Good Night’s Sleep

How to Get a Good Night’s Sleep with Diabetes

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Interrupted sleep can be a common annoyance when living with diabetes — whether you experience it yourself, or you’re a spouse or caregiver of someone who does. Find out more about how you can improve your sleep and manage these disruptions.

Sleeplessness is an epidemic of sorts, as the CDC suggests that more than 1 in 3 adults regularly do not get enough sleep. Constant diabetes-related sleep disruptions can accumulate over time, potentially leading to negative consequences.  While many with diabetes may have interrupted sleep, there are steps you can take to help you get a full night’s rest.

Sleep quality vs. quantity

When sleep is regularly interrupted, you miss out on the restorative processes that take place overnight. It’s not just the quantity of sleep (how many hours) that matters — the quality (how well) matters also.  Having a goal of 8 hours of sleep per night is great, but even if you get enough hours, your sleep quality may be low.

I can personally attest to years spent as a “diabetes zombie” after my 5-year-old, Emma, was diagnosed with T1D. It was 2007, and she was not yet using a continuous glucose monitor (CGM). But while we weren’t awakened by the bells and whistles of diabetes technology, we had alarms set for blood glucose testing and a baby monitor so she could signal when she was low and we’d come running. It was a tough time, and my sleep hasn’t been the same since.

When assessing sleep, research suggests that quality is a more important measure than quantity. But how do you know if you’re getting enough sleep in the first place?

According to an expert panel convened by the National Sleep Foundation, adults need between 7 and 9 hours of sleep every night, while teenagers need about 8 to 10.

Chronic interruptions to sleep can be especially problematic. These patterns can interfere with everyday life, resulting in daytime drowsiness and other health issues related to mood, brain function, and the heart. Simply put, a lack of sleep can affect how you think and feel.

Sleep and diabetes distress

Researchers have been using the term diabetes distress since the mid-1990s. Diabetes distress refers to the emotional implications of living with or supporting a loved one who has diabetes. Because diabetes is a 24/7 condition, it sometimes can’t help but interfere with one’s sleeping hours, potentially causing even more stress and anxiety.

Karen Oller, of Phoenix, Arizona — who was diagnosed with type 1 diabetes 23 years ago — is very familiar with interrupted sleep and the stressful, groggy mornings that follow. “I’d say that my sleep is moderately impacted by diabetes,” Oller said. “I’m only sleeping 2 or 3 nights a week without diabetes interruptions.”

Oller was diagnosed 5 years after marrying her husband Matt — who was diagnosed with T1D at age 14. Because Karen and Matt both have T1D, their son Carson was enrolled in a UCLA T1D Trigger Study at birth, tracking his autoantibodies across time. He also developed T1D just before his 14th birthday.

Sleep and mental health are closely tied together. Research suggests that many, if not all, mental health conditions are associated with disrupted quantity and quality of sleep. Over time, repeated disruptions can lead to changes in the brain’s level of serotonin, a chemical sometimes known as the “happy hormone”, given how it regulates mood, appetite, and sleep.

What are common causes of sleep disturbances with diabetes?

When nighttime blood glucose is out of range, you’re more likely to have a disrupted night’s sleep. If you use diabetes devices, it can be hard to catch a break some nights with the constant alerts.

“My sleep is mostly interrupted by caregiving,” said Oller. “Technology’s great — it’s helping me to sleep better, but it’s not perfect. Take last night for example, Carson (her son) changed his sensor, was eating Cheez-Its — and as a 16 year old, he stays up late. He went to bed after giving insulin for the carbs he ate and at 1:30 a.m., I got a Dexcom alert on my phone. His blood sugar was 49 — and he doesn’t wake up when his blood sugar is low — even when his pump is alarming. Our pediatrician says he should outgrow that, but he hasn’t yet.”

Researchers are increasingly interested in studying secondary disruptions to sleep, or sleep disruptions that result from a separate medical condition (such as diabetes). While more research is needed in this area, common causes of diabetes-related sleep disruptions include:

  • Alarms set to check blood glucose levels
  • Correcting highs and lows
  • CGM alerts (highs, lows, out-of-range alerts)
  • Insulin pump alarming (low insulin levels, occlusions, charging/battery needs)
  • Anxiety or worry about diabetes or your loved one’s diabetes
  • Extra trips to the bathroom
  • Increased thirst

There are a few common sleep disorders that can contribute to sleep issues with diabetes, including sleep apnea and restless leg syndrome. If you think you have one of these conditions, be sure to let your healthcare provider know; both are treatable and can improve the quality of your sleep.

Can interrupted sleep affect diabetes management?

