Extension Rural Health & Nutrition

Getting Restful Sleep with Diabetes: A Guide to Practicing Good Sleep Hygiene

Posted on by mbales
Initiating quality sleep begins with creating a conducive environment around you. This concept is known as sleep hygiene and encompasses items such as creating a comfortable bedroom space, minimizing unnecessary light, and practicing positive bedtime behaviors. Image Credit: RHN Team Picture Bank

Sleep: An Overview

Sleep is an essential component of human health and well-being. On average, individuals spend approximately 1/3 (33%) of their lives asleep, underscoring the critical role sleep plays in maintaining normal physiological and cognitive function.  Without sufficient sleep, the human body cannot sustain its optimal performance or maintain long-term health. This is because sleep is an incredibly complex biological process that affects nearly every type of bodily tissue and organ system in the body.

Sleep can be defined as a state of altered consciousness in which the brain transitions through different stages of activity. While wakefulness is characterized by the active processing of information and decisions that one faces in the external world, sleep, on the other hand, provides the brain time to fully process and store the information collected, heal the body, and consolidate memories. Collectively, this helps maximize physical and mental health functions, immunity, disease resistance, and metabolism. Therefore, without a consistent restful night of sleep, individuals with poor sleep patterns may experience inadequate health outcomes, which may include impaired insulin secretion and utilization, altered cardiometabolic function (such as an elevation in blood pressure), and disruptions in hormone secretion, including an increase in ghrelin (the hunger hormone) and a decrease in leptin (the fullness hormone). These shifts in bodily function may contribute to overeating, weight gain, metabolic disorders, and increase the likelihood that an individual may receive a future chronic disease diagnosis.

Stages of Sleep:

To comprehend how sleep impacts health, it is essential to understand the distinct stages of sleep. There are five stages that make up the sleep cycle: Wake, N1, N2, N3, and Rapid Eye Movement (REM). Among the stages mentioned, N1, N2, and N3 are collectively known as non-rapid eye movement (NREM) sleep.

During the NREM sleep stages, the body’s parasympathetic nervous system is activated. This is the part of the autonomic nervous system (a set of bodily controls that moderates bodily functions, such as organ function) that is responsible for the body’s “rest and digest” conditions. This shift essentially places the body into autopilot mode, and during these stages of sleep, a physiological shift occurs that allows brain activity, heart rate, and breathing to slow. As the body transitions through the NREM sleep stages, one experiences a state of total relaxation, allowing for bodily reparation and improved organ function.

In contrast, the REM stage follows the N3 stage and is characterized by heightened brain activity that often resembles wakefulness. This is the stage of sleep where one usually experiences dreams. Individuals in REM sleep often display fluttering eyelids, and most notably, their muscles are paralyzed to prevent the physical enactment of dreams.

Across a typical night, an individual cycles through these stages four to five times, with one full sleep cycle taking roughly 90 – 110 minutes to complete. As the night progresses, the NREM cycles become shorter while the REM cycle becomes longer and more pronounced. This supports deep physiological restoration in the body, which helps individuals wake up feeling refreshed.  

Learn more about the five sleep stages below:

  1. Wake: Wakefulness represents the stage where an individual begins their transition between alertness and sleep. During this period, the body undergoes a process of initial relaxation where breathing and heart rate begin to slow down, and the individual shifts into the first true stage of sleep.
  2. N1 (Stage 1, NREM): The N1 sleep stage accounts for approximately 5% (10 minutes) of the total sleep time and is categorized as the lightest of the sleep stages. During the N1 sleep stage, an individual can still be easily woken from external noise and touch. As the body’s muscle activity begins to slow and decline further, brain waves that initiate activity also begin to slow, allowing one to transition to the second sleep stage.
  3. N2 (Stage 2, NREM): The N2 sleep stage, often referred to as light sleep, lasts for roughly 30-60 minutes of a sleep cycle, encompassing 50% of one’s total sleep time. During the N2 stage, muscles continue to relax, while heart rate and respiratory rate slow, and one’s bodily temperature decreases. This stage is often viewed as a transitional phase to deep sleep, preparing the body for its most pronounced physical restoration.
  4. N3 (Stage 3, NREM): The N3 sleep stage, also known as deep sleep, typically lasts between 20-40 minutes per cycle. It is the most restorative of the sleep stages, during which time brain waves slow even further, making arousal from this stage difficult. During the N3 stage, the body can truly repair itself. This includes the regrowth of tissues, bones, and muscles, as well as the strengthening of the immune system.
  5. Rapid Eye Movement (REM): After leaving the NREM sleep stages, the body enters REM sleep, which accounts for roughly 25% of one’s sleep during the night. During this stage, brain wave patterns become heightened again, resembling what one might experience during wakefulness. As the night progresses, the REM stage lengthens from roughly 10 minutes early in the night to nearly 1 hour before the time one wakes. It is during this time that people most often dream, and most people wake up during or immediately following an episode of REM.

