Webinar: Sleep's impact on diabetes​

Dr. Baran: Hi, everybody. I’m pleased to be here, and we’re just gonna do a nice, brief presentation on diabetes and how sleep impacts it, and what we can do to, hopefully, prevent this from occurring.

So first, let’s start with a definition. What is type 2 diabetes? Well, first, let’s define diabetes. In general, there’s type 1 and type 2.

Diabetes is a disease of abnormal carbohydrate metabolism characterized by high blood sugar due to impaired insulin production by special cells in the pancreas and resistance to the action of insulin.

Glucose is the basic fuel that our body uses to generate energy to operate. Insulin helps glucose in the bloodstream get into cells where it can be used. If glucose can’t get into cells, it accumulates in the bloodstream causing health problems.

Type 1 diabetes is when the pancreas does not make insulin. This is about five to 10% of diabetes cases.

Type 2 diabetes is when the pancreas does not make enough insulin and there is insulin resistance in the tissues, so insulin does not have the effect that it normally would. This is 90% or more of diabetes cases and it typically occurs during adulthood.

An increase in body weight is a common cause. Over time, diabetes damages the heart, kidneys, eyes, brain and nervous system.

There’s increased risk of many medical problems, including heart attack, stroke, kidney failure and blindness. It’s a very serious chronic disease.

Prediabetes is when blood sugar levels are elevated, but not high enough to qualify for diabetes. Unless this is addressed, it can progress to Type 2 diabetes, and the good news is, it can be prevented.

Many people know that obesity is a major cause of type 2 diabetes. Did you know that insufficient sleep or poor quality of sleep can also play a role, too? Poor or insufficient sleep has three effects that raise blood sugar: reduced insulin production, increased insulin resistance and increased cortisol, which increases the blood glucose level.

When you’re sleep deprived, or when sleep is insufficient, or, in poor quality, it affects our eating behavior, making us more hungry, and eating more, and makes us eat foods higher in sugar, craving these foods more.

Deep sleep, It’s good for our health in many ways. This is what makes us feel rested. Our brain clears out waste products most efficiently in deep sleep and it promotes better regulation of blood glucose.

When we are deprived of deep sleep, whether it’s due to just not sleeping enough or having a sleep disorder that causes reduced sleep quality, our glucose regulation is impaired.

Also when rested, our behavior improves due to the physiologic regulation of hunger hormones, and we’re more likely to be motivated to be active and exercise.

When we’re fatigued, sleepy, sleep deprived, exercising is the last thing anybody wants to do.

There are three ways that sleep can be compromised.

The obvious one is duration, not enough sleep.

The study referenced in this slide used five hours as the cutoff, but other studies have shown increased risk with less than seven hours of sleep, as well. The shorter the sleep time, the higher the risk of getting diabetes, and, of course, the other detrimental effects of poor sleep and insufficient sleep.

Timing, irregular sleep times, reduce the ability to sleep well and affect the normal distribution of sleep stages.

We have a brain timekeeper that has a set point. It can adapt to change but only about one hour, plus or minus one hour, per day. So if there are major changes in the sleep schedule day-to-day, our brain just can’t keep up with that. And sleep quality is going to suffer as a result of the timing issue.

Sleep quality in general, there are sleep disorders that fragment sleep, such as obstructive sleep apnea. And these don’t let you get into the more restful deep stages of sleep because of all the interruptions that are occurring.

And these interruptions are, usually, most of these are so brief that we’re not aware of them, lasting just a few seconds.

So your sleep can be very fragmented, but you may think that you only woke up a few times, or perhaps not even at all, because anything, less than a few minutes in duration of an awakening, just goes by unnoticed. I mean, we’re not conscious of it and we don’t remember it.

So any one of these factors is, by itself, very important, but when there’s more than one inaction, things clearly become worse.

I think most people know that weight management, dietary changes and exercise are important for good health in general and for diabetes prevention, but it is also very important to get enough sleep and good sleep, and diagnose or treat sleep disorders that may be working against you.
Alright, some general rules of sleep hygiene. Many of these, I think, are common knowledge and they’re all very important but I’ll take the opportunity to elaborate on caffeine and alcohol because there are some misconceptions there, and I just want to make sure that we get that information across.

Caffeine is an enemy of sleep and it sticks around in your bloodstream for a long time. The half-life of caffeine in the blood of healthy individuals is about five hours, which means it takes five hours to clear half of it, and then another five hours to clear the remaining half and so on.

So it can really linger on for a while. The more caffeine you consume and the later you consume it, the more it can interfere with sleep.

