Insomnia is associated with an increased risk of type 2 diabetes in the clinical setting

Sleep problems and their predictors in community-dwelling older adults with diabetes in India: Evidence from the Longitudinal Ageing Study in India

Objectives

To ascertain the prevalence and predictors of sleep disorders and poor sleep quality among older adults with Diabetes (DM) in India, and to assess the relationship between sleep quality and DM.

Methods

Data was utilized from the nationally representative Longitudinal Ageing Study in India (Wave-1, 2017-18), with a total sample of 66606 older adults (≥45 years) selected for the study. Sleep problems and sleep quality score were assessed using an adaptation based on the Jenkins Sleep Scale. Multivariate linear and logistic regressions were conducted to determine the effect of sociodemographic and clinical factors on sleep quality. Mediation analysis (Karlson-Holm-Breen) was done to assess the direct and indirect effects of independent variables on the sleep quality scores. Further, Propensity score matching (PSM) was done to assess the impact of diabetes on sleep problems.

Results

The prevalence of DM was 12.34% (n = 8564, 95% CI: 11.54, 13.20) among whom 24.38% (95% CI: 21.38, 27.65) reported sleep problems. On adjusted analysis, sleep problems were significantly associated with increasing education, higher wealth quintile, lack of physical activity, and multimorbidity. Mediation analysis showed adherence to anti-diabetes medication improved sleep quality (aB = -0.28 (95% CI: -0.54, -0.02)), while comorbidities worsened sleep quality (aB = 0.79 (95% CI: 0.67, 0.92)). Analysis from PSM indicated that DM was associated with a 6.2% higher chance of sleep problems.

Conclusions

Poor sleep quality is present in nearly one in four individuals diagnosed with DM in India and linked with certain adverse social determinants. Focused interventions to improve assessment and treatment of sleep problems in resource-limited primary care settings require prioritization.

Chronic insomnia, high trait anxiety and their comorbidity as risk factors for incident type 2 diabetes mellitus

The main objective of this study was to evaluate the association of the insomnia-anxiety comorbidity with incident type 2 diabetes (T2D) in a large prospective cohort. We selected adults without diabetes at baseline from the French NutriNet-Santé cohort who had completed the trait anxiety subscale of the Spielberger State-Trait Anxiety Inventory (STAI-T, 2013-2016) and a sleep questionnaire (2014); insomnia was defined according to established criteria. Using multivariable Cox models, we compared T2D risk across 4 groups: no insomnia or anxiety (reference), insomnia alone, anxiety alone (STAI-T ≥ 40), and comorbid anxiety and insomnia. Among 35,014 participants (mean baseline age: 52.4 ± 14.0 years; 76% women), 378 (1.1%) developed T2D over a mean follow-up of 5.9 ± 2.1 years. Overall, 28.5% of the sample had anxiety alone, 7.5%-insomnia alone, and 12.5%-both disorders. In the fully-adjusted model, a higher T2D risk was associated with anxiety-insomnia comorbidity (HR = 1.40; 95% CI 1.01, 1.94), but not with each disorder separately, compared to the group without insomnia or anxiety. The findings supported a positive association between anxiety-insomnia comorbidity and incident T2D among general-population adults. Future research using clinical diagnoses of mental disorders could confirm the findings and guide diabetes prevention programs.

Sleep Characteristics are Associated with Risk of Treated Diabetes Among Postmenopausal Women

OBJECTIVE

The purpose of this study was to determine whether sleep characteristics are associated with incidence of treated diabetes in postmenopausal individuals.

METHODS

Postmenopausal participants ages 50-79 years reported sleep duration, sleep-disordered breathing, or insomnia at baseline and again in a subsample 3 years later. The primary outcome was self-reported new diagnosis of diabetes treated with oral drugs or insulin at any time after baseline. Multivariable Cox proportional hazards models were used.

RESULTS

In 135,964 participants followed for 18.1 (± 6.3) years, there was a nonlinear association between sleep duration and risk of treated diabetes. Participants sleeping ≤5 hours at baseline had a 21% increased risk of diabetes compared with those sleeping 7 hours (adjusted hazard ratio [aHR] 1.21; 95% confidence interval [CI], 1.00-1.47). Those who slept for ≥9 hours had a nonsignificant 6% increased risk of diabetes compared with those sleeping 7 hours (aHR 1.06; 95% CI, 0.97-1.16). Participants whose sleep duration had decreased at 3 years had a 9% (aHR 1.09; 95% CI, 1.02-1.16) higher risk of diabetes than participants with unchanged sleep duration. Participants who reported increased sleep duration at 3 years had a risk of diabetes (HR 1.01; 95% CI, 0.95-1.08) similar to those with no sleep duration change. Participants at high risk of sleep-disordered breathing at baseline had a 31% higher risk of diabetes than those without (aHR 1.31; 95% CI, 1.26-1.37). No association was found between self-reported insomnia score and diabetes risk.

CONCLUSIONS

Sleep-disordered breathing and short or long sleep duration were associated with higher diabetes risk in a postmenopausal population.

Assessing the Real-World, Long-Term Impact of Lemborexant on Sleep Quality in a Home-Based Clinical Study

Purpose

Both subjective and objective evaluations are essential for the treatment of insomnia. Lemborexant has been shown to be effective in the long-term based solely on a subjective basis, and no long-term objective measures have been evaluated under natural sleep conditions. Small, lightweight sleep electroencephalogram (EEG) monitor was used, instead of polysomnography, to objectively evaluate sleep at home 4 and 12 weeks after lemborexant treatment.

Patients and Methods

Adults and elderly subjects with insomnia disorder, per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, were enrolled in this open-label, single-arm, single-center trial. Objective and subjective measures of sleep were prospectively assessed. Sleep disturbance, excessive sleepiness, and depressive symptoms were assessed using questionnaires.

