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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Assessment of insomnia and sleep quality among patients with Type 2 diabetes


1 Internal Medicine, Malla Reddy Medical College for Women, Suraram, Hyderabad, Telangana, India
2 Department of Internal Medicine, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana, India

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Date of Submission26-Jan-2022
Date of Decision13-Feb-2022
Date of Acceptance16-Feb-2022
Date of Web Publication04-Aug-2022
 

  Abstract 


Background: Type 2 diabetes and insomnia are common health issues which have a detrimental relationship with each other. Clinical management of diabetes in patients with poor sleep quality is a challenge. Therefore, understanding the correlation between the diabetic status, the presence of diabetes-related complications, and poor sleep quality among diabetic patients can help physicians in the better management of such cases. Objective: The objective of this study was to study the sleep quality among patients with type 2 diabetes. Materials and Methods: A cross-sectional study was carried out among 200 patients with type 2 diabetes. “The Pittsburgh Sleep Quality Index (PSQI)” questionnaire was used to document the quality of sleep. HbA1c and fasting blood sugar were estimated. Complications of diabetes were assessed using investigations such as electrocardiography, urine albumin, and other relevant investigations as and when indicated. Type of treatment was recorded from the preexisting prescription. Binary logistic regression analysis was used to calculate the adjusted odds ratio. Results: The mean age was 55.08 ± 13.02 years. Forty-five percent reported fairly good subjective sleep quality. 26.5% had 31–60 min sleep latency. Fifty-one percent had sleep duration of more than 7 h. Habitual sleep efficiency was >85% in 82.5% of study participants. 58.5% had sleep disturbances for less than a week. Ninety-five percent did not use any sleep medication and 62% had no daytime dysfunction during the past month. The prevalence of poor sleep quality was 52%. Among all the factors studied for association with poor sleep quality, only the presence of complications of diabetes were found to be significantly associated with poor sleep quality after adjusting for other factors (adjusted odds ratio = 4.33; 95% confidence interval = 2.13–8.78; P = 0.000). Conclusion: The prevalence of poor sleep quality among diabetics in the present study was high. This association was noted only with the presence of complications of diabetes. Hence, efforts to prevent complications of diabetes by regular follow-up and appropriate treatment along with regular screening for complications can prevent complications associated with diabetes and hence prevent poor sleep quality.

Keywords: Diabetes, insomnia, Pittsburgh Sleep Quality Index, questionnaire, sleep quality


How to cite this URL:
Karumanchi S, Mallela VR, Alam KC, Pendurthi AK, Manjula B S, Pakalapati A. Assessment of insomnia and sleep quality among patients with Type 2 diabetes. APIK J Int Med [Epub ahead of print] [cited 2022 Sep 25]. Available from: https://www.ajim.in/preprintarticle.asp?id=353259





  Introduction Top


In modern society with the advent of urbanization and social networking, irregular sleep patterns have become the norm. Multiple studies have shown that irregular sleep, lack of sleep, and frequent awakenings lead to glucose intolerance. Type 2 diabetes mellitus (DM) is a metabolic disorder characterized by high levels of blood sugar. Due to complications arising out of diabetes and due to poor glycemic control, patients can have disturbed sleep or irregular sleep patterns. Therefore, type 2 DM and poor sleep quality are harmful to each other as sleep disorders can favor the development of type 2 diabetes and poor diabetic control often leads to sleep disorders.[1]

As per 2019 statistics, globally about 463 million or 9.3% population are known to be affected with diabetes. This number is expected to increase to 700 million in absolute numbers or 10.9% by 2045. Diabetes is a public health problem not only in developing countries but also in the developed world.[2]

Adequate, undisturbed sleep plays an important role in keeping a person healthy. Sleep plays a major role in maintaining bodily functions, neuroendocrine regulation, and glucose metabolism in the body. The lack of sleep can lead to insulin resistance, at the same time, decreased leptin and increased ghrelin which in turn lead to increased food intake and sedentary behavior leading to obesity and diabetes. Hence, sleep is such an essential factor in maintaining regular bodily functions efficiently.[3],[4]

Good sleep in known diabetic patients has many advantages. It helps to regulate the insulin levels, it also preserves the body's calorie intake, decreases the chances of behavior that is not healthy and many more. However, diabetics are exposed to the risk of poor quality of sleep. The most common complaint is the initiation of sleep and/or maintenance of sleep. There is excessive somnolence. The sleep-wake schedule is disturbed. It is also seen to be associated with more sleepiness during the daytime. They tend to use a greater number of sleep pills compared to their nondiabetic counterparts.[5]

Poor quality of sleep is a common health problem in patients with known diabetes. It has been estimated that about 47.6% of people with known diabetes have poor quality of sleep.[6]