I recommend no more than two caffeinated beverages per day, the last one, no later than the early afternoon, And if you feel like you’re consuming too much caffeine and you need to cut down, be sure to do it gradually to avoid caffeine withdrawal, which can be pretty uncomfortable especially with headaches. I would suggest reducing by no more than one cup per day, starting with the later cups of caffeinated beverage in a day as the first ones to go.

Many people think that alcohol helps you sleep better. Well, at first, it does, but after a few hours as the blood level starts to decline, sleep becomes fragmented and the overall effect is negative.

It also worsens sleep apnea and certain other sleep disorders that we call parasomnias. So, it is detrimental to sleep in a variety of ways.

As I mentioned earlier, sleep apnea causes sleep fragmentation, which is really the equivalent of insufficient sleep. You can have a normal duration of sleep, but if it’s fragmented, the value of that sleep goes down and it’s the equivalent of a really shorter duration.

And another point here that maybe I can comment on is the bright light exposure. Bright light tends to alert us and actually stimulates a part of our brain, that timekeeper that I mentioned earlier.

It’s called a suprachiasmatic nucleus; it has a direct connection to our eyes. And bright light tends to alert us and makes us think that it’s time to keep going and not go to sleep. So bright light exposure in the evenings and at night is best avoided. Early in the morning is fine. And, actually, early morning, bright light exposure is one good way to keep people on a good sleep schedule and just keep things on track.

And I’ll make one more comment here, also, it’s very important to have a winding down time prior to bedtime. You don’t want to be going full speed ahead with whatever you may be doing, certainly not exercising near bedtime. You need to allow at least three hours between finishing exercising and bedtime. That’ll also prevent you from falling asleep.

But, also, even if it’s not exercise, just any engaging activity, should be halted at least half an hour or so prior to bedtime, to let you wind down and get ready to go to bed and go to sleep. You can’t just be, you know, doing something in an actively engaged manner and then go straight to bed and expect to fall asleep quickly.

So all these little things matter, and it does all add up, But, sleep hygiene is one of the first steps in making sure that sleep is on track. And it’s the fundamental building blocks of good sleep. That’s where it all starts.

So how can SleepCharge help you? Sleep is so important in so many ways. So check out the Sleep CheckupTM. It’s a good way to get some information, more information about sleep and learn some additional facts about sleep. And if you have a sleep disorder, you’ll be in good hands with SleepCharge.

We have a team of board-certified sleep specialists who are available for consultation, depending on eligibility and medical necessity, but it’s a great resource. Certainly, I would strongly advise looking into it.

Moderator: And we did have a couple of questions come in, but can you go back to the sleep hygiene tips and maybe elaborate on the recommended hours of sleep we should be getting each night.

Dr. Baran: Oh, yes. Certainly, yes. Yes, the recommended hours of sleep are really, for most adults, between seven and nine hours, and no less than seven.

Everybody has a different sleep need. And it’s really, there’s no way to calculate how much sleep each individual needs.

The best way to know you’re getting enough sleep is, if you’re on a certain sleep schedule and even on your days off, your weekends, your vacations, you pretty much get the same number of hours of sleep and you don’t feel the need to catch up.

A lot of people think that just because they can get by on less during the week, that’s all they need. Well, if you’re catching up on the weekends, then you need more and that’s why you’re catching up.

So, seven to nine hours, no less than seven, unfortunately. There are a lot of people out there who are getting less sleep than they need. And over time, it really adds up.

It may seem fine after a day or two, but the effects of insufficient sleep are really additive over time so that it gradually creeps up and gets worse. And the level of fatigue gets worse. The impaired functioning gets worse in a way that, unfortunately, a lot of people get used to feeling worse and not feeling at their best and adapt to this new normal of being unrested. And they don’t typically realize what they’re missing until they catch up on their sleep and get the proper amount of sleep, so things to keep in mind.

Moderator: OK, great. Thank you so much. The first one, sometimes, I get hungry at night and have a snack when I wake up. Is this OK?

Dr. Baran: It’s best, not to eat at night or even eat close to bedtime. If you have a full stomach or food in your stomach, sleep is usually impaired by this for a variety of reasons, one of which is, it increases the chance of having acid reflux, and this can be a problem even if you don’t have prominent symptoms. So, I would advise allowing at least three hours between dinner and bedtime and to keep the snacks light, and avoid eating before bedtime and certainly don’t eat when you get up at night. That can just make things worse.

Moderator: OK, that makes a lot of sense. Another question is, can I trust the information that my wearable is giving me about my sleep?

Dr. Baran: Yeah, there are a lot of cool devices out there: Apple Watch, Fitbits and Garmin devices. There are all sorts of watch-like devices that give us information about our sleep.

These are not the same as a sleep study but they do provide useful information.