Results

A total of 45 subjects were screened, of which 33 were enrolled. Paired t-tests were conducted to evaluate changes in sleep variables and compared with the baseline; subjects showed significant improvements in objective sleep efficiency (SE) and subjective sleep parameters at weeks 4 and 12 following treatment with lemborexant. When baseline values were taken into account, a repeated-multivariate analysis of variance (MANOVA) revealed statistically significant changes in the objective measures. Sleep disturbance, excessive sleepiness, and depressive symptoms improved after three months of lemborexant treatment.

Conclusion

Furthermore, lemborexant therapy improved nocturnal sleep, when measured objectively using sleep EEG monitoring at home, and improved daytime sleepiness and depressive symptoms in older adults with insomnia disorder.

Insomnia symptoms as risk factor for somatic disorders: An umbrella review of systematic reviews and meta-analyses

The objective of this umbrella review is to present a comprehensive summary of systematic reviews and meta-analyses on the longitudinal association between insomnia and the risk of developing somatic disorders. Pubmed, Medline, CINAHL, PsycInfo and PsycArticles were searched until 16 December 2022. Fourteen systematic reviews and meta-analyses met the inclusion criteria. Results suggest that insomnia symptoms (i.e. aspects of disturbed sleep continuity as a single symptom) convey a risk factor for cardiovascular diseases, hypertension and thyroid cancer. The presence of insomnia symptoms may also enhance the risk for obesity, cognitive decline and dementia-however, results are contradictory and not conclusive here. Results do not suggest an association between insomnia symptoms and mortality. No conclusions can be drawn regarding insomnia disorder because the reviews did not ensure a valid diagnosis. It remains unclear what proportion of participants with insomnia symptoms fulfil diagnostic criteria for insomnia disorder and/or suffer from an organic sleep disorder such as sleep-related breathing disorder. Moreover, most of the included reviews were assessed to have critically low confidence according to the AMSTAR-2 tool. Inconsistent definitions of insomnia and methodological unclarities further underline that results should be interpreted with caution. There is a need for future longitudinal studies that focus on a careful definition and differential diagnosis of both insomnia and the outcome.

The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).

Unraveling the associations and causalities between glucose metabolism and multiple sleep traits

Purpose

The aim of our study is to estimate the associations and causalities of glucose metabolism traits of fasting blood glucose (FBG), fasting insulin (FINS), glycosylated hemoglobin (HbA1c), and 2-h glucose post-challenge (2hGlu) with sleep traits consisting of excessive daytime sleepiness (EDS), insomnia, and sleep duration.

Methods

We employed standard quantitative analysis procedures to assess the associations between sleep traits and glucose metabolism. Moreover, we acquired published genome-wide association studies (GWAS) summary statistics for these traits and conducted Mendelian randomization (MR) analyses to estimate their causal directions and effects. Inverse variance weighting (IVW) was employed as the primary approach, followed by sensitivity analyses.

Results

A total of 116 studies with over 840,000 participants were included in the quantitative analysis. Our results revealed that participants with abnormal glucose metabolism had higher risks for EDS (OR [95% CI] = 1.37 [1.10,1.69]), insomnia (OR [95% CI] = 1.65 [1.24,2.20]), and both short and long sleep duration (OR [95% CI] = 1.35 [1.12,1.63]; OR [95% CI] = 1.38 [1.13,1.67] respectively). In addition, individuals with these sleep traits exhibited alterations in several glycemic traits compared with non-affected controls. In MR analysis, the primary analysis demonstrated causal effects of 2hGlu on risks of EDS (OR [95% CI] = 1.022 [1.002,1.042]) and insomnia (OR [95% CI] = 1.020[1.001,1.039]). Furthermore, FINS was associated with short sleep duration (OR [95% CI] = 1.043 [1.018,1.068]), which reversely presented a causal influence on HbA1c (β [95% CI] = 0.131 [0.022,0.239]). These results were confirmed by sensitivity analysis.

Conclusion

Our results suggested mutual risk and causal associations between the sleep traits and glycemic traits, shedding new light on clinical strategies for preventing sleep disorders and regulating glucose metabolism. Future studies targeting these associations may hold a promising prospect for public health.

Association Between Insomnia Symptoms and Trajectory With the Risk of Stroke in the Health and Retirement Study

BACKGROUND AND OBJECTIVES

Insomnia is a common condition affecting more than a third of the US population. However, the link between insomnia symptoms and stroke is understudied and the underlying mechanism remains unclear. This study aimed to investigate the relationship between insomnia symptoms and the incidence of stroke.

METHODS

The Health and Retirement Study, a survey of Americans older than 50 years and their spouses, from 2002 to 2020 was used as the data source. Only those who were stroke-free at baseline were included in this study. The exposure variable was insomnia symptoms and was derived from self-reported sleep-related factors including difficulty initiating sleep, difficulty maintaining sleep, waking up too early, and nonrestorative sleep. Repeated-measures latent class analysis was used to identify insomnia trajectories over time. To investigate the relationship between insomnia symptoms and stroke events reported during the follow-up period, Cox proportional hazards regression models were used. Mediation analyses of comorbidities were performed using causal mediation within a counterfactual framework.

RESULTS

A total of 31,126 participants were included with a mean follow-up of 9 years. The mean age was 61 years (SD = 11.1) and 57% were females. Insomnia symptom trajectories remained constant over time. Compared with those with no insomnia symptoms, an increased risk of stroke was observed for those with insomnia symptom scores ranging from 1 to 4 and 5 to 8 (hazard ratio (HR) = 1.16, 95% confidence interval (CI) 1.02-1.33) and (HR = 1.51, 95% CI 1.29-1.77), respectively, indicating a dose-response relationship. The association was stronger in participants younger than 50 years (HR = 3.84, 95% CI 1.50-9.85) than in those aged 50 years and older (HR = 1.38, 95% CI 1.18-1.62), comparing those with insomnia symptoms ranging from 5 to 8 with those with no insomnia symptoms. This association was mediated by diabetes, hypertension, heart disease, and depression.