Getting a good night of sleep can potentially have an impact on blood glucose. And in general, interrupted sleep patterns have a wide array of potential health effects. Diabetes interruptions are similar in nature to sharing your bed space with someone who snores. All of the disruptions add up, but with diabetes, these disruptions often require action, like a “midnight picnic.” It’s not just a matter of rolling over and poking someone awake to stop snoring.

My girls are 18 months apart; Emma has T1D, and Hannah, my oldest, had night terrors. With that layered upon my own T1D, I’m certain my cortisol (the “stress” hormone) levels were through the roof for several years. I never discussed this with my providers at the time, but I sure wish I did. While my T1D was well managed, having more insight into the physiology behind these stress-related swings in glucose would have been helpful.

Why does this matter? Because interrupted sleep is stressful and can increase cortisol levels. It’s the body’s half-hearted attempt to increase alertness, but high cortisol levels can actually increase the need for more insulin. Again, this is why healthy sleep habits are important.

How do I improve my quality of sleep?

While sleep experts warn about the potential harm of electronic devices on sleep for people with and without diabetes, as those with diabetes know, their devices don’t just “turn off.” Individuals who use diabetes devices have alarms and alerts that can go off at all times of the day and night. That being said, there are some things you can do to increase the odds for a better pattern of night time rest.

  • Set a specific time or use an alarm for when it’s time to go to bed
  • Identify other health factors that may be affecting sleep
  • Personalize CGM targets and alarms and upload your data to an app to see patterns during sleep
  • Identify behaviors associated with these patterns
  • Reach out to your care team between appointments and make small adjustments regularly
  • If fear of hypoglycemia or diabetes distress may be keeping you awake, communicate this with your healthcare team
  • Turn your personal alarms off and have another loved one or caregiver monitor them instead – take some time off, if possible.
  • Take the night off. Switch duties with another adult. (Caregivers and parents)

Diabetes management is best done in routines. If you do similar things at similar times, you’re more likely to have the same results. This may equate to: exercising, eating dinner, going to bed, or having a similar snack at regular times. Predictability is a good thing. While it may sound boring and it doesn’t have to be all of the time, it simply makes life easier.

Should I see a healthcare provider about my interrupted sleep?

If you’ve made suggested changes, but are still having regular interruptions in your sleep, talk to your diabetes care team. They can help you get to the bottom of why diabetes is keeping you awake. Although CGM and automated insulin delivery (AID) devices are super helpful in addressing overnight lows (and the worry that goes along with it), the alarms can be relentless.

Research suggests that interrupted sleep can cause short- and long-term health consequences and may increase the risk of:

  • Memory issues
  • Stress and irritability factors
  • Mood disorders
  • Increased weight
  • Inflammation

“I haven’t seen a healthcare provider about interrupted sleep, but what helps me is having a regimented sleep schedule,” said Oller. “I go to bed early and get up early. I’m often tired in the morning, but I cowboy up and power through  — there’s no time for naps either. Having a good attitude has been tremendously helpful with the lack of sleep my husband and I deal with.”

It’s easy to think you’re “just fine” and getting enough sleep. But a sleep app, digital tracker, or printable tracker may tell you otherwise. If you find yourself in a pattern of frequent awakenings from diabetes, take action and discuss strategies with your healthcare provider to improve your sleep.

What Makes a Good Night’s Sleep

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Sleep is a time for the brain and body to engage in vital growth and repair. It’s an essential part of a healthy lifestyle1, yet our demanding work schedules, family responsibilities, and busy social lives mean that many people are going short on sleep.

The 2018 NSF Sleep in America poll found that while we recognize the importance of sleep, most adults prioritize work, fitness, and other obligations first. Just a quarter of American adults get the recommended seven to nine hours of sleep per night, and one in six has either turned to sleep medication or been diagnosed with a sleep disorder.

What Is a Good Night’s Sleep?

A good night’s sleep should leave you feeling refreshed, alert, and ready to begin the day. If you happen to wake from a deep sleep, you may need a few minutes to wake up properly2. But overall, people with healthy sleep patterns find it easy to fall asleep and experience minimal nighttime awakenings.

Quality sleep is not just about the hours you spend in bed. Fragmented sleep can also disrupt the natural rhythm of the sleep stages, leading to a less productive rest. You may get exactly eight hours of sleep every night and still feel groggy as a result of light or restless sleep.

If you’re experiencing any of the following symptoms, you might not be getting the rest you need:

    • Difficulty waking up or falling asleep
  • Not feeling well-rested when you wake up
  • Feeling tired, sleepy, or drowsy during the day
  • Reduced performance or trouble focusing at school, work, or sports
  • Excessive reliance on caffeine
  • Frequent nighttime awakenings
  • Subjective feelings of not sleeping well

In the short term, poor sleep3 leads to problems with memory, concentration, mood, and daytime sleepiness. Those who are short on sleep may be at a higher risk of car accidents or work injuries.