There are many reasons for poor quality of sleep among diabetic patients. It can be due to myalgias, sleep disturbances due to nighttime awakenings for urination, episodes of hypoglycemia, burning pains due to diabetic neuropathy, etc., Poor sleep quality adversely affects the day-to-day functioning of the patient leading to increased morbidity. It can lead to impairment of the functions of the central nervous system resulting in poor judgment and excessive fatigue and daytime sleepiness depriving their capacity to work efficiently. Poor quality of sleep among diabetics depends on certain factors such as age, sex, addictions, environment and body mass index, etc.[7]

Poor quality of sleep among diabetics can even affect their adherence to their prescription. This can have severe consequences in terms of increase in complications. Cognitive functionality can be impaired. They are exposed to the risk of depression and stroke.[8]

Clinical management of diabetes in patients with poor sleep quality is a challenge. Therefore, understanding the correlation between the diabetic status, the presence of diabetes-related complications and poor sleep quality among diabetic patients can help physicians in the better management of such cases. Hence, with this background, the present study was carried out to study the prevalence and risk factors associated with poor quality of sleep among patients with type 2 diabetes.


  Materials and Methods Top


Permissions, ethics, and informed consent

The Institutional Ethics Committee permission was obtained vide letter no. MRIMS-DHR-IEC-94/2021 dated November 27, 2021. Informed consent was obtained from all study participants.

  • Study design: Cross-sectional study
  • Study duration: Two months from December 2021 to January 2022
  • Place of study: Malla Reddy Hospital, Hyderabad
  • Sample size: A total of 200 patients with type 2 diabetes were included in this study.


Inclusion criteria

  1. Age more than 18 years of either gender
  2. Patients with type 2 diabetes.


Exclusion criteria

  1. Individuals not willing to give the data or not willing to participate in the study
  2. Patients with type 1 DM
  3. Patients with sleep disturbances due to other known causes
  4. Pregnant women.


Methodology

Know diabetic status was confirmed from the previous prescription of the patients irrespective of the duration of diabetes. Other causes of sleep disturbances were ruled out.

”Pittsburgh Sleep Quality Index (PSQI)”[9] was used to document the quality of sleep among selected individuals in the present study. The questionnaire does not include the identifying information of the patients, and thus, confidentiality can be ensured. It is a self-administered questionnaire. It is a standardized one. It effectively measures the quality of sleep. It includes seven components related to the “subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction.” The score ranges from 0 to 21. The total for an individual is called as “global score of PSQI.”[10] If the total score for an individual is more than or equal to five, it is considered poor quality of sleep.[9] It tells that the particular individual is having a problem with at least two components. Good quality of sleep is when the score is <5.[11] The PSQI is a valid instrument to assess the quality of sleep with Cronbach's alpha of 0.83.[12]

HbA1c and fasting blood sugar were estimated using standard techniques and guidelines for all included patients. All other details were recorded as per the predesigned, pretested, and semi-structured study questionnaire. Complications of diabetes were assessed using investigations such as electrocardiography, urine albumin, and other relevant investigations as and when indicated based on the history and thorough clinical examination. Type of treatment was recorded from the preexisting prescription.

Statistical analysis

The data were entered in the Microsoft Excel worksheet and analyzed using proportions and mean. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was calculated using binary logistic regression analysis.


  Results Top


The mean age was 55.08 ± 13.02 years. The mean duration of diabetes was about 7 years. The fasting and postprandial blood sugar were raised as well as HbA1c was also raised. Males and females were almost equal. 65.5% of the patients had some or other associated comorbidity. Forty-seven percent had some addictions such as tobacco use or alcohol use. Sixty-nine percent of the cases had one or the other complication associated with diabetes. Seventy-seven percent were on oral hypoglycemic drugs [Table 1].
Table 1: Baseline characteristics of the study participants

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Forty-five percent reported fairly good subjective sleep quality. 26.5% had 31–60 min sleep latency. Fifty-one percent had sleep duration of more than 7 h. Habitual sleep efficiency was >85 in 82.5% of study participants. 58.5% had sleep disturbances for less than a week. Ninety-five percent did not use any sleep medication and 62% had no daytime dysfunction during the past month [Table 2].
Table 2: Distribution of the study participants as per the Pittsburgh Sleep Quality Index components

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The overall prevalence of poor sleep quality was 52%, while 48% had good sleep quality [Table 3].
Table 3: The prevalence of poor sleep quality among diabetics

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[Table 4] shows the results of the binary logistic regression model. Among all the factors studied for association with poor sleep quality, only the presence of complications of diabetes was found to be significantly associated with poor sleep quality after adjusting for other factors (AOR = 4.33; 95% CI = 2.13–8.78; P = 0.000). All other factors were not found to be associated with poor sleep quality in the present study.
Table 4: Factors associated with poor sleep quality among diabetics