DISCUSSION

Insomnia symptoms were associated with an increased risk of stroke, especially in adults younger than 50 years, and the risk was mediated by certain comorbidities. Increased awareness and management of insomnia symptoms may contribute to the prevention of stroke occurrence.

Economic burden of comorbid insomnia in 5 common medical disease subgroups

STUDY OBJECTIVES

Approximately 85% of insomnia co-occurs with other disorders. Whereas insomnia was once considered "secondary" to these disorders, it is now widely recognized as an independent condition warranting treatment. While it is clear that insomnia can affect the course of other medical conditions, there is scant literature on the economic impact of comorbid insomnia among patients with common medical conditions. The aim of this study was to determine the economic burden of comorbid insomnia in 5 medical diseases commonly associated with insomnia: type 2 diabetes mellitus (T2DM), cancer undergoing treatment, menopause undergoing hormone replacement therapy, osteoporosis, and Alzheimer's disease and related dementias (ADRDs).

METHODS

This retrospective cohort study used claims data from the IBM MarketScan Commercial and Medicare Supplemental Databases from January 1, 2014, through December 31, 2019. Insomnia and comorbid disease groups were defined using physician-assigned International Classification of Diseases diagnostic codes. Insomnia medication treatment was defined based on ≥1 prescription fills for the most commonly prescribed insomnia medications (zolpidem, low-dose trazodone, and benzodiazepines [as a class]). For each comorbid disease subgroup, 4 cohorts were created: (1) patients with either treated or untreated insomnia, (2) non-sleep-disordered controls, (3) patients with untreated insomnia, and (4) patients with treated insomnia.

RESULTS

Sample sizes for individuals with comorbid insomnia ranged from 23,168 (T2DM) to 3,015 (ADRDs). Within each disease subgroup and relative to non-sleep-disordered controls, patients with comorbid insomnia demonstrated greater adjusted health care resource utilization and costs across most points of service. Likewise, relative to individuals with untreated insomnia, those with treated insomnia generally demonstrated greater adjusted health care resource utilization and costs.

CONCLUSIONS

In this national analysis, both untreated comorbid insomnia and comorbid insomnia treated with commonly prescribed insomnia medications were associated with increased health care resource utilization and costs across most points of service.

CITATION

Wickwire EM, Juday TR, Kelkar M, Heo J, Margiotta C, Frech FH. Economic burden of comorbid insomnia in 5 common medical disease subgroups. J Clin Sleep Med. 2023;19(7):1293-1302.

Identifying complementary and alternative medicine recommendations for insomnia treatment and care: a systematic review and critical assessment of comprehensive clinical practice guidelines

Background

There is a need for evidence-informed guidance on the use of complementary and alternative medicine (CAM) for insomnia because of its widespread utilization and a lack of guidance on the balance of benefits and harms. This systematic review aimed to identify and summarize the CAM recommendations associated with insomnia treatment and care from existing comprehensive clinical practice guidelines (CPGs). The quality of the eligible guidelines was appraised to assess the credibility of these recommendations.

Methods

Formally published CPGs incorporating CAM recommendations for insomnia management were searched for in seven databases from their inception to January 2023. The NCCIH website and six websites of international guideline developing institutions were also retrieved. The methodological and reporting quality of each included guideline was appraised using the AGREE II instrument and RIGHT statement, respectively.

Results

Seventeen eligible GCPs were included, and 14 were judged to be of moderate to high methodological and reporting quality. The reporting rate of eligible CPGs ranged from 42.9 to 97.1%. Twenty-two CAM modalities were implicated, involving nutritional or natural products, physical CAM, psychological CAM, homeopathy, aromatherapy, and mindful movements. Recommendations for these modalities were mostly unclear, unambiguous, uncertain, or conflicting. Logically explained graded recommendations supporting the CAM use in the treatment and/or care of insomnia were scarce, with bibliotherapy, Tai Chi, Yoga, and auriculotherapy positively recommended based on little and weak evidence. The only consensus was that four phytotherapeutics including valerian, chamomile, kava, and aromatherapy were not recommended for insomnia management because of risk profile and/or limited benefits.

Conclusions

Existing guidelines are generally limited in providing clear, evidence-informed recommendations for the use of CAM therapies for insomnia management due to a lack of high-quality evidence and multidisciplinary consultation in CPG development. More well-designed studies to provide reliable clinical evidence are therefore urgently needed. Allowing the engagement of a range of interdisciplinary stakeholders in future updates of CPGs is also warranted.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=369155, identifier: CRD42022369155.

Type 2 Diabetes and Its Association With Psychiatric Disorders in Young Adults in South Korea

Importance

Because type 2 diabetes (T2D) has become increasingly prevalent among young adults, the study of the association of T2D with psychiatric disorders in young adults is important for early detection and timely intervention.

Objective

To determine whether a diagnosis of a psychiatric disorder is associated with increased risk of developing T2D in young adults.

Design, Setting, and Participants

This large-scale prospective cohort study used data collected by the South Korean National Health Insurance Service between 2009 and 2012, representing 97% of the South Korean population. Young adults aged 20 to 39 years with and without diagnoses of psychiatric disorders were included in the study. Young adults with missing data and those with a history of T2D were excluded from the study. The cohort was followed up to monitor development of T2D until December 2018. Data were analyzed from March 2021 to February 2022.

Exposure

Diagnosis of 1 of 5 psychiatric disorders, including schizophrenia, bipolar disorder, depressive disorder, anxiety disorder, and sleep disorder.

