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Relationship between Nocturnal Hypoglycemia and Sleep Quality in T1D

Nocturnal Hypoglycemia and Sleep Quality


This study delves into the complex interplay between nocturnal hypoglycemia (NH) and subjective sleep quality among individuals with type 1 diabetes (T1D). A group of twenty-seven adults diagnosed with T1D participated in this research, utilizing the Freestyle Libre Pro Continuous Glucose Monitoring (CGM) system to monitor glucose levels.

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They reported their daily sleep quality using a Likert scale. Various metrics related to NH, including frequency, duration, area under the curve (AUC), nocturnal mean glucose, Time in Range (3.9–10 mmol/L), and glucose variability, were meticulously calculated and analyzed.

The study found that nights with NH < 3.9 mmol/L were associated with lower sleep scores compared to nights without NH. Moreover, higher frequency and longer duration of NH < 3.9 mmol/L were significantly linked to poorer sleep quality. Interestingly, NH < 3.0 mmol/L metrics did not exert a significant impact on sleep quality.

These findings suggest that recurrent NH episodes at the lower threshold might have a more substantial effect on subjective sleep quality, potentially indicating a lack of awareness among individuals with a higher NH burden.

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Introduction: Unraveling the Impact of Nocturnal Hypoglycemia on Sleep Quality in Type 1 Diabetes

The quality of sleep among individuals diagnosed with type 1 diabetes is influenced by multifaceted factors, with nocturnal hypoglycemia (NH) emerging as a significant contributor. Chronic sleep disturbances are prevalent in this demographic, and Nocturnal Hypoglycemia, nocturia due to hyperglycemia, and scheduled nighttime glucose checks are known culprits disrupting sleep patterns.

These disturbances not only impact immediate well-being, leading to irritability, distraction, and decreased energy levels but also pose long-term health risks such as glucose intolerance, hypertension, and pro-inflammatory states, especially concerning in a population already predisposed to metabolic complications.

Furthermore, disrupted sleep could impede learning, work productivity, and overall quality of life for individuals diagnosed with type 1 diabetes, potentially affecting them from a young age and throughout their lives.

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Exploring Nocturnal Hypoglycemia: Implications for Sleep Quality

The impact of NH on sleep quality remains a subject of intense investigation and variation in findings. While symptomatic NH is known to disrupt sleep patterns overtly, a considerable portion of NH occurrences, even below clinically significant thresholds like 3 mmol/L and 2.2 mmol/L, are asymptomatic.

Studies have indicated a diminished awakening threshold during NH among individuals with type 1 diabetes and possibly increased sleep efficiency during these episodes. Paradoxically, asymptomatic hypoglycemia has also been correlated with altered sleep quality in some studies, while others have found no such association.

Technological advancements in diabetes management, particularly real-time Continuous Glucose Monitoring (RT-CGM) and closed-loop systems, have shown promising but inconsistent effects on subjective sleep quality. Consequently, the relationship between NH and sleep quality remains heterogeneous.

Understanding Nocturnal Hypoglycemia Characteristics and Sleep Quality

The diverse glycemic characteristics of NH present a significant challenge in understanding its impact on sleep quality. While continuous glucose monitoring has facilitated detailed characterization of NH, most experimental studies have focused on inducing prolonged single episodes of hypoglycemia, failing to capture the heterogeneity of real-life nocturnal hypoglycemia. Nocturnal Hypoglycemia episodes vary in duration, depth, frequency, and even the levels of hypoglycemia experienced.

Despite technological advancements allowing for detailed monitoring, there remains a dearth of comprehensive data linking the duration, depth, frequency, and nocturnal glucose variability of NH to sleep quality among individuals with type 1 diabetes. This study aims to bridge this gap by examining how these heterogeneous characteristics of Nocturnal Hypoglycemia collectively impact subjective sleep quality in this population.

Methodology: Investigating NH and Sleep Quality Relationships

This pilot study recruited adults diagnosed with type 1 diabetes from the Diabetes and Metabolism Centre at Singapore General Hospital. The study, approved by the SingHealth Central Institutional Review Board, adhered to relevant guidelines and regulations. Participants wore Freestyle Libre Pro blinded CGM systems and self-reported their sleep quality daily using a 5-point Likert Scale.

Demographic and diabetes-related data were collected via questionnaires. Metrics for NH (< 3.9 mmol/L & < 3 mmol/L), including episodes, duration, AUC, nocturnal mean glucose, Time-in-Range (3.9–10 mmol/L), and glucose variability (coefficient of variation), were calculated and analyzed. Mixed models and regression analyses were employed to assess the relationships between sleep scores and glycemic indices, adjusting for relevant factors.

Insights from NH Analysis and Sleep Scores

The cohort, comprising 27 adults with T1D, exhibited a median HbA1c of 7.4% and various insulin delivery methods, with a notable proportion experiencing nocturnal hypoglycemia. Analysis of sleep scores across nights with and without NH revealed a significant impact of NH < 3.9 mmol/L on subjective sleep quality, particularly concerning higher frequency and longer duration of these episodes.

Interestingly, Nocturnal Hypoglycemia < 3.0 mmol/L metrics did not exert a considerable influence on sleep quality. This indicates a nuanced relationship between NH characteristics and subjective sleep quality, underscoring the potential lack of awareness among individuals experiencing higher NH burden regarding its impact on sleep.

Discussion: Implications for Diabetes Management and Sleep Quality

The findings emphasize the significance of recurrent episodes of Level 1 NH in influencing subjective sleep quality among individuals with type 1 diabetes. In contrast, prolonged episodes of Level 2 Nocturnal Hypoglycemia did not exhibit a significant impact on sleep scores despite their longer duration.

This observation highlights potential subjective unawareness among individuals experiencing extended and deep NH episodes, posing challenges in identifying those at the highest risk based on symptoms alone.

The complex relationship between nocturnal mean glucose and sleep quality further adds depth to understanding sleep disturbances in this population. This study suggests a need for continuous glucose monitoring and comprehensive sleep assessment strategies to optimize care for individuals with type 1 diabetes.

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Conclusion: Implications for Future Research and Clinical Care

Recurrent episodes of Level 1 nocturnal hypoglycemia, rather than prolonged Level 2 episodes, significantly impact subjective sleep quality in individuals with type 1 diabetes.

These findings underscore the potential lack of awareness among individuals experiencing higher Nocturnal Hypoglycemia burdens, making it challenging to diagnose solely based on symptomatic cues.

The study also highlights the intricate relationship between nocturnal hypoglycemia characteristics and subjective sleep quality, emphasizing the necessity for more detailed characterization of NH in future research.

This understanding will aid in developing more tailored and effective strategies for managing NH-related sleep disturbances in individuals with type 1 diabetes.