In the long term, poor sleep has also been linked to a higher chance of developing diabetes, obesity, and heart disease. Shift workers4 with irregular sleeping patterns have a higher chance of developing breast cancer, stroke, and other medical conditions. Poor sleep may also exacerbate mental health problems such as anxiety and depression.

How Does Sleep Change Throughout the Lifespan?

Sleep needs change as we age, and individual sleep needs can vary depending on a number of additional factors. Sleep is regulated by our circadian rhythm, an internal “body clock” that tells us when to feel sleepy and when to feel alert. If we go too long without sleeping, a function called sleep-wake homeostasis5 kicks in and makes us feel tired.

Still-developing babies and young children require the most sleep, with most children sleeping 9-10 hours and babies sleeping as many as 18 hours a night. Teens require eight to 10 hours of sleep per night, and adults should be sleeping between seven and nine hours a night.

Older adults6 also need between seven and eight hours of sleep per night. However, seniors often suffer from light sleep, an earlier circadian rhythm, multiple nighttime awakenings, and a shorter overall sleep time. These problems may be exacerbated by medication or medical conditions.

Some people may have a circadian rhythm that is at odds with societal requirements. For example, teenagers are programmed to wake up and go to sleep later, which is contradictory with early school start times. Likewise, shift workers with constantly changing schedules may find it difficult to keep a consistent bedtime, and their sleep may suffer as a result.

Even among healthy adults, some people are programmed to wake up earlier and some people prefer to wake up later. It’s increasingly recognized that jobs that require early wake times may cause chronic insomnia and secondary health conditions for night owls7. Emerging research also suggests that women8 have a shorter circadian rhythm and require more sleep than men.

Pregnancy, menopause, or medical conditions can all interfere with sleep, as can sleep disorders such as restless legs syndrome, sleep apnea, REM sleep behavior disorder, narcolepsy, and gastroesophageal reflux disease (GERD). If you think a secondary health condition could be causing sleep issues, reach out to your healthcare provider to help manage your symptoms.

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How to Wake Up Feeling Refreshed

Ideally, you won’t even need an alarm clock to wake up at the proper time. If you’re getting enough sleep, your body will wake up on its own.

During the night, we cycle through four stages of sleep. Stage one and stage two sleep are considered light sleep, as our bodies prepare to enter a deeper slumber. Stage three sleep is known as slow-wave sleep, when the body carries out repairs and growth. Finally, stage four or rapid eye movement (REM) sleep is when we dream.

It typically takes about 90 minutes to cycle through all four stages of sleep, with time spent in REM sleep increasing as the night goes on. To wake up feeling well-rested, we must get sufficient amounts of both slow-wave and REM sleep.

We feel most refreshed9 when we wake up during light (stage one or two) sleep. By contrast, waking up during slow-wave sleep can cause feelings of grogginess10, and waking up from a vivid dream during REM sleep may be disorienting.

In an attempt to time the alarm with the end of a sleep cycle, some people calculate their bedtime by counting backwards from their preferred wake-up time. However, it’s important to note that sleep cycles can vary in length, even within the same night, and disruptions or difficulties falling asleep can throw off the schedule.

A more sustainable way to train your body to wake up at the right time is to keep a consistent routine, practice proper sleep hygiene, and ensure you get enough hours of sleep overall. Monitoring how you feel when you wake up within the context of this routine can help you identify areas that you might need to adjust. A wearable device or smartphone app may help you track your sleep architecture so you can better plan your night.

Sleep Hygiene Tips for Better Sleep

Sleep hygiene refers to the concept of adopting certain daytime and nighttime habits to improve your sleep. The idea is that by sending day-night cues to your body clock, you’ll be able to establish a circadian rhythm and get better sleep at night.

  • Create the Right Bedroom Environment: A dark, cool, and quiet bedroom should help you drift off. To avoid associating your bed with work or other stimuli, it should be reserved for sleeping and sex. Investing in a better mattress, pillow, or sheets may help you feel more comfortable.
  • Stick to Your Schedule: Waking up and going to bed at the same time every day is one of the best ways to beat insomnia. Trying to catch up on missed sleep by sleeping in on weekends is disruptive to your circadian rhythm, so a short nap in the early afternoon may be a better option if you’re suffering from sleep debt. And, since fragmented sleep is not as refreshing, try to wake up the first time your alarm goes off instead of hitting snooze.
  • Limit Technology: Blue screens have an arousing effect, so sleep experts recommend turning off your phone an hour before bed and silencing notifications. Avoid turning the overhead light on if you wake up in the middle of the night, using a nightlight instead if necessary.
  • Harness Sunlight: Exposure to daylight early in the day can help you regain a more natural circadian rhythm11. It also improves the quality12 of your sleep, leading to longer periods of slow-wave sleep.
  • Exercise and Eat Well: Exercising and eating well can actually help you sleep better at night, as long as you don’t exercise too late in the day. Avoid eating big meals too close to bedtime, especially if you suffer from heartburn, and reduce your alcohol and caffeine intake as these stimulants can disrupt sleep.
  • Relax: If stress is keeping you up at night, try practicing yoga, meditation, or other relaxation techniques. Many people find that a soothing bedtime routine helps them get sleepy in preparation for bedtime. This may include things like reading a book, taking a bath, brushing your teeth, and putting on pajamas. If you find yourself tossing and turning for more than 15 minutes, get up and do an alternate relaxing activity for a while before trying to sleep again.
  • Use Sleep Aids with Caution: Melatonin, sleeping pills, CBD oil, and other sleep aids have been used successfully by many people, but they may have side effects and should only be used as a last resort.