The main thing that they will tell you is how much movement or it detects movement and as a result, it estimates your sleep quality. So the more movement there is, the less the sleep quality is. And, typically, when there is sleep fragmentation, due to any cause, whether it’s environmental noise or whether it’s sleep apnea, we tend to move and shift position. And even minor movements can be detected by these devices. So they will give you an idea of your sleep quality.

However, clearly, these don’t take the place of a sleep study and cannot be used as an absolute gauge of how your sleep is. If you’re not feeling well, if you’re not feeling rested or if someone’s telling you that you’re snoring or having certain movements during sleep, or issues during sleep that you’re not aware of, it still deserves to be checked out. We can’t rely on these devices by themselves. But they’re definitely useful to put into the picture.

Moderator: Gotcha, OK, So our next question that just came in, Are short afternoon naps, healthy?

Dr. Baran: Naps in general are best avoided.

However, if for any reason someone is not able to get sufficient nightly sleep due to shift work, schedule or temporary circumstances limiting sleep time, a short afternoon nap is a good way to get through the day. The key there is to make sure it’s in the early afternoon and that it’s 30 minutes or less.

Anything later or longer is going to throw off that brain timekeeper that we have, and it will make it harder to sleep at night and perpetuates the problem. So short 20 to 30 minute naps, early afternoon, OK, if necessary. But if you’re finding that you need a daily nap on a regular basis, even if you’re getting enough nightly sleep, then there still could be a problem there and it needs to be looked into.

Moderator: OK, that makes a lot of sense. So, our next question for you is: I sometimes have trouble falling asleep. At what point do I need to talk to my doctor about this?

Dr. Baran: Everybody can have a difficult night of sleep due to stress circumstances or anything that might be going on temporarily in their lives. If this is more than occasional, if it’s happening on a regular basis, and it’s not going away, and you haven’t been able to improve it by optimizing your sleep hygiene, then it deserves a conversation with your doctor or our Sleep Checkup would be a good idea to look further into this. So it definitely may require more attention if it’s on any level of frequency or regularity.

Moderator: OK, great, thank you for answering that, and one last here: My wife snores, and I can’t sleep. Does this mean she has sleep apnea?

Dr. Baran: She may very well have sleep apnea. Snoring is the noise that our throat makes when we force air through it. And it’s a common feature of sleep apnea, obstructive sleep apnea.

When we go to sleep, our body relaxes and our throat relaxes. So the muscles that keep our throat open while awake, when relaxed, in some people, don’t leave enough room to breathe freely.

And when that space in the throat is narrow, and there’s not enough air coming through, our brain compensates by making us work harder and pull the air in more forcefully. As you force the air through a narrow floppy space, it vibrates and that’s snoring.

So that means you’re working harder than you should to breathe, and with that extra work, and sleep becomes fragmented, and can have all kinds of effects, and that’s what sleep apnea basically is. So anybody who snores should definitely have that looked into and most people who snore are not aware of their own snoring, it’s usually people around them that are aware.

And speaking of wearable devices and tools that can be used to help us get more information about our sleep: there are apps that can be downloaded that will detect and record your snoring. If you don’t have someone around and you’re curious whether you might be snoring, people are often surprised to find that they may actually be snoring very loudly, and not even be aware of it at all.

Moderator: So Dr. Baran, can you give us any recommendations for these snoring apps that can possibly record?

Dr. Baran: Oh, there’s, you know, I don’t really promote any of them. But if you go into the App Store and just search for snore or snoring, there’ll be a number of options there. I don’t want to specifically recommend any particular one, but I do know that at least several are out there, and I think at least several of them are free as well.

Moderator: OK, great, that’s great to know. One more question here. How long does it take to establish a new sleep pattern? I’ve tried, but I can’t seem to get more than five hours of sleep.

Dr. Baran: If, despite all efforts and keeping a nice regular sleep schedule and paying attention to good sleep hygiene and avoiding alcohol, caffeine, nicotine, etc., if despite all efforts, your sleep is still problematic, that means it’s time to get it looked into. As I mentioned earlier, if there’s a shift in a schedule, if you travel across time zones, or if you’re working at a different work shift, our brain will adjust, it will adapt at about one hour per day.

So, if there’s a seven hour time difference, it’s going to take about seven days to adapt to the new location or the new schedule, If despite sufficient time and all efforts, things are just not normalizing, then clearly, it needs to be investigated further and a Sleep Checkup, sleep consultation may be a good idea.

Moderator: OK, great, I don’t think there are any further questions. So, Dr. Baran, thank you so much for your time, and thank you, everybody, for taking the time to learn more about sleep and how it impacts other areas of life.

Alp Sinan Baran, MD

Medical director of Nox Health, Dr. Baran is a board-certified psychiatrist and sleep medicine physician with 25 years of experience. His professional experience spans academic, military and telemedicine settings.