Main Outcomes and Measures

The primary outcome was newly diagnosed T2D during a follow-up period of 7.59 years. The incidence rate of T2D was calculated as the number of new cases per 1000 person-years during the follow-up period. The Cox proportional hazards regression model was used to estimate the hazard ratios (HRs) and 95% CIs for T2D incidence. Exploratory analyses were performed for subgroups stratified by age and sex.

Results

In total, 6 457 991 young adults (mean [SD] age, 30.74 [4.98] years; 3 821 858 men [59.18%]) were followed up, including 658 430 individuals with psychiatric disorders. The cumulative incidence of T2D differed significantly between individuals with and without psychiatric disorders (log-rank test, P < .001). Incidence rates of T2D for individuals with and without psychiatric disorders were 2.89 and 2.56 per 1000 person-years, respectively. Individuals with a diagnosis of any psychiatric disorder showed a higher risk of developing T2D than those without a diagnosis (adjusted HR, 1.20; 95% CI, 1.17-1.22). The adjusted HRs for T2D were 2.04 (95% CI, 1.83-2.28) for individuals with schizophrenia, 1.91 (95% CI, 1.73-2.12) for individuals with bipolar disorder, 1.24 (95% CI, 1.20-1.28) for individuals with depressive disorder, 1.13 (95% CI, 1.11-1.16) for individuals with anxiety disorder, and 1.31 (95% CI, 1.27-1.35) for individuals with sleep disorder.

Conclusions and Relevance

In this large-scale prospective cohort study of young adults, 5 psychiatric disorders were significantly associated with an increased risk of developing T2D. Young adults with schizophrenia and bipolar disorder in particular were at a higher risk of T2D. These results have important implications for early detection of and timely intervention in T2D for young adults with psychiatric disorders.

'It's like Taking a Sleeping Pill': Student Experience of Autonomous Sensory Meridian Response (ASMR) to Promote Health and Mental Wellbeing

Autonomous Sensory Meridian Response (ASMR) is purposely elicited by some individuals to promote health and mental wellbeing. The aim of the current study was to explore how ASMR is used and its perceived benefits in a student population. We employed semi-structured qualitative interviews, with eight female students who self-reported as ASMR-sensitive users. Inductive thematic analysis, underpinned by a phenomenological framework, was applied to the data. Two themes, each with three subthemes, were identified; these highlighted the journey from first discovering ASMR to present experience and the use of ASMR to promote health and mental wellbeing both directly and indirectly. For some, ASMR was used daily, whilst for others it was used in a relapsing-remitting fashion: usage increased when struggling with mental wellbeing and was most often used as a tool to induce sleep or distraction when feeling anxious. Participants also reported ASMR-eliciting content as intriguing, and that the phenomenon was regarded as taboo. ASMR appears to play an important role in promoting health and mental wellbeing; frequency of use, preferred triggers, and purpose of use varied, highlighting its flexible and subjective nature. It provides a potential cost-effective tool in populations such as students where mental health needs are burgeoning.

Improvement of Insomnia Symptoms following a Single 4-Hour CBT-I Workshop

STUDY OBJECTIVES

: Cognitive behavioral treatment for insomnia (CBT-I) is the first line of treatment for insomnia. However, the expanded use of CBT-I is limited by the number of specialty-trained clinicians in addition to the duration and cost of individual treatment sessions. One viable option is a single-session educational group format delivered by a trained health educator.

METHODS

: In a preliminary, single group pretest-posttest design, the effectiveness of group CBT-I delivered to community dwelling individuals with self-reported insomnia symptoms was evaluated. Participants completed the Insomnia Severity Index (ISI) and provided information on sleep aid use, prior to and 1-month post attendance of a single 4-hour CBT-I workshop.

RESULTS

: Participants (N = 45) were 54 ± 16 years and 71% female. ISI scores significantly improved from baseline (20.09 ± 4.1) to 1-month follow-up (11.89 ±5.7; t = 10.1, p < .001) with an average change of 8.2 ± 5.4 points. Frequency of sleep aid use significantly dropped (χ² = 105.7, p = .017). Eighty percent of participants reported sleeping better or much better at follow-up. Twenty percent of participants met criteria for remission of insomnia and 35.6% of participants had ISI change scores meeting criteria for a Minimally Important Difference associated with improvements in fatigue, work productivity, and health related quality of life.

CONCLUSIONS

: These preliminary data suggest that a single 4-hour CBT-I workshop delivered by a health educator can significantly improve insomnia symptoms, improve subjective sleep quality, and reduce sleep aid use among community dwelling adults with and without co-morbidities within 1-month.

Sleep Problems and New Occurrence of Chronic Conditions during the COVID-19 Pandemic in the UK

The COVID-19 pandemic has negatively impacted upon sleep health. Relatively little is known about how this may influence the population's health subsequently. This prospective longitudinal study aims to examine the consequences of sleep problems for physical and mental health during the COVID-19 pandemic in the UK, using data from the Understanding Society: COVID-19 Study, a large-scale population-based survey with 12,804 adults aged 16 and above. A measure of sleep problems was derived from Pittsburgh Sleep Quality Index (PSQI) questions, reflecting seven dimensions of sleep quality. Binary logistic regressions were applied to investigate the relationship between sleep problem and the incidence of cardiovascular disease (CVD), hypertension, diabetes, obesity, arthritis and an emotional, nervous or psychiatric problem over the 15 months follow-up period. The analysis confirms that sleep problems are prevalent and vary between sub-groups among adults. Notably, sleep problems are then significantly associated with a higher risk of cardiovascular disease, hypertension, diabetes, obesity, arthritis and emotional, nervous or psychiatric problems, independent of demographic, socioeconomic, familial and health confounders. Our findings suggest promoting good sleep hygiene should be prioritised during the pandemic, and more generally as part of wider programmes aimed at promoting good physical and mental health.