Sleep and Our Health:

Sleep plays a critical role in maintaining cardiovascular, metabolic, and overall physiological health. During non-rapid eye movement sleep (stages N1, N2, and N3), the parasympathetic nervous system takes control of the body, resulting in a decrease in heart rate and blood pressure. This shift supports bodily recovery and cardiovascular resilience. However, during rapid eye movement (REM) sleep and periods of wakefulness, our body’s sympathetic nervous system is activated, which increases brain wave activity and, subsequently, increases one’s heart rate and blood pressure. Because of this, individuals who experience insufficient sleep or who wake up multiple times a night have a higher risk of developing cardiovascular complications such as hypertension (high blood pressure), heart disease, and obesity, but are also at an elevated risk for experiencing cerebrovascular events such as a stroke, and/or cardiovascular events such as a heart attack.

Beyond the potential cardiovascular implications resulting from a lack of sleep, being sleep-deprived is strongly linked to an increase in metabolic dysregulation or dysfunction, particularly insulin resistance. Insulin resistance is a key indicator in the development of type 2 diabetes and reflects the body’s inability to effectively secrete (release) insulin or properly utilize glucose within the body. This can make a lack of sleep a serious problem for those diagnosed with diabetes. However, it is not only one’s insulin secretion process that can be damaged by a lack of sleep; research also demonstrates that less sleep disrupts hormones that are required for appetite management. This can lead to an overconsumption of sugary, fat-laden foods and eating that extends longer into the evening, which increases total caloric consumption throughout the day, and can lead to weight gain and further worsen diabetes symptoms.

Sleep deprivation symptoms are now seen as so vitally important for those with diabetes that sleep has recently been added to the American Diabetes Association’s (ADA) Standards of Care in Diabetes, which is the gold standard in evidence-based care and intervention strategies for diagnosing and managing the symptoms of diabetes, as well as preventing the onset of diabetes in individuals with a diagnosis of prediabetes. 

Understanding the Link Between Cardiovascular Health, Diabetes, and Sleep

Diabetes is a significant risk factor for the development of cardiovascular disease. The cardiovascular system, comprising the heart, arteries, and veins, is responsible for pumping and circulating blood throughout the body, which carries glucose (the body’s primary source of energy), oxygen, white blood cells (pathogen fighters that keep the body healthy), and platelets (responsible for clotting factors). In individuals with diabetes, blood sugar levels are persistently higher, which typically indicates a greater viscosity (thickness) of one’s blood. Thicker, sugary, sticky blood can be harder to circulate throughout the body, and this can put stress, strain, and pressure on the body’s heart, arteries, and vessels. This may further contribute to elevated blood pressure, the hardening of arteries (atherosclerosis), and the development of clots, which can lead to a heart attack or stroke. Additionally, the lack of blood, nutrients, and oxygen circulation to peripheral tissues, such as the fingers, hands, toes, and feet, can lead to other problems, including neuropathy. This can eventually develop into numbness, weakness, or even pain in the affected extremities. Neuropathic discomfort often intensifies at night, and this example of symptom progression may only worsen one’s sleep outcomes. Those with advanced neuropathy often discuss sleep disruption as a side effect of their condition; this may only further aggravate symptoms related to cardiovascular disease and diabetes.  

Circadian Synchrony and Self-Care Behaviors

Two of the most influential self-care behaviors, physical activity and consuming a high-quality, nutritious diet, are closely interconnected to sleep quality. Together, these three self-care behaviors work in tandem within the body’s biological framework, representing a phenomenon known as circadian synchrony. Circadian synchrony refers to the alignment of daily self-care behaviors, including sleeping well, eating healthily, and engaging in regular physical activity.  It recognizes that these behaviors operate in a cyclical rhythm to produce better health outcomes, where one behavior influences the next.

