Inadequate sleep can have an impact on how blood glucose fluctuates, and this is particularly important for individuals with underlying sleep deficiencies and who have type 2 diabetes mellitus (T2DM).
The recommended sleep duration varies by age group, according to the Centers for Disease Control and Prevention. Adults ages 18 and over should get at least 7 hours of sleep to avoid adverse consequences related to poor sleep duration.1 These consequences are closely associated with complications of diabetes, such as obesity, hypertension, impaired immune function, and more specifically, nephropathy, retinopathy, and neuropathy.
Obtaining the appropriate amount of sleep each night has many benefits. According to the American Sleep Apnea Association (ASAA), this is the time our bodies undergo “routine maintenance” to help support bodily functions such as maintaining a strong immune system, conserving energy, and releasing the necessary hormones for growth and development.2
As mentioned in a review conducted by Schipper et al,3 sleep duration below 5 to 6 hours has an equally detrimental impact as other well-known risk factors for diabetes, such as inactivity, obesity, and a positive family history. Diving deeper into the effects of inadequate sleep, hormones that are involved in feelings of satiety (leptin) and hunger (ghrelin) are decreased with less sleep, causing an irregularity in the brain, prompting the body to feel inappropriately hungry and insufficiently full.4 Antza and colleagues4 further explain other physiological changes that poor sleep may induce, including endocannabinoid system overactivation, which causes beta cell dysfunction and a reduction in glucagon-like peptide-1 in women.
The 2024 American Diabetes Association (ADA) Standards of Care (SOC) in Diabetes strongly urge the need for health care professionals to screen individuals with diabetes for sleep health. This includes assessing patients’ sleep health during initial, annual, and every follow-up visit and making referrals to sleep medicine specialists or qualified behavioral health professionals if necessary. Health care professionals are urged to evaluate the lifestyles of those with diabetes to decrease risk factors, including low sleep duration, shift work, and days off, because these have association with hyperglycemia, hypertension, dyslipidemia, and weight gain.5
A meta-analysis conducted by Kothari et al6 demonstrated that poor, short, or long sleep duration is associated with a higher A1C in those with T2DM. This meta-analysis showed nonstatistically significant results, but a separate study had some insightful conclusions about the association between poor sleep health and diabetes. Chattu and colleagues7 highlighted significant findings, including that the lowest risk of developing diabetes occurs when an individual receives 7 to 8 hours of sleep per day, and those who slept less had 2.8 times greater risk to develop diabetes. Both men and women are susceptible to these risks, but women were also seen to have an associated risk with increased gestational diabetes. It is further explained that chronic sleep disturbances increase insulin resistance risk and that diabetes itself can decrease the quality of sleep. These complications combined further exacerbate poor sleep and increase the risk of developing diabetes.7
Overall, the 2024 ADA SOC emphasized the importance of maintaining a healthy sleep schedule for patients with diabetes and highlighted the importance of assessing sleep health during patient visits.
Sleep-disordered breathing is prevalent in as high as 58% of those with T2DM, and obstructive sleep apnea (OSA) is responsible for 23% of that statistic. OSA has a few mechanisms to increase the risk of T2DM, but it is largely contributed to the hypoxia seen when there is airway closure or partial upper airway collapse. Hypoxia can lead to a disruption of normal metabolism, resulting in the formation of reactive oxygen species (ROS), which damages various cells and leads to the development of insulin resistance.7,8
Wang et al8 conducted a comprehensive metaanalysis looking into the impact of OSA and risk for T2DM. It was found that OSA was associated with increased diabetes risk in both cohort and crosssectional studies that were analyzed. In the cohort analysis, the incidence of OSA and T2DM had an odds ratio (OR) of 2.15, whereas the cross-sectional demonstrated an OR of 3.62, with P values of 0.472 and <0.001, respectively. The apnea-hypopnea index (AHI) was used to grade OSA severity, and it was correlated that the higher the AHI, the higher the prevalence of diabetes was.8 In addition, women with OSA developed gestational diabetes mellitus (GDM) during pregnancy more often, and a study suggested that the 48.3% of women with OSA developed GDM compared to only 23.7% developing GDM who did not have OSA.9
It is important to consider the bidirectional nature of OSA and T2DM because complications such as diabetic neuropathy seen in T2DM may affect central control of respiration and upper airway reflexes. This can promote the disordered breathing seen in OSA and other common risk factors, such as obesity.10,11
There have been far fewer studies conducted on the correlation between OSA and patients with type 1 diabetes mellitus (T1DM), but a cohort study of 67 participants yielded an OSA prevalence of 46%. Like in T2DM, diabetes-associated neuropathy may also impair the upper airways and control of pharyngeal muscles to cause the disordered breathing seen in OSA. Although obesity was not an established characteristic seen in this cohort, the prevalence of OSA was noted to increase with the duration of T1DM.11
Continuous positive airway pressure (CPAP) is the gold standard treatment for obstructive sleep apnea, and its use is becoming more promising to decrease nocturnal hyperglycemia in affected individuals. CPAP machines provide pressurized air that prevents airway collapse, and in doing so, required oxygenation throughout the body is reestablished, as is a decrease in ROS.12 Proper use of CPAP also reduces A1C and insulin resistance with continued use, leading to a reduced risk of developing diabetes.
