Does Chronic Sleep Deprivation Cause Diabetes?

There is increasing evidence that sleep disorders are linked to metabolic problems like sugar control disorders and weight management problems.  It is common for patients to note improvements in their blood sugars, reduction in their weight and a drop in their blood pressure when they effectively treat their sleep disorder and start to get adequate, well-consolidated sleep. 

The question is whether inadequate sleep or poor sleep is a minor cofactor or if it is a significant contributing cause of diabetes.  Roughly 30% of American adults sleep less than 7 hours per night and are therefore chronically sleep deprived.  Since the cycle of glucose levels in the bloodstream and the pancreatic function according to the 24 hour circadian sleep-wake cycle and fail to achieve full compensation with the curtailed sleep duration.  Other hormones such as growth hormone, corticotropin (affecting cortisol) as well as the adrenalin (sympathetic) and vagal (parasympathetic) all require a full sleep cycle to function properly and they all affect the glucose system directly or indirectly. 

Experiments as early as the 1960's showed that short term sleep deprivation showed glucose intolerance and high blood sugar levels.  Since then longer term studies on people in real life circumstances.  In the Sleep Heart Health Study patients who had reduced sleep had significantly more likely to have diabetes than those who slept 7-8 hours per night. 

Another study looking at patients with known diabetes and reduced sleep duration each night found that their Hemoglobin A1C was 1.1 points higher than those who slept a normal amount of sleep per night. 

Multiple studies have been performed over years to more than a decade following patients and their sleep habits and blood sugars.  Patients who sleep 6 hours per night or less versus 7-8 hours per night are 1.5 - 3 times as likely to develop type 2 diabetes. 

Although there are many suggested causes for this link.  Reduced sleep is known to be associated with excess weight gain, for example.  However, one thing is for certain: 

Chronic sleep deprivation is bad for the health.  Diabetes Mellitus Type 2 is another reason. 

Darius Zoroufy, M.D.

Cleveland Clinic Journal Of Medicine - Volume 78 - Number 8 - August 2011

Seasonal Affective Disorder

It seems like we find out new things are bad for us all of the time and the news often seems contradictory.  Alcohol is bad for us, but a little bit of red wine might be good for some people.  Fried fish is bad, but take the oil out of the fish and put it in a capsule and it is good for the cholesterol.  Sun exposure can cause skin cancer, but is absolutely necessary for Vitamin D production and, as it turns out, for normal brain functioning. 

Sitting indoors in dark rainy weather doesn't just feel dismal, it actually has a negative affect on the neurochemistry of the brain with wide ranging effects that can last for months.  In fact, sometime the effect can persist long after the seasons change back to sunny, warm weather and long days, well beyond the typical October to April, Autumn to Spring time frame.   

So now we have our diet, our alcohol, and even the calendar that we have to watch out for. Fortunately, there are ways of managing this condition, known as Seasonal Affective Disorder. 

Seasonal Affective Disorder does not affect everyone.  However, people in latitudes that are further from the equator (Seattle is one of those) are more likely to be affected because there are fewer hours of daylight during the winter.  Climate plays a significant role as well.  In areas with less sunlight, the residents of the area are more likely to be affected.  According to NOAA data, Seattle has sunshine 43% of the time.  Compare that statistic to California Cities San Francisco, Los Angeles, San Diego  at 66-76%, major desert Southwest cities 75-80%, and even Green Bay, Wisconsin (known for cold winter weather) at 54%. 

Short daylight time during fall, winter and spring months and limited sunlight are predisposing factors for many to develop Seasonal Affective Disorder.  However, there are factors within the individual that may predispose the person to suffering from this disorder.  Some are more obvious such as underlying depression or depressed mood.  Increased stress, excessive fatigue, disrupted sleep, limited outdoor activity and therefore limited exposure to the limited outdoor light that is present, uncontrolled medical illness such as diabetes, or othe medical or psychological issues. 

People with Seasonal Affective Disorder are often challenging to diagnose.  Their symptom patterns are frequently complicated and do not easily follow a seasonal pattern when first described because of the multiplicity of symptoms.  Patients can present with any of a wide variety of concerns and they
will not always seem directly tied to the change in the season when the patient
explains the symptoms.  Instead, the interconnectedness of symptoms, life stressors and coexisting problems can make diagnosis somewhat challenging.  Typical presenting symptoms include mood symptoms such as: depression, crying spells, irritability, sensitivity to social circumstances and rejection, loss of sex drive.  They may present with cognitive symptoms such as: trouble concentrating, memory effects. It is very common for there to be physical symptoms like: fatigue, body aches and body heaviness, decreased activity level.  Sleep disturbances happen quite often such as insomnia, prolonged sleep, unrefreshing sleep.  Surprisingly, there are metabolic changes like: overeating, especially of carbohydrates, with associated weight gain, and an increased rate of Metabolic Syndrome. Weight gain can affect other health conditions like diabetes and sleep apnea which can also affect sleep and fatigue. 