For example, individuals who eat a nutritious diet are more likely to engage in physical activity, which can then promote restorative sleep. Conversely, consistent and sufficient sleep may influence an individual’s feelings of focus, motivation, and energy, which may subsequently increase the likelihood that one will begin their day engaging in positive behaviors such as consuming a healthy breakfast and exercising. The combination of these self-care behaviors together in synchronicity can reduce the acceleration of a chronic disease diagnosis, as well as the associated symptoms. When these behaviors work together, they contribute to an overall increase in metabolic function and emotional health outcomes and can help reduce or prevent the progression and severity of chronic disease symptoms.

Influencing Positive Sleep Outcomes

Sleep hygiene refers to the behaviors and environment that facilitate restful sleep. Engaging in poor sleep hygiene practices and behaviors can potentially diminish the quality and quantity of sleep. As many with diabetes have a difficult time getting restful sleep due to symptoms previously mentioned, establishing a strong sleep hygiene routine can help set the stage for more restful and restorative sleep.

Sleep Hygiene Strategies:

  1. Establish a regular bedtime schedule/routine
    • Go to bed at the same time every night, even on weekends! Sticking to a specific bedtime helps to regulate the body’s circadian rhythm and internal clock. It also improves sleep quality and overall physical health.
  2. Create a bedroom environment that is comfortable and ideal for one’s sleep needs
    • Consider using a white noise machine if one needs sounds in the background. One’s bedroom should also be at a comfortable temperature. Use a fan for better air circulation and cooler temperatures. The room should be free of excess light, meaning the television and other devices should be turned off before preparing for bed.
  3. Avoid stimulants before bedtime
    • Minimize caffeine intake at least 4 to 6 hours before heading to bed. Caffeine blocks adenosine receptors in the brain, which prevents one from feeling sleepy. Adenosine is a neurotransmitter that accumulates in the brain during the day and promotes sleep; however, when caffeine is consumed, adenosine cannot bind to its receptor, and therefore, tiredness does not occur. Therefore, to promote sleep, it is recommended to limit or avoid caffeinated beverages and foods.
  4. Engage in positive lifestyle behaviors
    • Exercising daily and consuming a healthy diet are great places to start! Regular exercise can help one fall asleep more easily when it’s time. In addition to eating a healthy diet, avoid large meals and spicy foods before bed, as they can cause indigestion or acid reflux that could prevent one from falling asleep.
  5. Avoid screens as much as possible
    • Put the phone down and turn the TV off at least 30 minutes before going to bed. The blue light emitted from most devices interferes with the production of melatonin, the main hormone that regulates our sleep cycles.
  6. Engage in positive coping strategies
    • Try a variety of self-care behaviors such as journaling, taking a hot shower, or reading before bedtime to help wind down. Self-care is a great way to set the stage for better sleep, as it induces relaxation and helps relieve stress.
  7. Use the bedroom for sleep
    • Limit the amount of time spent simply lounging in bed. This will train the body to associate your bed with going to sleep. Consider removing a television or other distractions that may encourage spending time in the bedroom for purposes other than rest.
  8. Limit daytime napping
    • Avoid taking naps throughout the day, as this will cause one to be less sleepy when it’s bedtime, making it much harder to fall asleep.

Conclusion:

Striving for restful sleep is an important part of one’s overall wellness routine. However, this may be an especially important area of concern for those living with a chronic disease diagnosis like diabetes or cardiovascular disease. While many may struggle with restful sleep due to a whole host of symptoms, working to influence our environment and establish better bedtime practices within the environment around us may be a good place to make changes that can have a positive outcome on the duration of sleep, blood sugar levels, and cardiometabolic outcomes.

For more recommendations on diabetes and sleep, check out this video from the American Diabetes Association: Spotlight on Diabetes Education: Diabetes and Sleep.

References:

Authors:

  • Julianna Lyle, Rural Health and Nutrition Extension, Anderson and Abbeville Counties
  • Elizabeth McCabe, UPIC Intern, Rural Health and Nutrition

Reviewed By:

  • Melissa Bales, Extension Associate, Rural Health and Nutrition
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