Diabetes & Metabolic Syndrome: Clinical Research & Reviews
Original articlePredictors of sleep disorders among patients with type 2 diabetes mellitus
Introduction
The health burden and cost associated with metabolic disorders, such as Type 2 diabetes mellitus (T2DM) and obesity, have increased dramatically in the past 3 decades across the globe and now represent a major health challenge in the 21st century. Recent reviews have reported that approximately 37% of the world’s population are now overweight or obese, with an estimated 382 million individuals diagnosed with diabetes (including T2DM) [1], [2]. As a consequence of this rapid increase, and the significant associated health and economic burden, researchers have sought to establish a better understanding of metabolic illness and the role of suspected risk factors for disease. The development and implementation of effective public health interventions, guided by such research, is considered critical if the burden of metabolic disease is to be curbed.
Sleep disorders represent one such risk factor that possesses a relationship with both metabolic disease and obesity. Emphasizing the complexity of this triad of illness conditions, studies have suggested that poor sleep quality and sleep disorders may represent risk factors in the development of both obesity and T2DM [3], [4]. Sleep quality may therefore represent a risk factor in the development of two highly prevalent and burdensome disease conditions.
Disrupted or insufficient sleep is thought to possess a number of adverse effects on metabolic and neuroendocrine mediators of health; most likely through promoting increased appetite and consequent caloric consumption [4], [5]. The quality and quantity of sleep can range from sleep disorders, sub threshold symptomatology to persistent chronic disturbances. In the US, it has been estimated that 50–70 million suffer from chronic sleep disturbances, including insufficient sleep, insomnia, and obstructive sleep apnea [6]. Critically, sleep hygiene (promotion of better sleep practices) represents an important and cost-effective treatment for sleep disturbances, and thus sleep problems represent modifiable risk factors for both primary and secondary prevention of metabolic disease.
A number of epidemiological studies describe a connection between T2DM, and sleep disorders [5]. Studies suggest that a high proportion of T2DM sufferers also manage comorbid sleep apnea, particularly males and those overweight. Estimates from recent studies range from 18% to 36%, suggesting the importance of addressing sleep disorders among this patient group [7], [8], [9]. A large-scale survey study found that sleep problems were reported by up to 40% of individuals with T2DM, with sleep apnea, and restless legs symptoms the most likely among sufferers [10]. A further comprehensive report by the International Diabetes Federation Taskforce on Epidemiology and Prevention highlighted the frequent co-occurrence of diabetes and sleep disordered breathing, noting that the high degree of comorbidity requires that health professionals routinely assess for this condition among diabetic patients [11].
Further research has sought to explore the complex causal relationship that may exist between disrupted sleep and T2DM [12]. Tang and colleagues reported insufficient sleep quality and quantity as a risk factor of developing T2DM and poor glycemic control among sufferers [13]. Similar results were reported in a German study by Taub and colleagues, with the authors hypothesizing that future research should examine insulin resistance as a potential mechanism by which these two highly prevalent conditions may be associated [14]. Sleep duration has also been associated with higher risk of developing T2DM [15], [16], as well representing a strong predictor of hemoglobin A1c (HbA1c), with sleep loss being associated with increased HbA1c [17].
Attention to the potentially negatively reinforcing relationships that may exist between sleep disturbance, obesity and T2DM is growing [18]. Critically however, there exists a paucity of literature assessing all three conditions, and the relationship between them, in large-scale representative populations. The current study will seek to contribute to this critical area of study and report on the rates and interrelationships between sleep disorders and symptoms, obesity and T2DM. This study will examine the prevalence of sleep disorders and symptoms and their association with risk factors among adult patients diagnosed with T2DM in the US.
Section snippets
Sample source
This study included patients with self-reported physician diagnosis of T2DM, identified from the 2012 US National Health and Wellness Survey (NHWS; N = 71,157). The NHWS is a self-administered, Internet-based questionnaire from a sample of adults (aged 18 or older). The NHWS collects individual demographic characteristics, medical history, healthcare utilization, behaviors, attitudes and outcomes from all respondents. A stratified random sample (with strata by gender, age and race/ethnicity) was
Results
Among patients with T2DM, the average age was 59.9 (SD = 12.2), 59.5% were male, 76.2% were White ethnicity, 35.8% were college educated, 88.9% had health insurance, 27.5% were obese class I, 17.2% were obese class II, 16.8% were obese class III and 15.6% were current smokers.
24.4% of adults with T2DM reported a diagnosis of a sleep disorder and 76.8% of them reported experiencing a sleep symptom regularly. The most prevalent sleep symptom regularly experienced was waking up to go to bathroom
Discussion
Metabolic disorders such as obesity and T2DM exert a tremendous burden of disease globally, and are associated with a variety of comorbid conditions, impaired quality of life, and increased health care costs [23]. Individuals with T2DM who are obese also frequently report sleep problems, with research suggesting that all three may represent a complex interwoven triad of conditions [4], [18]. Despite this, there is a dearth of literature assessing all three conditions among large-scale
Conclusion
Almost 25% of patients with T2DM were diagnosed with a sleep disorder and over 75% reported experiencing at least one sleep symptom regularly. Sleep disorders and symptoms were strongly associated with obesity, White ethnicity, gender, low income, and smoking. Interventions focusing on modifiable risk factors, including weight management and smoking cessation, have been shown to improve T2DM and may also potentially improve sleep disorders in those patients.
Disclosures
SG is an employee of Kantar Health, which conducted National Health and Wellness Survey, and analyzed the data on behalf of, and with funding from, Eisai Inc., including funding for the manuscript publication. ZW is an employee of Eisai Inc., which funded this study.
Author contributions
All authors contributed to the study design, interpretation of results, and review, revision, and approval of the final manuscript.
Acknowledgments
The authors would like to thank Errol J. Philip for writing and editorial support on behalf of Kantar Health, with funding from Eisai Inc.
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