Variant-to-gene-mapping analyses reveal a role for pancreatic islet cells in conferring genetic susceptibility to sleep-related traits

We investigated the potential role of sleep-trait associated genetic loci in conferring a degree of their effect via pancreatic α- and β-cells, given that both sleep disturbances and metabolic disorders, including type 2 diabetes and obesity, involve polygenic contributions and complex interactions. We determined genetic commonalities between sleep and metabolic disorders, conducting linkage disequilibrium genetic correlation analyses with publicly available GWAS summary statistics. Then we investigated possible enrichment of sleep-trait associated SNPs in promoter-interacting open chromatin regions within α- and β-cells, intersecting public GWAS reports with our own ATAC-seq and high-resolution promoter-focused Capture C data generated from both sorted human α-cells and an established human beta-cell line (EndoC-βH1). Finally, we identified putative effector genes physically interacting with sleep-trait associated variants in α- and EndoC-βH1cells running variant-to-gene mapping and establish pathways in which these genes are significantly involved. We observed that insomnia, short and long sleep-but not morningness-were significantly correlated with type 2 diabetes, obesity and other metabolic traits. Both the EndoC-βH1 and α-cells were enriched for insomnia loci (p = .01; p = .0076), short sleep loci (p = .017; p = .022) and morningness loci (p = 2.2 × 10-7; p = .0016), while the α-cells were also enriched for long sleep loci (p = .034). Utilizing our promoter contact data, we identified 63 putative effector genes in EndoC-βH1 and 76 putative effector genes in α-cells, with these genes showing significant enrichment for organonitrogen and organophosphate biosynthesis, phosphatidylinositol and phosphorylation, intracellular transport and signaling, stress responses and cell differentiation. Our data suggest that a subset of sleep-related loci confer their effects via cells in pancreatic islets.

Sleep behaviours and associated habits and the progression of pre-diabetes to type 2 diabetes mellitus in adults: A systematic review and meta-analysis

INTRODUCTION

Certain sleep behaviours increase risk of type 2 diabetes mellitus (T2DM) in the general population, but whether they contribute to the progression from pre-diabetes to T2DM is uncertain. We conducted a systematic review to assess this.

METHODS

Structured searches were performed on bibliographic databases (MEDLINE, EMBASE and CINAHL) from inception to 26/04/2021 for longitudinal studies/trials consisting of adults⩾18 years with pre-diabetes and sleep behaviours (short or long sleep duration (SD), late chronotype, insomnia, obstructive sleep apnoea, daytime napping and/or night-shift employment) that reported on incident T2DM or glycaemic changes. The Newcastle-Ottawa Scale was used for quality assessment.

RESULTS

Six studies were included. Meta-analysis of three studies (n = 20,139) demonstrated that short SD was associated with greater risk of progression to T2DM, hazard ratio (HR) 1.59 (95% CI 1.29-1.97), I² heterogeneity score 0%, p < 0.0001, but not for long SD, HR 1.50 (0.86-2.62), I² heterogeneity 77%, p = 0.15. The systematic review showed insomnia and night-shift duty were associated with higher progression to T2DM. Studies were rated as moderate-to-high quality.

CONCLUSIONS

Progression from pre-diabetes to T2DM increases with short SD, but only limited data exists for insomnia and night-shift duty. Whether manipulating sleep could reduce progression from pre-diabetes to T2DM needs to be examined.

Sleep Quality among Patients with Type 2 Diabetes: A Cross-Sectional Study in the East Coast Region of Peninsular Malaysia

Poor sleep is related to type 2 diabetes and adversely influences a person’s quality of life. This study aimed to evaluate sleep quality in patients with type 2 diabetes (T2DM), its associated factors, and its relationship with quality of life. A cross-sectional study was conducted at a primary care clinic in a tertiary hospital on the east coast of Malaysia. This study included 350 participants (175 men and 175 women). Data were collected using the Malay version of the Pittsburgh Sleep Quality Index (PSQI-M) with a cut-off point of >5 as poor sleep, the Malay version of Diabetes Distress Scale (MDDS-17) and the revised Malay version of T2DM-related quality of life (Rv-DQOL). Statistical analysis was conducted using the SPSS software version 26.0. The respondents’ median (interquartile range (IQR)) age was 62.0 (11.0) years, and poor sleep was reported in 32% (95% confidence interval (CI) = 27.1, 36.9) of the participants. Multivariate logistic regression analysis revealed that poor sleep quality was significantly associated with nocturia (odds ratio (OR) = 2.04; 95% CI = 1.24, 3.35), restless legs syndrome (OR = 2.17; 95% CI = 1.32−3.56) and emotional burden (OR = 2.37; 95% CI = 1.41−3.98). However, no statistically significant association was observed between sleep quality and quality of life among our participants.

Fall Risk, Healthcare Resource Use, and Costs Among Adult Patients in the United States Treated for Insomnia with Zolpidem, Trazodone, or Benzodiazepines: A Retrospective Cohort Study

INTRODUCTION

Falls are a common cause for morbidity and mortality among patients taking prescription insomnia medication. The objective of this study is to compare the risk of falls, all-cause healthcare resource utilization (HCRU), and costs among patients treated with commonly used, older generation insomnia medications and non-sleep-disordered controls.

METHODS

This retrospective cohort study used the IBM^® MarketScan^® Commercial and Medicare Supplemental Databases to identify patients aged at least 18 years treated with commonly prescribed medications for insomnia (zolpidem, trazodone, benzodiazepines) between 1 January 2012 and 30 September 2017. The insomnia-treated cohort were age- and sex-matched (1:1) to non-sleep-disordered controls. Odds ratios (ORs) compared risk of falls in each cohort, adjusting for covariates. Costs were adjusted to 2018 dollars, the most recent year for the study data.

