft music. This helps your body shift to a peaceful place.
Food and Drink
Do not eat heavy food choices or full meals prior to bedtime. Avoid cold cuts which are high in sodium and will make you feel bloated and thirsty. This will lead to increased nighttime urination and being up all night in the bathroom. Avoid hard cheese or meat which is high in saturated fat and difficult to digest. Do not drink caffeine such as coffee, tea or diet cola soft drinks before bed because it takes 6-10 hours to metabolize caffeine. Try not to have caffeine after 2PM.
Understand that alcohol is a stimulant and may make you tired for a few hours but will wake you up about 4 hours after drinking. Limit all fluids after dinner and do drink plenty of sugar free drinks early in the day to stay hydrated. Do not go to bed on an empty stomach which is grumbling and causing gas and pain. Never skip your dinner. With diabetes you should eat a small snack consisting of one serving of a carbohydrate such as 1-2 whole wheat crackers with a light protein source like one tablespoon of a nut butter.
See if you are deficient in vitamin B which may cause sleep irregularities. B vitamins are found in seeds, eggs, seafood and yogurt. Know if you need extra iron. Iron deficiency may cause sleep problems. Iron is found in beans, spinach, seafood and poultry. Discuss tryptophan supplements with your physician which may induce sleep. Tryptophan is an amino acid that raises serotonin levels, a precursor to sleep hormones. Tryptophan can also be found in a glass of milk, turkey, or peanuts.
Get on a Proper Sleep Cycle
Changing nightly sleep times is counter-productive. Try to get into bed around the same time every night and get up about the same time every day. Your body has a circadian rhythm which it prefers. If you are lucky enough to be able to keep those sleep times, do take advantage of it. Do not think you can sleep 3-4 hours during the week and make it up on the weekends by staying in bed all day. This disrupts your sleep cycles and throws off your circadian rhythm. You will be more groggy and tired even with lots of sleep.
Consider wearing a CGM (Continuous Glucose Monitor)
When you have difficulty regulating blood sugars, nighttime highs or lows, you will definitely disturb your sleep. By wearing a CGM, you will receive more information and blood sugars trends which will help you regulate blood sugars. Talk to your health care provider about trying a CGM for improved control and better sleep. Check blood sugars with a glucose monitor and document them if you do not wear a CGM. Check blood sugars before bedtime, at 2AM and then upon awakening. Do this for 3 days in a row. These blood sugar results can give your physician information about how blood sugars change during the night and affect your sleep patterns.
If you enjoy napping then you may not require so much sleep during the night. Short naps, early in the day rarely affect nighttime sleep. Keep naps to 10-30 minutes and take them no later than 2-3PM. Naps can make you more groggy and disoriented if they are too long. Short naps can help your mood. You may experience the “afternoon slump” and a short nap may help. With diabetes, blood sugar highs and lows can cause intense fatigue. Aging changes your sleep routine and lighter cycles of sleep occur. Understand your need to nap. Get your blood sugars controlled to avoid intense tiredness during the day.
Treat Chronic Pain
You may have repetitive, throbbing, burning, itching and aching pain due to peripheral neuropathy, arthritis, back pain or fibromyalgia which becomes chronic and prevents you from falling or staying asleep. The pain may be there during the day but lying down and being still just intensifies the painful sensation. Always talk to your health care provider to find ways to effectively treat your pain, whether it is with physical therapy or medication.
There are many different breathing techniques that you can do before bedtime for more restful sleep. Breathe in slowly for 4-6 seconds, hold for 4-6 seconds, breathe out 4-6 seconds and hold for 4-6 seconds. This is called boxed breathing. It can lower your heart rate, respirations and blood pressure and get you more relaxed for sleep. It is known that “slow, deep breaths can have a calming effect and promote sleep”.
Treat the Sleep Problem/Disorder
Discovering that you have a true sleep disorder is the first step towards treatment. Discuss and find the best specialist who is equipped to help you. For instance, insomnia may be treated with cognitive behavior therapy (talk therapy). Sleep counseling from a therapist can help reduce anxiety and depression which may be disturbing your sleep. Sleep apnea can be treated with a CPAP machine, a mouthguard or surgery. Bruxism can be treated with a night bite guard and stress management. Losing weight may help treat a sleep disorder. Restless leg syndrome may require medication such as Gabapentin or Lyrica (also used for neuropathic pain in diabetes). Rely on a specialist to help you come up with a reasonable plan to treat the disorder and achieve better sleep.
When all else fails you may require a sleeping aid prescribed by your physician. There are natural herbal supplements such as chamomile pills or tea. Others take Benadryl prior to sleep. You may need magnesium or zinc supplements, melatonin pills or Tylenol/Advil PM. Melatonin is a naturally occurring hormone in your system that regulates sleep and wake cycles. “Melatonin supplements may increase insulin resistance.” Discuss this with your physician. Sometimes sleeping pills such as Ambien, Lunesta or Sonata are required. They may cause disturbing and vivid dreams. Some physicians are now recommending CBD oil for sleep. Sleep Apps are available too. Sleep Cycle is one of the sleep Apps most recommended. An Apple watch or FitBit can also track your sleep cycles and sleep quality. Work with your doctor since it may involve trial and error until you find the specific sleep aid you need.
The physical and emotional toll of sleepless nights can be overwhelming especially when you have diabetes. Poor sleep causes increased insulin resistance. High and low blood sugars can certainly interrupt your sleep. Without proper sleep, your mood and ability to concentrate will be impaired. You may forget or be too tired to practice your self-care behaviors which help keep your diabetes controlled. These include keeping up with proper food choices, taking medications correctly, exercising and testing your blood sugars.
Poor sleep can trigger overeating, weight gain and severe depression. Sleeping less than 6 hours or more than 10 hours can mess with your hormones that stimulate overeating. Cravings will come for processed foods, empty calories and simple sugars. Keep your overnight blood sugars controlled for the best sleep. The best sleep will help with your blood sugars. Always get your physician involved before leaving your visit to discuss your sleep habits. Try to get the best shut eye you can. You will feel so much better!