10 Tips for Better Sleep with Type 1 Diabetes

A Common Scenario

“The low alarm on my CGM goes off at 4 AM, and I get up to double-check with a fingerstick. It’s a real low, not a compression problem, so I take a few glucose tablets from my bedside table. I wait 15 minutes to see what happens. I’m still low, stuck in the 60s, so I drink a few sips of juice and wait another 15 minutes. Finally my blood sugar is over 100, but now there’s an up arrow. Did I overdo it? Am I going to wake up in the 300s feeling awful? My glucose finally starts to level off in the 150s and I turn off my light. Then I stare at the ceiling, hoping I got the correction right, and thinking about how to adjust my insulin tomorrow. I’m worried and I have trouble getting back to sleep. Eventually I give up and get out of bed to start my day, exhausted.”

Sound familiar? Getting a good night’s sleep can be challenging with type 1 diabetes for a variety of reasons. Many people can relate to the frustrating story above that came from one of my patients. Aside from the very real annoyance of alerts and alarms going off at all hours, the majority of people don’t have problems with sleep itself. However, certain people do have a tougher time, and this article will cover common challenges as well as solutions to get better quality shuteye.

The Importance of Sleep in T1D

Endocrinologists are increasingly recognizing the importance of sleep in diabetes care. Several recent studies have demonstrated that reduced sleep quality can impact insulin resistance, glycemic variability, and quality of life in people living with type 1 diabetes. Studies to date have been small and therefore limited in their power to guide clinical care. The NIH (National Institutes of Health), however, has now called for a renewed focus on sleep pathology in type 1 diabetes.

Clinical recommendations consider both sleep duration and quality. The National Sleep Foundation recommends 7-9 hours of sleep nightly for the general adult population. Over a third of adults, however, get less than 6 hours of sleep nightly, and people living with type 1 diabetes may be especially susceptible to sleep disruption. Difficulty falling asleep is described as longer sleep latency. Difficulty staying asleep or frequent awakenings can result in sleep fragmentation. Additionally, sleep stages (light sleep, rapid eye movement (REM), and slow wave/deep sleep) can be disrupted by type 1 diabetes.

Managing Blood Sugars Is Particularly Challenging at Night

Bedtime blood sugar and nighttime hypoglycemia concerns can interfere with the process of falling asleep. High blood sugars can exacerbate frequent urination and increase the number of nighttime bathroom trips. Nighttime low blood sugars can create anxiety and keep people awake: in a recent analysis, >13% of people reported difficulty returning to sleep after an episode of nighttime hypos, and >50% reported increased fatigue the next day. Glycemic variability (lots of unpredictable ups and downs) in type 1 diabetes is associated with reduced deep sleep, altered melatonin signaling, and disrupted circadian rhythms. These issues can affect sleep timing, making it difficult for people to match restorative sleep with rest periods. Sleep disruption then contributes to additional daytime fatigue, difficulty with attention and concentration, and memory impairment. Combined, these burdens make diabetes self-care more difficult and reduce quality of life.

The Relationship between Sleep and Type 1 Diabetes Is a Two-Way Street

T1D interrupts sleep, and impaired sleep makes T1D more difficult to manage. Sleep disruption is associated with higher A1c and greater glycemic variability. Studies demonstrate that even one night of severe sleep deprivation (4 hours or less) increases insulin resistance the next day. People getting up to six hours of sleep may still experience problems with blood sugar levels. In addition, people living with type 1 diabetes are at higher risk for sleep apnea and nighttime high blood pressure. Several studies demonstrate that 28-55% of people living with type 1 diabetes also experience nocturnal sleep apnea, or interruption in breathing at night. Obstructive sleep apnea (airway blockage during sleep) has classically been attributed to obesity, but increased risk for sleep apnea persists in patients with normal body mass and type 1 diabetes.

In addition, type 1 diabetes increases the risk for central sleep apnea, a problem of decreased respiratory drive in the brain. Sleep apnea is associated with microvascular complications of diabetes (neuropathy and retinopathy), and increased macrovascular disease (heart attack and stroke). Sleep disruption in T1D is also associated with increased nocturnal blood pressure, which can increase cardiovascular disease even in patients with well-controlled T1D.

So What Can We Do about It? 10 Tips for Better Sleep

It’s time we focused on sleep hygiene. Yes, this is a thing! Just like taking care of your personal hygiene or your dental hygiene, there are steps we can take to promote better sleep health:

1. We need to start taking sleep seriously. Physicians are among the worst offenders — I’ve cheated many a night’s sleep with an extra pot of coffee. But when we sleep, our bodies undergo essential restorative processes including muscle repair, immune system strengthening, and hormone regulation. Chronic sleep deprivation can lead to serious health issues. Prioritizing sleep is crucial for maintaining physical and mental health.
2. Get checked for sleep disorders including sleep apnea, as these are common and often silent conditions. Alternately, your partner may tell you that you are NOT silent, and snoring loudly if you ask! If so, discuss sleep apnea screening with your doctor.
3. Establish regular bedtime routines: the same wakeup and bedtimes every day help the body establish a predictable sleep schedule
4. Prepare for rest: 30 minutes prior to sleep, wind down by dimming the lights and planning quiet activities. Avoid TV, computers, and phone screens in the bedroom.
5. Build a calm environment: dark, quiet rooms are ideal; let the pets sleep somewhere else and add some white noise if you like (I like rain sounds).
6. Avoid caffeine, alcohol, and/or large meals late at night or before bed, as these disrupt sleep cycles
7. Use pump and CGM alerts strategically to safeguard against lows, but avoid extra interruptions. (i.e. utilizing hybrid closed loop systems, raising high alarm threshold overnight)
8. Schedule regular physical activity, because exercise promotes more consistent sleep patterns
9. If you’re wearing a smartwatch, take a look at your sleep data. Modern smartwatch actigraphy is increasingly accurate and informative. Is the issue going to bed too late? Difficulty falling asleep? Getting woken up often?
10. Do what you can to work on reducing stress. Try practicing relaxation techniques such as meditation, mindfulness, or utilizing an app like Calm, Headspace, or Plum Village.

There are lots of sources of sleep disruption: noisy neighbors, shift work, and interruptions from kids, to name a few. Type 1 diabetes presents unique challenges for a good night’s sleep, and the consequences of sleep disruption can echo throughout the next day’s glucose trends. Promoting healthy sleep can improve diabetes care. For more reading, take a look at the Breakthrough T1D recommendations and sleep literature. We’re currently also studying sleep and type 1 diabetes in our lab at the Altman Clinical and Translational Research Institute at UCSD. Stay tuned for future updates about how to get your best night’s sleep!

Additional Resources:

Counting Sheep & Losing Sleep: The Link Between Diabetes and Sleep Apnea

Dawn Phenomenon: How to Identify and Manage It

How to Treat Foot to Floor Phenomenon