RESULTS

Relative to matched controls (n = 313,086), the insomnia-treated cohort had a higher rate of falls (3.34% vs. 1.33%), and higher risk of falls [OR = 2.36 (95% confidence interval 2.27-2.44)]. Relative to other index treatments, patients treated with trazodone had the greatest risk of falls. Compared with matched controls, the estimated mean number of inpatient visits, emergency department visits, outpatient visits, and mean length of inpatient stay were all significantly higher among patients treated for insomnia. Such patients incurred greater total costs per patient per month than matched controls ($2100 versus $888; estimated mean ratio, 2.36; 95% CI 2.35-2.38; p < 0.0001).

CONCLUSIONS

Relative to matched controls, the insomnia-treated cohort showed higher risk of falls with greater HCRU and costs. Each outcome measured was highest among patients treated with trazodone, relative to other index treatments. Findings suggest the need for new treatment options to optimize quality of care for patients with insomnia.

Network Mendelian randomization study: exploring the causal pathway from insomnia to type 2 diabetes

INTRODUCTION

Insomnia is a novel pathogen for type 2 diabetes mellitus (T2DM). However, mechanisms linking insomnia and T2DM are poorly understood. In this study, we apply a network Mendelian randomization (MR) framework to determine the causal association between insomnia and T2DM and identify the potential mediators, including overweight (body mass index (BMI), waist-to-hip ratio, and body fat percentage) and glycometabolism (HbA1c, fasting blood glucose, and fasting blood insulin).

RESEARCH DESIGN AND METHODS

We use the MR framework to detect effect estimates of the insomnia-T2DM, insomnia-mediator, and mediator-T2DM associations. A mediator between insomnia and T2DM is established if MR studies in all 3 steps prove causal associations.

RESULTS

In the Inverse variance weighted method, the results show that insomnia will increase the T2DM risk (OR 1.142; 95% CI 1.072 to 1.216; p=0.000), without heterogeneity nor horizontal pleiotropy, strongly suggesting that genetically predicted insomnia has a causal association with T2DM. Besides, our MR analysis provides strong evidence that insomnia is causally associated with BMI and body fat percentage. There is also suggestive evidence of an association between insomnia and the waist-to-hip ratio. At the same time, our results indicate that insomnia is not causally associated with glycometabolism. Higher BMI, waist-to-hip ratio, and body fat percentage levels are strongly associated with increased risk of T2DM.

CONCLUSIONS

Genetically predicted insomnia has a causal association with T2DM. Being overweight (especially BMI and body fat percentage) mediates the causal pathway from insomnia to T2DM.

Insomnia symptoms are associated with an increased risk of type 2 diabetes mellitus among adults aged 50 and older

PURPOSE

To evaluate the association of the different degrees of insomnia symptoms with subsequent incidence of type 2 diabetes mellitus (T2DM).

METHODS

The data were extracted from Health and Retirement Study 2006-2014 waves. The association of insomnia symptoms with T2DM incidence was evaluated by the competing risk model with cumulative incidence function (death was considered a competing event) and Cox proportional hazard model with the Kaplan-Meier method. Population attributable fraction (PAF) was calculated. All analyses related to our study were conducted between November 2020 and January 2021.

RESULTS

A total of 14,112 patients were included in this study, with an average follow-up of 6.4 years, and the incidence density was 17.9 per 1000 person-years. Insomnia symptoms were positively associated with T2DM incidence compared with those with no insomnia symptoms, regardless of competing risk model (≥ 1 symptoms: sub-distribution hazard ratio (SHR) 1.13; 95% confidence interval (CI) 1.02-1.26; P-trend = 0.012) and Cox proportional hazard model (≥ 1 symptoms: hazard ratio (HR) 1.13; 95% CI 1.02-1.26; P-trend = 0.013). The cumulative incidence function (Gray's test, p < 0.001) and Kaplan-Meier estimate (log-rank test, p < 0.001) also presented this positive relationship. This positive association was more apparent in women and participants with ages from 50 to 65 years. The PAF was 4.1% with 95% CI (0.7-7.9%).

CONCLUSIONS

Insomnia symptoms may be an important risk factor for the development of T2DM, which is unbiased by the death competing risk. These findings suggest that management of sleep problems may be an important part of strategies to prevent T2DM.

Comparison of the effect of lemborexant with placebo and zolpidem tartrate extended release on sleep architecture in older adults with insomnia disorder

STUDY OBJECTIVES

Changes to sleep architecture that occur as a result of the normal aging process may also exacerbate insomnia in older individuals. Therefore, this study assessed the impact of lemborexant compared with placebo and zolpidem tartrate extended release on objective sleep architecture parameters, as measured by polysomnography, in older adults (ages ≥ 55 years) with insomnia disorder from a phase 3 study.

METHODS

Study E2006-G000-304 (SUNRISE 1; NCT02783729) was a global, multicenter, randomized, double-blind, placebo-controlled, active comparator (zolpidem)-controlled, parallel-group study comparing 2 dose levels of lemborexant (5 mg and 10 mg). Sleep architecture was measured using polysomnography. Assessments were collected at baseline during a single-blind placebo run-in and during the first 2 nights and last 2 nights of treatment. Mean values for each sleep stage were based on the 2 consecutive polysomnograms.

RESULTS

Treatment with lemborexant resulted in significantly greater increases from baseline in total sleep time compared with both placebo and zolpidem. Significant increases from baseline in rapid eye movement sleep and significant decreases from baseline in latency to rapid eye movement sleep were also observed with lemborexant compared with placebo and zolpidem.