References

  • 1.Chaput, J. P., Dutil, C., & Sampasa-Kanyinga, H. (2018). Sleeping hours: what is the ideal number and how does age impact this?. Nature and science of sleep, 10, 421–430.https://doi.org/10.2147/NSS.S163071
  • 2.Trotti L. M. (2017). Waking up is the hardest thing I do all day: Sleep inertia and sleep drunkenness. Sleep medicine reviews, 35, 76–84.https://doi.org/10.1016/j.smrv.2016.08.005
  • 3.Medic, G., Wille, M., & Hemels, M. E. (2017). Short- and long-term health consequences of sleep disruption. Nature and science of sleep, 9, 151–161.https://doi.org/10.2147/NSS.S134864
  • 4.Rivera, A. S., Akanbi, M., O’Dwyer, L. C., & McHugh, M. (2020). Shift work and long work hours and their association with chronic health conditions: A systematic review of systematic reviews with meta-analyses. PloS one, 15(4), e0231037.https://doi.org/10.1371/journal.pone.0231037
  • 5.National Institute of Neurological Disorders and Stroke. (n.d.). Brain Basics: Understanding Sleep | National Institute of Neurological Disorders and Stroke. NIH. Retrieved November 9, 2020, fromhttps://www.ninds.nih.gov/Disorders/patient-caregiver-education/understanding-sleep
  • 6.A.D.A.M. Medical Encyclopedia. (2018, July 12). Sleep disorders in older adults. Retrieved November 9, 2020, fromhttps://medlineplus.gov/ency/article/000064.htm
  • 7.Jones, S. E., Tyrrell, J., Wood, A. R., Beaumont, R. N., Ruth, K. S., Tuke, M. A., Yaghootkar, H., Hu, Y., Teder-Laving, M., Hayward, C., Roenneberg, T., Wilson, J. F., Del Greco, F., Hicks, A. A., Shin, C., Yun, C. H., Lee, S. K., Metspalu, A., Byrne, E. M., Gehrman, P. R., … Weedon, M. N. (2016). Genome-Wide Association Analyses in 128,266 Individuals Identifies New Morningness and Sleep Duration Loci. PLoS genetics, 12(8), e1006125.https://doi.org/10.1371/journal.pgen.1006125
  • 8.Santhi, N., Lazar, A. S., McCabe, P. J., Lo, J. C., Groeger, J. A., & Dijk, D. J. (2016). Sex differences in the circadian regulation of sleep and waking cognition in humans. Proceedings of the National Academy of Sciences of the United States of America, 113(19), E2730–E2739.https://doi.org/10.1073/pnas.1521637113
  • 9.Hilditch, C. J., & McHill, A. W. (2019). Sleep inertia: current insights. Nature and science of sleep, 11, 155–165.https://doi.org/10.2147/NSS.S188911
  • 10.Howard S. K. (2005). Sleep deprivation and physician performance: why should I care?. Proceedings (Baylor University. Medical Center), 18(2), 108–113.https://doi.org/10.1080/08998280.2005.11928045
  • 11.Stothard, E. R., McHill, A. W., Depner, C. M., Birks, B. R., Moehlman, T. M., Ritchie, H. K., Guzzetti, J. R., Chinoy, E. D., LeBourgeois, M. K., Axelsson, J., & Wright, K. P., Jr (2017). Circadian Entrainment to the Natural Light-Dark Cycle across Seasons and the Weekend. Current biology : CB, 27(4), 508–513.https://doi.org/10.1016/j.cub.2016.12.041
  • 12.Wams, E. J., Woelders, T., Marring, I., van Rosmalen, L., Beersma, D., Gordijn, M., & Hut, R. A. (2017). Linking Light Exposure and Subsequent Sleep: A Field Polysomnography Study in Humans. Sleep, 40(12), zsx165.https://doi.org/10.1093/sleep/zsx16