The official diagnosis requires that there is determination of depression symptoms in a cyclical, seasonal pattern for a minimum of 2 years.  Clearly, we do not wait 2 years to initiate treatment.  When there is a clinical pattern, we initiate treatment and follow the patient carefully to assess for improvement. 

Treatment for Seasonal Affective Disorder may include antidepressant medication, referral to a pychologist for psychotherapy, chronotherapy (managing the patient's sleep schedule), Vitamin D therapy, sleep hygiene (placinge the patient on a more appropriate and healthy sleep schedule, exercise therapy (which usually involves taking walks outdoors), and therapeutic light therapy. 

Therapeutic light therapy is bright light therapy that mimics the wavelength of light not available in traditional room lights.  These lights help to reset the hypothalamus to improve the dysfunction that occurs as the cause of Seasonal Affective Disorder.  Typically the person needs to be exposed to the light for roughly 30 minutes per day, with the light in the periphery of his or her vision.  It is safe for the eyes and has minimal side effects.  Staring at the light might give a person a headache.  Staring at the fluorescent tubes in your office at work might give you a headache, too.  The light is mood elevating to a mild degree.  A patient who has uncontrolled manic bipolar disorder might become irritable with the light.  Also, because it promotes alertness, looking at it during the few hours right before bed might make it hard to go to sleep. 

Seasonal Affective Disorder is common and likely significantly underdiagnosed.  Simple interventions could probably be used for some of the milder cases to dramatically improved their quality of life.  We could also significantly alter the course of the disease in more severe cases, if people came to medical attention. 

Treating Obstructive Sleep Apnea: The Mask and Beyond

 “I am not going to use one of those machines to breathe with,” my patient says making a smothering gesture over his face.  I know he is talking about CPAP, continuous positive airway pressure, the most effective form of treatment for obstructive sleep apnea.  In my practice most people tolerate CPAP very well.  It is also true that many people have negative ideas about CPAP before they try it.  As their physician I step them through the process of diagnosing their problem, educating them about the condition, and presenting their treatment alternatives. 

            Obstructive sleep apnea is diagnosed by a sleep study called a polysomnogram.  “Poly” means many, “somno” means sleep, and “gram” means recording.  If those three are put together it means that we are recording many physiologic parameters of sleep overnight.  In more practical terms a patient sleeps in a normal bed (a queen-sized Sleep Number bed in my sleep facility) with some wires attached with adhesive so we can monitor brain activity and sleep stages, breathing, heart rhythm, movements, oxygen levels, etc.  We record all of that data and analyze it.  If the patient stops breathing frequently during the night we can detect it, measure its severity and frequency, and stratify the degree of sleep apnea into mild, moderate or severe.  

It is important to stratify the severity of obstructive sleep apnea, because severity of sleep apnea correlates with degree of cardiac risk. Once obstructive sleep apnea has been diagnosed, the patient needs to be treated. 

The most commonly used treatment is CPAP which stands for Continuous Positive Airway Pressure.  Since Obstructive sleep apnea is a condition of soft tissues of the throat such as the tongue and soft palate collapsing and closing the airway the treatment needs to prevent that process from happening.  CPAP uses a tube and mask to deliver a specified setting of air pressure to inflate the airway and make an open conduit for breathing.  CPAP consists of a small, quiet machine, a mask and a tube, as well as a humidifier to make the air comfortable.  In the past the success rate was approximately 50%, not because of treatment failures but because patients simply found the devices too uncomfortable for daily use over the long term.  Newer CPAP units are much smaller and quieter with better humidifiers and airflow features that allow breathing to feel more normal and natural.  Masks are lighter, more comfortable and easier to use.  Some just fit at the nostrils.  Success rates are now 80-90% with CPAP. 

Another common treatment is a Mandibular Advancement Device.  This is an oral device that is somewhat like the mouth guard a dentist makes for people who grind their teeth except it is more sophisticated.  This device has a piece for top and bottom teeth and keeps the jaws held together when the person is sleeping to prevent the bottom jaw from sinking down and back which is a natural position for the bottom jaw in sleep.  Since the tongue and muscle under the tongue are attached to the bottom jaw, those structures are also held forward and they are less likely to collapse the airway. The advantages of this treatment are night time convenience and travel size.  The treatment is not always as successful as CPAP in every individual.  

