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06-21-2018 | Sleep disorders | Article

Relationship between sleep disturbance and self-care in adults with type 2 diabetes

Journal: Acta Diabetologica

Authors: Bingqian Zhu, Laurie Quinn, Mary C. Kapella, Ulf G. Bronas, Eileen G. Collins, Laurie Ruggiero, Chang G. Park, Cynthia Fritschi

Publisher: Springer Milan



Type 2 diabetes (T2D) is a metabolic disorder requiring intensive self-care to maintain optimal glycemic control. Sleep disturbance is common in T2D patients and likely impairs glycemic control. Our aim was to examine the relationship between sleep disturbance and self-care in adults with T2D.


This study used a correlational design. Sixty-four adults with T2D were recruited. Validated instruments were used to measure self-care, subjective sleep disturbance, and covariates (e.g., diabetes distress, self-efficacy, fatigue, and daytime sleepiness). Over an 8-day period, the ActiGraph-wGT3X was used to measure objective sleep outcomes (e.g., total sleep time and number of awakenings). Bivariate correlation and multiple linear regression analyses were conducted.


The mean age of the participants was 60.6 (SD 6.8) years (range 50–78), and 51.6% were women. Controlling for covariates, subjective sleep disturbance (β = − 0.26), diabetes distress (β = − 0.39), and daytime sleepiness (β = − 0.21) were strong predictors of diabetes self-care (R2 = 0.51, p < 0.001). When objective sleep parameters were used, the number of awakenings (β = − 0.23) also predicted self-care along with diabetes distress, fatigue, and daytime sleepiness (R2 = 0.57, p < 0.001).