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  Discussion Top


The mean age was 55.08 ± 13.02 years. The mean duration of diabetes was about 7 years. The fasting and postprandial blood sugar were raised as well as HbA1c was also raised. Males and females were almost equal. 65.5% of the patients had some or other associated comorbidity. Forty-seven percent had some addictions such as tobacco use or alcohol use. Sixty-nine percent of the cases had one or the other complication associated with diabetes. Seventy-seven percent were on oral hypoglycemic drugs. Forty-five percent reported fairly good subjective sleep quality. 26.5% had 31–60 min sleep latency. Fifty-one percent had sleep duration of more than 7 h. Habitual sleep efficiency was >85 in 82.5% of study participants. 58.5% had sleep disturbances for less than a week. Ninety-five percent did not use any sleep medication and 62% had no daytime dysfunction during the past month. The overall prevalence of poor sleep quality was 52%, while 48% had good sleep quality. Among all the factors studied for association with poor sleep quality, only the presence of complications of diabetes was found to be significantly associated with poor sleep quality after adjusting for other factors (AOR = 4.33; 95%CI = 2.13–8.78; P = 0.000). All other factors were not found to be associated with the poor sleep quality in the present study.

Birhanu et al.[13] studied 430 cases of diabetes. The overall prevalence of poor sleep quality was 47.2% which is comparable to the present study of 52%. They found that alcohol use, smoking, comorbidity, poor glycemic control, and depression were significantly associated with the poor sleep quality. While we found that all these factors were not associated with the poor sleep quality in the present study, complications of diabetes were associated with the poor sleep quality.

Khandelwal et al.[5] in their review of “common sleep disorders associated with type 2 diabetes stated that type 2 diabetes is commonly associated with the more incidence of disorders of sleep. They also noted that this association could be due to diabetes itself or its associated complications or comorbidities. Obesity, type 2 diabetes, and metabolic syndrome are also associated with the erratic sleep behavior and reduced duration of sleep. They recommended that all diabetics should be assessed for the presence of the disorders of the sleep and quality of the sleep.

Darraj et al.[14] studied 307 diabetic patients. They noted that 55.4% of the diabetics had poor sleep quality, and this is also comparable to the findings of the present study of 52%. They also noted that the factors such as increasing age, lack of education, smoking, presence of complications of diabetes, presence of associated comorbidities, and presence of psychological symptoms were significantly associated with the poor sleep quality among diabetics. Whereas, we found that only the presence of complications of diabetes was significantly associated with the poor sleep quality.

Barakat et al.[15] found that among 1211 patients with type 2 diabetes, the prevalence of poor sleep quality was very high at 81%. This is very high compared to the present and other studies mentioned above. They also found that high HbA1c, being female, smoking, lack of employment, and use of insulin were significantly associated with the poor sleep quality. All these factors were not found to be significantly associated with the poor sleep quality in the present study.

Cho et al.[15] investigated disturbances of sleep in 614 type 2 diabetes cases. 48.2% had insomnia and 8.5% had excessive daytime sleepiness. Forty-nine percent were poor sleepers. The author found that HbA1c is not associated with the sleep disturbances which are similar to the present study finding. The author recommended that in cases with type 2 diabetes, it is important to make patients aware about the sleep quality to improve their quality of life.

Luyster et al.[16] studied 300 cases of type 2 diabetes for the assessment of sleep quality and insomnia. They found that the prevalence of poor sleepers was 55% which is similar to the finding of the present study of 52%. They also used the PSQI. The poor sleep quality was found to be significantly predicting the poor quality of life.

Zhang et al.[17] studied diabetes-specific quality of life among 944 patients with type 2 diabetes. They observed that the poor quality of sleep and depression symptoms increased the diabetes-specific quality of life. The presence of these two factors reduced the diabetes-specific quality of life by 3.96 points which were statistically significant.

Limitations of the study

The present study was a single-center study with limited sample size. However, the results are concurrent with large-scale study which is compared in the discussion section. We did not take into account the effect of other drugs such as those used for neuropathy etc., which may have sedation action and thus may affect the study results. This is the major limitation of the present study. Another limitation is that the study is based on the history given by the patients, and thus, the reliability may be of concern. This limitation was tested in the discussion section while comparing with other studies and found similar results in most aspects with other studies.


  Conclusion Top


The prevalence of poor sleep quality was high in the present study among patients with type 2 diabetes. More than half of the diabetics were suffering from poor sleep quality. The presence of complications of diabetes was a significant predictor of poor sleep quality in this population. Hence, emphasis should be given for the early diagnosis of type 2 diabetes in the general population. Patients should be educated upon treatment compliance and lifestyle modifications to delay or prevent the complications. It is also necessary to make them aware about sleep disturbances so that they can take appropriate steps to prevent the poor sleep quality. This will improve their overall quality of life while having type 2 diabetes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Birhanu TT, Hassen Salih M, Abate HK. Sleep quality and associated factors among diabetes mellitus patients in a follow-up clinic at the University of Gondar comprehensive specialized hospital in Gondar, Northwest Ethiopia: A cross-sectional study. Diabetes Metab Syndr Obes 2020;13:4859-68.  Back to cited text no. 13
    
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Correspondence Address:
Amith Kumar Pendurthi,
Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajim.ajim_20_22




 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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    -  Mallela VR
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    -  Manjula B S
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