Surgery is a treatment that has had a role in sleep apnea therapy since sleep apnea was first identified.  In fact, the first treatment for obstructive sleep apnea was a surgical tracheostomy to bypass the obstructed upper airway.  There were no other effective treatments to directly manage sleep apnea.  Today there are surgical methods to correct a deviated nasal septum and improve nasal airway obstruction to allow better airflow.  Procedures are performed to reduce the size of the soft palate as well as the base of the tongue to decrease the obstruction.  There are also procedures to tether the hyoid bone of the neck to help keep the airway from closing during sleep.  In children with sleep apnea tonsils and adenoid tissue are often removed to successfully treat sleep apnea.  There are even occasional adult cases benefiting from this procedure.  Surgery is usually considered a second-line treatment for adults with sleep apnea because surgery is actually less successful than CPAP and there can be a small possibility of surgical side effects.

Weight loss can have a remarkable effect on the upper airway and sleep apnea.  As a person loses excess weight, fat tissue is reduced in and around the neck opening the diameter of the upper airway and decreasing the obstruction of sleep apnea.  In some cases sleep apnea can be improved from severe sleep apnea to mild or even to the point where other treatment is no longer necessary.  It is often very hard to lose weight with untreated sleep apnea because of excessive fatigue, associated changes in eating behaviors, and metabolic changes caused by sleep apnea.  However, when a person has treated sleep apnea and then embarks on a weight loss regimen, we often see dramatic improvements in the degree of sleep apnea. 

A relatively new advance in the treatment of obstructive apnea is Provent^TM. It is a deceptively simple little device that looks a lot like a small oval band-aid.  In the center of the adhesive there is a small plastic valve.  One valve goes into each nostril and the adhesive holds it on the nose making an airtight seal.  Provent’s valves treat sleep apnea by taking advantage of the physiology of the upper airway by producing partial resistance to the exhale part of the respiratory cycle.  This resistance to flow increases the pressure in the airway and inflates it somewhat like CPAP does.  When the next inhale cycle occurs the valves have no resistance and the airway starts somewhat inflated and much less likely to collapse.  Provent^TM does not work for every sleep apnea patient, but can be effective and convenient for some patients. 

Long scoffed at by many sleep professionals, positional therapy is starting to take a role in serious sleep apnea management.  The principle is deceptively simple.  It does not take a full polysomnographic study lab to determine what bed partners will freely report:  a large percentage of sleep apnea sufferers exhibit some degree of worsening of their sleep apnea and snoring when they are on their backs.  When studied we can determine that some patients will manifest sleep apnea nearly exclusively on their backs.  Gravity is clearly having an effect on the airway structures on the front of their airways (the tongue, soft palate, uvula) and pulling them back to close the airway.  If we could simply prevent gravity from causing those structures to close the airway we would solve the sleep apnea.  In order to prevent the effects of gravity we could send every sleep apnea patient with this type of positional component to the International Space Station.  Unfortunately, there are millions with sleep apnea, so overcrowding would be a problem.  We could instruct all of the patients to get a t-shirt, sew a long pocket down the center of the back and tell them to put half a dozen tennis balls down the pocket.  Then that shirt is their new pajama shirt.  The idea is that the patient needs to sleep on his or her side.  Rolling onto the back will be very uncomfortable and cause the person to wake up and roll onto a side once again.  Since the tennis ball t-shirt was quite seriously the mainstay of physician directed positional therapy for sleep apnea, positional therapy was not considered a serious modality for years.  Many did not want sleep with a bizarre shirt.  Others found the discomfort of the tennis ball shirt unpleasant and annoying.  Surprisingly, some would sleep so deeply they would roll onto the tennis balls, stay asleep and wake with a backache.  A number of years ago one of my patients even fashioned a positional device out of an empty 2 liter soda bottle filled with sand strapped to his back with seatbelt straps so he would be physically unable to roll over onto his back. The space station might have been less inconvenient.  Today there are specific devices which can be worn comfortably and gently but firmly resist rolling from side to back.  One is called the Zzoma^TM which attaches around the torso and has a specially shaped foam block on the back. 

Treatments for obstructive sleep apnea continue to improve and exciting new advancements are in trials.  One promising development is an implantable device which electrically stimulates the hypoglossal nerve which is the nerve under the tongue that controls tongue muscle tone.  This pacemaker-type device is switched on at sleep time and stimulates the hypoglossal nerve which triggers a neuromuscular response to open the airway.  So far published trials have shown successful deployment of the devices and significant reduction in sleep apnea, even in severe cases.  As studies continue to go forward we are optimistic about this novel treatment.

Obstructive sleep apnea affects a significant percentage of the population and there is not a single treatment that is appropriate for every individual.  Fortunately, there are multiple ways to manage sleep apnea and with the support of a multidisciplinary sleep center a patient can explore options to resolve obstructive sleep apnea, its symptoms and its health risks.