Subjective sleep disturbance and frequent nocturnal awakenings are associated with worse diabetes self-care in adults with T2D. Healthcare providers are recommended to include comprehensive sleep assessment at every clinical visit. Diabetes educators may consider including sleep-related education in their diabetes self-management classes and/or counseling sessions.
Weinger K, Butler HA, Welch GW, La Greca AM (2005) Measuring diabetes self-care. Diabetes Care 28(6):1346–1352CrossRefPubMedPubMedCentral
American Diabetes Association (2015) Standards of medical care in diabetes—2015 abridged for primary care providers. Clin Diabetes 33 (2):97CrossRefPubMedCentral
Zhuo X, Zhang P, Hoerger TJ (2013) Lifetime direct medical costs of treating type 2 diabetes and diabetic complications. Am J Prev Med 45(3):253–261CrossRefPubMed
Beverly EA, Ritholz MD, Shepherd C, Weinger K (2016) The psychosocial challenges and care of older adults with diabetes:“can’t do what I used to do; can’t be who I once was”. Curr Diab Rep 16(6):48CrossRefPubMedPubMedCentral
Gupta S, Wang Z (2016) Predictors of sleep disorders among patients with type 2 diabetes mellitus. Clin Res Rev 10(4):213–220
Nefs G, Donga E, van Someren E et al (2015) Subjective sleep impairment in adults with type 1 or type 2 diabetes: results from diabetes MILES—The Netherlands. Diabetes Res Clin Pract 109(3):466–475CrossRefPubMed
Ancoli-Israel S (2009) Sleep and its disorders in aging populations. Sleep Med 10:S7–S11CrossRefPubMed
Lee SWH, Ng KY, Chin WK (2017) The impact of sleep amount and sleep quality on glycemic control in type 2 diabetes: a systematic review and meta-analysis. Sleep Med Rev 31:91–101CrossRefPubMed
Chasens ER, Korytkowski M, Sereika SM, Burke LE (2013) Effect of poor sleep quality and excessive daytime sleepiness on factors associated with diabetes self-management. Diabetes Educ 39(1):74–82CrossRefPubMed
Lee Y, Shin S, Wang R, Lin K, Lee Y, Wang Y (2016) Pathways of empowerment perceptions, health literacy, self-efficacy, and self-care behaviors to glycemic control in patients with type 2 diabetes mellitus. Patient Educ Couns 99(2):287–294CrossRefPubMed
Pintaudi B, Lucisano G, Gentile S, Bulotta A, Skovlund SE, Vespasiani G, Rossi MC, Nicolucci A, BENCH-D Study Group (2015) Correlates of diabetes-related distress in type 2 diabetes: findings from the benchmarking network for clinical and humanistic outcomes in diabetes (BENCH-D) study. J Psychosom Res 79(5):348–354CrossRefPubMed
Kirk JK, Arcury TA, Ip E, Bell RA, Saldana S, Nguyen HT, Quandt SA (2015) Diabetes symptoms and self-management behaviors in rural older adults. Diabetes Res Clin Pract 107(1):54–60CrossRefPubMed
Shen J, Barbera J, Shapiro CM (2006) Distinguishing sleepiness and fatigue: focus on definition and measurement. Sleep Med Rev 10(1):63–76CrossRefPubMed
Kontopantelis E, Springate D, Parisi R, Reeves D (2016) Simulation-based power calculations for mixed effects modelling: Ipdpower in Stata. J Stat Softw 74(12):1–25CrossRef
Bode BW, Irvin BR, Pierce JA, Allen M, Clark AL (2007) Advances in hemoglobin A1c point of care technology. J Diabetes Sci Technol 1(3):405–411CrossRefPubMedPubMedCentral
Schmitt A, Gahr A, Hermanns N, Kulzer B, Huber J, Haak T (2013) The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health Qual Life Outcomes 11(1):138–151CrossRefPubMedPubMedCentral
Buysse DJ, Reynolds CF III, Monk TH, Hoch CC, Yeager AL, Kupfer DJ (1991) Quantification of subjective sleep quality in healthy elderly men and women using the Pittsburgh Sleep Quality Index (PSQI). Sleep 14(4):331–338PubMed
Sadeh A (2011) The role and validity of actigraphy in sleep medicine: an update. Sleep Med Rev 15(4):259–267CrossRefPubMed
Rosenberger ME, Buman MP, Haskell WL, McConnell MV, Carstensen LL (2016) Twenty-four hours of sleep, sedentary behavior, and physical activity with nine wearable devices. Med Sci Sports Exerc 48(3):457–465CrossRefPubMedPubMedCentral
Cellini N, McDevitt EA, Mednick SC, Buman MP (2016) Free-living cross-comparison of two wearable monitors for sleep and physical activity in healthy young adults. Physiol Behav 157:79–86CrossRefPubMedPubMedCentral
Slater JA, Botsis T, Walsh J, King S, Straker LM, Eastwood PR (2015) Assessing sleep using hip and wrist actigraphy. Sleep Biol Rhythms 13(2):172–180CrossRef
Cole RJ, Kripke DF, Gruen W, Mullaney DJ, Gillin JC (1992) Automatic sleep/wake identification from wrist activity. Sleep 15(5):461–469CrossRefPubMed
Ancoli-Israel S, Martin JL, Blackwell T, Buenaver LF, Liu L, Meltzer LJ, Sadeh A, Spira AP, Taylor DJ (2015) The SBSM guide to actigraphy monitoring: clinical and research applications. Behav Sleep Med 13(sup1):S4–S38CrossRefPubMed
Anderson RM, Fitzgerald JT, Gruppen LD, Funnell MM, Oh MS (2003) The diabetes empowerment scale-short form (DES-SF). Diabetes Care 26(5):1641–1642CrossRefPubMed
Polonsky WH, Fisher L, Earles J, Dudl RJ, Lees J, Mullan J, Jackson RA (2005) Assessing psychosocial distress in diabetes development of the diabetes distress scale. Diabetes Care 28(3):626–631CrossRefPubMed
Arbuckle RA, Humphrey L, Vardeva K, Arondekar B, Danten-Viala MSc M, Scott JA, Snoek FJ (2009) Psychometric evaluation of the diabetes symptom checklist-revised (DSC-R)—A measure of symptom distress. Value Health 12(8):1168–1175CrossRefPubMed
Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep 14(6):540–545CrossRefPubMed
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381CrossRefPubMed
American Diabetes Association (2017) Standards of medical care in diabetes: glycemic targets. Diabetes Care 40 (Suppl. 1):S48–S56CrossRef
Pandit AU, Bailey SC, Curtis LM, Seligman HK, Davis TC, Parker RM, Schillinger D, DeWalt D, Fleming D, Mohr DC (2014) Disease-related distress, self-care and clinical outcomes among low-income patients with diabetes. J Epidemiol Community Health 68(6):557–564CrossRefPubMed
Chasens ER, Olshansky E (2008) Daytime sleepiness, diabetes, and psychological well-being. Issues Ment Health Nurs 29(10):1134–1150CrossRefPubMed
Riegel B, Weaver TE (2009) Poor sleep and impaired self-care: towards a comprehensive model linking sleep, cognition, and heart failure outcomes. Eur J Cardiovasc Nurs 8(5):337–344CrossRefPubMedPubMedCentral
Redeker NS (2008) Sleep disturbance in people with heart failure: implications for self-care. J Cardiovasc Nurs 23(3):231–238CrossRefPubMed
Libman E, Fichten C, Creti L, Conrod K, Tran D, Grad R, Jorgensen M, Amsel R, Rizzo D, Baltzan M (2016) Refreshing sleep and sleep continuity determine perceived sleep quality. Sleep Disord 2016:1–10CrossRef
Ohayon MM (2010) Nocturnal awakenings and difficulty resuming sleep: their burden in the European general population. J Psychosom Res 69(6):565–571CrossRefPubMed
Crowley K (2011) Sleep and sleep disorders in older adults. Neuropsychol Rev 21(1):41–53CrossRefPubMed
Short MA, Banks S (2014) The functional impact of sleep deprivation, sleep restriction, and sleep fragmentation. In: Bianchi MT (ed) Sleep deprivation and disease: effects on the body, brain and behavior. Springer, New York, pp 13–26CrossRef
Hursel R, Rutters F, Gonnissen HKJ, Martens EAP, Westerterp-Plantenga MS (2011) Effects of sleep fragmentation in healthy men on energy expenditure, substrate oxidation, physical activity, and exhaustion measured over 48 h in a respiratory chamber. Am J Clin Nutr 94(3):804–808CrossRefPubMed
Stepanski EJ (2002) The effect of sleep fragmentation on daytime function. Sleep 25(3):268–276CrossRefPubMed
Reutrakul S, Van Cauter E (2014) Interactions between sleep, circadian function, and glucose metabolism: implications for risk and severity of diabetes. Ann N Y Acad Sci 1311(1):151–173CrossRefPubMed
Martins RC, Andersen ML, Tufik S (2008) The reciprocal interaction between sleep and type 2 diabetes mellitus: facts and perspectives. Braz J Med Biol Res 41(3):180–187CrossRefPubMed
Larcher S, Benhamou P-Y, Pépin J-L, Borel A-L (2015) Sleep habits and diabetes. Diabetes Metab 41(4):263–271CrossRefPubMed
Grandner MA, Seixas A, Shetty S, Shenoy S (2016) Sleep duration and diabetes risk: Population trends and potential mechanisms. Curr Diab Rep 16(11):106CrossRefPubMedPubMedCentral
American Diabetes Association (2018) Standards of medical care in diabetes: comprehensive medical evaluation and assessment of comorbidities. Diabetes Care 41 (Suppl. 1):S28–S37CrossRef

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