CONCLUSIONS

These findings suggest that treatment with lemborexant may address some of the alterations in sleep architecture normally observed in older individuals with insomnia.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Study of the Efficacy and Safety of Lemborexant in Subjects 55 Years and Older With Insomnia Disorder (SUNRISE 1); URL: https://clinicaltrials.gov/ct2/show/NCT02783729; Identifier: NCT02783729.

Evaluating lemborexant for the treatment of insomnia

INTRODUCTION

Insomnia is a complex sleep disorder that compromises quality of life and affects approximately 10% of the general population. Insomnia, defined as trouble initiating or maintaining sleep associated with impaired daytime function or distress, is treated using a comprehensive approach comprised of cognitive behavioral therapy and pharmacotherapy. Lemborexant, a dual orexin receptor antagonist, is a new pharmacotherapeutic option recently approved for the treatment of insomnia.

AREAS COVERED

Here, the authors describe lemborexant, assess its efficacy and safety profile in clinical trials, and evaluate its role in the current insomnia treatment landscape.

EXPERT OPINION

Lemborexant may offer an improved treatment option compared with other pharmacotherapies for insomnia because it is effective both over the long term and over a wide range of outcome measures. Importantly, lemborexant improves latency to sleep onset and sleep maintenance and is able to help people who experience early morning awakenings. Safety data reveal that lemborexant has minimal residual effects on morning alertness or next day function, and that patients are able to respond to an external auditory stimulus in the middle of the night. In conclusion, lemborexant represents a new, effective, and well-tolerated medication for patients with insomnia.

[Sleep characteristics of a population of patients seeking bariatric surgery]

INTRODUCTION

Investigation for obstructive sleep apnea syndrome (OSAS) is mandatory before bariatric surgery. Data regarding chronic insomnia and chronic sleep deprivation are scarce in this population.

METHODS

A cross-sectional study assessing the prevalence of chronic insomnia, OSAS and chronic sleep privation in an obese population referred for bariatric surgery.

RESULTS

In all, 88 patients (74% women, median age 41 [33.5-50] years and median body mass index 42 [39.2-45.7] kg/m²) were included. The prevalence of chronic insomnia was 31% in the 87% suffering from OSAS that required continuous positive airway pressure therapy. Comorbid insomnia and sleep apnoea (COMISA) were found in 27% of our population. Chronic insomnia was associated with a lower quality of life (median EQ5D analogue visual scale: 60 [50-70] P=0.04) and a poor sleep quality (median Pittsburgh sleep quality index (PSQI): 8 (6-11 P<0.01) The deleterious combination of sleep privation and insomnia had a higher impact in terms of impairment of quality of life and sleep quality (median EQ5D analogue visual scale: 50 [40-65] P=0.02 et median PSQI: 11 [9-14, P<0.01) CONCLUSION: Chronic insomnia and sleep privation have synergistic deleterious effects in candidates for bariatric surgery. Further studies need to be conducted to evaluate the evolution after surgery.

Investigating Causal Relations Between Sleep-Related Traits and Risk of Type 2 Diabetes Mellitus: A Mendelian Randomization Study

Objective

Extensive literature put forward the link between sleep and type 2 diabetes mellitus (T2DM), however, little is known about the underlying causality of the associations. Here we aim to assess the causal relationships between five major sleep-related traits and T2DM.

Design, Setting, and Participants

Two-sample Mendelian randomization (MR) was utilized to investigate the potential causal relations. Independent genetic variants associated with five sleep-related phenotypes—insomnia, sleep duration, short sleep duration, long sleep duration, and morningness—were chosen as instrumental variables to estimate the causal associations with T2DM. Summary statistics were acquired from the genome-wide association studies of UK Biobank and 23andMe (for sleep-related measures), the DIAbetes Genetics Replication And Meta-analysis and the FinnGen (for T2DM).

Main Methods

Individual Cochran’s Q statistic was applied to remove the pleiotropic instruments, global Q statistics and MR-Egger regression were adopted to test for the global heterogeneity and horizontal pleiotropy of the screened instruments, respectively. Two T2DM cohorts were selected to analyze their associations with sleep traits. A modified inverse variance weighted (IVW) estimate was performed to combine the ratio estimators from each instrument and acquire the causal estimate, alternative methods including IVW with first-order weights, simple and weighted median estimations, and MR-Egger regression were conducted as sensitivity analyses, to ensure the robustness and solidity of the findings.

Results

Two-sample MR supported findings for an adverse effect of genetically predicted insomnia on T2DM risk (odds ratio [OR] = 1.14, 95% confidence interval [CI]: 1.09–1.19, p = 1.29E–08) at the Bonferroni-adjusted level of significance (p < 0.005). We further investigated the causal role of T2DM on insomnia but obtained a non-significant estimation. There was also little evidence for the causal effect of other sleep-related measures on T2DM. Results were largely consistent when leveraging two different T2DM cohorts, and were robust among various sensitivity analyses.

Conclusion

Findings provide significant evidence for an adverse effect of insomnia on T2DM risk. The study extends fundamental knowledge to further understanding of the pathophysiological mechanisms of T2DM, and points out the non-negligible role of insomnia on epidemiologic intervention and clinical therapeutics of T2DM.

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

INTRODUCTION

Diabetic mellitus has a negative impact on the quality of sleep. It is one of the leading public health conditions which can result in poor sleep quality. Poor sleep quality is an unreported and unrecognized problem which can affect the prognosis of diabetes patients.

OBJECTIVE

The aim of this study is to assess the prevalence of poor sleep quality and its associated factors among patients with diabetes mellitus attending follow-up clinics at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2019.

METHODS

An institution-based cross-sectional study was conducted among 430 diabetes mellitus patients at the University of Gondar Comprehensive Specialized Hospital from February 1, 2020 to March 28, 2020. A systematic random sampling method was used to reach the study subjects. An interviewer-administered questionnaire was used for data collection. Pittsburgh sleep quality index was used for assessing sleep quality. To explain study variables, frequency tables and percentages were used. A binary logistic regression was conducted to see the relation between dependent and independent variables.

