American Diabetes Association Conference Highlights: Sleep and Glucose Control

Overcoming barriers to sleep and assisting families with sleep hygiene aids in glucose management

With Michelle A. Van Name MD, Sarah S. Jaser PhD, and Michelle Perfect PhD

Studies show that inconsistent sleep timing and duration, particularly social jet lag, or extended bedtimes and wake times on weekends, are more strongly linked with impacting glycemic control than sleep duration. One of the best recommendations doctors can make is for patients to aim for consistent bedtimes and wake times.

Mounting evidence suggests that sleep loss along with insufficient sleep impact patients with both type 1 and type 2 diabetes. At an American Diabetes Association conference session titled "Diabetes Meets the Sandman: Sleep, Diabetes, and Glycemic Management," experts discussed current research about what can be done to assist patients with type 1 diabetes in particular to improve sleep and their management of diabetes in the process. Here, some highlights touching on how technology can help, identifying and overcoming the barriers, and information on a clinical trial designed to help families work together on managing diabetes.

Technology to the rescue

Parents of young children with type 1 diabetes worry often about their children's time out of range at night, said Michelle Van Name MD, assistant professor of pediatrics at Yale University School of Medicine. Her session, "Technology and Overnight Diabetes Management: Is Nighttime Still the Worst Time?" focused on research suggesting that yes, it is, and moved on to the remedy of technology.

She cited the DirectNet study, which found of the participants with type 1 diabetes, ages 4-10: ''During overnight, at best half their time was in range." That was regardless of whether they had continuous glucose monitoring (CGM).

"No wonder parents worry," Dr. Van Name said, citing her research from 2018, which polled parents of 549 children under the age of seven with a mean diabetes duration of 2.4 years and a mean HbA1c of 8.2%. She found that the greatest worries were related to hypoglycemia during sleep and other times when it would be difficult to detect it.

''Based on this data, it's not surprising that parents remain worried about hypoglycemia," she said. Specific worries from parents of diabetic children included:

  • A child not recognizing a low episode
  • A parent not being around to help
  • Long-term complications of a low episode 
  • Having a low episode while asleep

Recently, results of the SENCE Study Group (of which Dr. Van Name is a member) six-month study were published. ''We enrolled 143 kids, age 2 to 7," Dr. Van Name said. They were randomized to CGM plus family behavioral intervention, standard CGM and no CGM.

In her talk, she focused on the overnight time period. ''There is really no change in time in range during the study," she said. Much lower time in hypoglycemia was seen in both CGM groups, however, compared to no CGM. There was improvement in worry among parents from the CGM groups, she said.

Young children have high variability of insulin requirements, Dr. Van Name said, citing findings in a study of hybrid closed-loop systems in children, teens and adults.

With what she calls a sharp, recent increase in CGM use among children, Dr. Van Name says the next important question is: Will real-time CGM improve overnight blood sugars in young children, along with improving quality of life for parents?

Parents cannot stay up all night responding to alerts and managing ever changing insulin needs," Van Name said. Semi-automatic insulin delivery systems are critically needed to address these issues.

Research is progressing on hybrid closed loop systems, she said, for younger age groups.

How to help teens and children with diabetes sleep better

To help teens and children with diabetes sleep better, it's important to first know the barriers, said Sarah S. Jaser, PhD, associate professor of pediatrics at Vanderbilt University Medical Center, Nashville. Findings from her research include:  

  • Shifts in circadian rhythm at puberty. "It's harder to wake up," she said. "If they wake up at 6 am, it feels like 4 am
  • Extracurricular activities, social media, and other screen time
  • A large ''sleep debt" from lack of sleep
  • Inconsistent sleep patterns, with under sleeping on weekdays and over sleeping on weekends.

Dr. Jaser and her colleagues also asked about strategies to improve sleep,  including:

  • Relaxation apps on the phone
  • Using ''white noise" machines
  • Watching television (although usually viewed as a barrier)
  • Enforcing early bedtime (parents' suggestions)

Dr. Jaser's team then put that information to the test, with her Sleep Coach Intervention Study. She randomized 19 teens to usual care and 20 to the sleep coach intervention.The sleep-coached group received educational information on healthy sleep and completed three individual phone sessions.

Follow-up data were collected at three months, including interviews with teens and parents. Eighty percent of teens did all three sessions. Based on actigraphy data, a significant improvement in sleep duration and efficacy was observed, with a 48-minute increase in duration. Those in the control group were 7.5 times more likely to report poor sleep quality after three months than the coached group.

Dr. Jaser tells Endocrine Web: "Studies show that inconsistent sleep timing and duration, particularly social jet lag, or extended bedtimes and wake times on weekends, are more strongly linked with impacting glycemic control than sleep duration. One of the best recommendations doctors can make is for patients to aim for consistent bedtimes and wake times."

Involving families to improve sleep habits in chidren with diabetes

"We need to take a comprehensive approach to evaluating sleep in both adults and children with diabetes," said Michelle Perfect PhD, associate professor at the University of Arizona, Tucson.

That includes sleep disordered breathing, inconsistent sleep, inadequate sleep, poor sleep quality and daytime sleepiness, she said. It's a lot to tackle, she acknowledged.

In her recent research, Dr. Perfect has examined the effect of a ''sleep extension" intervention on glucose control in youth with type 1 diabetes. In an RCT, she looked at whether increasing sleep duration over a one-week period in a youth's natural environment improved glucose control (the team also looked at neurobehavioral performance). In the study, 111 youth, ages 10-16, were randomized to a sleep extension condition or fixed sleep.

Those in the extension group were instructed to extend their sleep to 10 hours a night, or by one hour, whichever was longer. Those in the fixed group were told to continue as they usually did in terms of amount of sleep.

Over one week, 80% increased sleep by more than 15 minutes, and one-third increased it by one hour. The average increase, as verified by actigraphy and a sleep diary, was 43 minutes in the extension group and .30 in the fixed group.

The blood glucose in the extension group was lower than the fixed sleep group by 17 mg/dl points (p=.003).

Dr. Perfect is continuing to study the effect of lengthening sleep time in her ongoing NIH-sponsored clinical trial, FREADOM (Family Routines Enhancing Adolescent Diabetes by Optimizing Management). It began in June, 2017 and is expected to finish in June, 2021. The aim is to determine the effect of sleep extension on glycemic control as well as psychosocial functioning. Dr. Perfect hopes to enroll 175 youth with type 1 diabetes, assigning them to the sleep extension group or assigning them to follow the routine their doctor has set up for them.

Drs. Van Name, Jaser and Perfect have no disclosures.

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