RESULTS

A total of 430 diabetes mellitus patients participated in the study with a response rate of 100%. The overall prevalence of poor sleep quality was 47.2%. Drinking alcohol (AOR = 2.45, 95% CI: 1.28-4.69), smokers (AOR = 6.26, 95% CI: 2.04-19.21), comorbidity (AOR = 1.80, 95% CI: 1.10-2.96), BMI ≥ 30 (AOR = 4.87, 95% CI: 1.07-22.09), having type 2 diabetes mellitus (AOR = 2.16, 95% CI: 1.04-4.50), poor glycemic control (AOR = 2.61, 95% CI: 1.81-4.81) and having depression (AOR = 9.95, 95% CI: 4.85-20.38) were associated with poor sleep quality.

CONCLUSION

In this study, nearly half of the patients had poor sleep quality. Drinking alcohol, smoking, comorbidities, higher BMI, type 2 diabetes mellitus, poor glycemic control and having depression were factors in poor sleep quality. Creating awareness of the need for weight reduction, minimizing alcohol intake, cessation of smoking, and improving sleep hygiene for DM patients would be effective management for improving poor sleep quality.

Sleep Regularity and Cardiometabolic Heath: Is Variability in Sleep Patterns a Risk Factor for Excess Adiposity and Glycemic Dysregulation?

PURPOSE OF REVIEW

Night-to-night variability in sleep patterns leads to circadian disruption and, consequently, could increase cardiometabolic risk. The purpose of this review is to summarize findings from studies published between 2015 and 2020 examining various measures of night-to-night variability in sleep in relation to metabolic syndrome (MetS), type 2 diabetes (T2D), and their risk factors. We illustrate a potential causal pathway between irregular sleep patterns and T2D, highlighting knowledge gaps along the way.

RECENT FINDINGS

Across different measures of sleep variability, irregular sleep patterns were associated with poorer cardiometabolic outcomes. Higher standard deviations (SD) across nights of sleep duration and onset or midpoint of sleep were associated with increased odds of having MetS and clusters of metabolic abnormalities as well as greater adiposity and poorer glycemic control. Conversely, greater regularity of rest-activity patterns related to lower risk for T2D. Social jetlag was associated with glycemic dysregulation, adiposity, T2D, and MetS. These associations are often observed in both metabolically healthy and unhealthy individuals; both higher SD of sleep duration and social jetlag relate to poorer glucose regulation in individuals with diabetes. There is consistent evidence of associations of sleep variability with increased risk for adiposity, glucose dysregulation, T2D, and MetS. Although experimental evidence is needed to determine causation, there is support to recommend stabilizing sleep patterns for cardiometabolic risk prevention.

Which sleep hygiene factors are important? comprehensive assessment of lifestyle habits and job environment on sleep among office workers

BACKGROUND

Although several lifestyle habits are associated with sleep, it is unclear which factors are important. Among office workers, the effect of job environment should also be considered. The multivariate analyses on the effects of lifestyle habits and job environment on sleep among office workers was conducted.

METHODS

A cross-sectional survey of 6,342 employees from 29 companies was conducted in 2017-2019. Complete responses and informed consent were provided by 5,640 participants. The survey examined demographic variables, sleep schedules, Pittsburgh Sleep Quality Index (PSQI), Brief Job Stress Questionnaire (BJSQ), and lifestyle habits.

RESULTS

Mean values were as follows: age, 36.9 years (±10.2); PSQI, 6.52 (±2.83); and total sleep time, 6h06m (±1h40m) on work days and 7h39m (±1h58m) on free days. After adjusting for job environment and demographic variables, irregular meal time (1.45-2.86), not eating vegetables every day (1.35), nightcap (2.74-3.55), weight gain (1.20-1.42), lack of sunlight in the morning in the bedroom (1.48-1.60), waking up before dawn (2.18), electronic display use in bed (1.50), and daily caffeine intake (1.27) were significantly associated with sleep disturbance. Irregular meal time (1.51-2.37), lack of morning breakfast (1.74-2.95), having dinner within 2 hours before bed time (0.49-0.64), not eating vegetables every day (1.52), lack of sunlight exposure in the morning (1.43-2.01), and caffeine use every day (1.42) were also associated with eveningness (p<.01).

CONCLUSION

Each sleep hygiene factor had a different effect size. Sleep hygiene interventions to promote worker sleep health should prioritize factors in accordance with effect size.

Neurobehavioural complications of sleep deprivation: Shedding light on the emerging role of neuroactive steroids

Sleep deprivation (SD) is associated with a broad spectrum of cognitive and behavioural complications, including emotional lability and enhanced stress reactivity, as well as deficits in executive functions, decision making and impulse control. These impairments, which have profound negative consequences on the health and productivity of many individuals, reflect alterations of the prefrontal cortex (PFC) and its connectivity with subcortical regions. However, the molecular underpinnings of these alterations remain elusive. Our group and others have begun examining how the neurobehavioural outcomes of SD may be influenced by neuroactive steroids, a family of molecules deeply implicated in sleep regulation and the stress response. These studies have revealed that, similar to other stressors, acute SD leads to increased synthesis of the neurosteroid allopregnanolone in the PFC. Whereas this up-regulation is likely aimed at counterbalancing the detrimental impact of oxidative stress induced by SD, the increase in prefrontal allopregnanolone levels contributes to deficits in sensorimotor gating and impulse control, signalling a functional impairment of PFC. This scenario suggests that the synthesis of neuroactive steroids during acute SD may be enacted as a neuroprotective response in the PFC; however, such compensation may in turn set off neurobehavioural complications by interfering with the corticolimbic connections responsible for executive functions and emotional regulation.