Given these findings, it is especially important to follow up with patients exhibiting symptoms suggestive of sleep apnea, such as excessive daytime sleepiness, snoring, and witnessed apnea. Implementing appropriate interventions can improve patients’ sleep patterns, nocturnal blood glucose levels, and overall quality of life.7
Other specific sleep disorders, such as insomnia, restless leg syndrome (RLS), and circadian rhythm sleep-wake disorders (CRSWDs), pose significant concerns for health complications and quality of life for individuals with diabetes. Insomnia, which can be categorized as sleep maintenance insomnia or sleep onset insomnia, is prevalent in 39% of patients with T2DM.3 Insomnia can be associated with poorer control of A1C and fasting blood glucose levels in those with T2DM and insomnia.3 Although there is insufficient evidence to establish a direct association between RLS and abnormal blood glucose levels, it is worth noting that RLS is associated with depression and reduced quality of life. CRSWDs affect the body’s circadian rhythm, in which the desire to sleep and wake at appropriate times is disrupted. Although the review by Schipper et al3 noted limited evidence regarding the prevalence of CRSWDs in individuals with type 2 diabetes, the idea of shiftwork can fall under this category. It has been observed that those who work late nights or overnight shifts tend to have more elevated blood glucose levels compared to those working day shifts.3
Poor sleep interferes with the balance of ghrelin and leptin hormones and leads to overactivation of the orexin system, which results in overeating and, subsequently, obesity. In addition, OSA increases an obese patient’s risk for diabetes by 49% and is already prevalent in 86% of obese patients with T2DM.3
In terms of cardiovascular health, insufficient sleep is also associated with increased blood pressure. Makarem et al13 showed statistically significant daytime and nighttime systolic blood pressure differences. An increase of 12.1 and 9.3 mmHg was seen as a difference, respectively, in individuals who slept less compared to those who obtained an average of 7 hours of sleep per night.13 The American Heart Association states that short sleepers and shift workers have behaviors, such as irregular eating and mealtime variability, that disrupt the circadian rhythm, including 24-hour blood pressure diurnal patterns. Consequently, this may lead to higher blood pressure levels throughout the day and nondipping of blood pressure during sleep, which is a known risk for cardiovascular events.13
A systematic review and meta-analysis by Yang and colleagues14 showed that coexistence of sleep disorders and diabetes was associated with a higher risk of stroke and all-cause mortality compared to patients with diabetes and no sleep disorder. Choi and Choi15 describe that diabetes and sleep disorders were associated with an increased risk of cardiovascular events, particularly in females with a BMI of 23 or higher. Additionally, the risk of all-cause mortality increased significantly in men with type 2 diabetes and older adults with sleep disorders when compared to those without sleep disturbances.15
Health care professionals should continually screen sleep habits of patients with diabetes because it is an important parameter for monitoring diabetes and keeping blood glucose levels in good control. The ASAA urges everyone to maintain good sleep hygiene, an important factor to achieve a restful night’s sleep.
When it comes to treating many sleep conditions, the first-line therapy is usually nonpharmacological, and adopting lifestyle changes that promote a restful night’s sleep is of the upmost importance.
Habits and tips that can promote better sleep include the following2:
Establish a consistent nighttime routine and sleep schedule.
Resist daytime napping.
Avoid caffeine at least 6 hours before sleep.
Abstain from screen or technology use before bedtime.
Exercise regularly (but not before bedtime).
Avoid alcohol and foods that are heavy, spicy, or sugary before bed.
Consult your provider if any medications may keep you awake at night (examples could include diuretics, psychostimulants, amphetamines, decongestants, steroids, etc).
Adopting these lifestyle changes may help promote a sense of tiredness and prepare the body for sleep when bedtime comes. If needed, refer patients to specialists who can recommend appropriate pharmacological interventions and explore other nonpharmacological measures, such as sleep studies, which are used to diagnose sleep disorders and initiation of treatment of OSA if indicated.
Sleep plays a vital role in both physical and mental restoration, and it is particularly critical for people with diabetes to achieve adequate sleep duration to minimize the negative health consequences and complications associated with sleep disorders.
Nicole Silva, PharmD Candidate 2025; Hailey Choi, PharmD, BCACP, CDCES; and Jennifer Goldman, PharmD, CDCES, BC-ADM, FCCP, are with the Massachusetts College of Pharmacy and Health Sciences in Boston, MA.
Nicole Silva declares that she has no conflict of interest. Hailey Choi is a member of the Speakers Bureau for NovoNordisk. Jennifer D. Goldman is a member of the Speakers Bureau for NovoNordisk, Lilly, Xeris, Abbott Diabetes, and Sanofi.
The authors declare having received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors related to the content or development of this article.
Nicole Silva https://orcid.org/0009-0003-7328-3144
Hailey Choi https://orcid.org/0000-0002-1472-2835
Jennifer Goldman https://orcid.org/0000-0002-9617-3998
Centers for Disease Control and Prevention. How much sleep do I need? https://www.cdc.gov/sleep/about_sleep/how_much_sleep.html. Accessed June 12, 2023.
SleepHealth. The state of Sleep Health in America in 2023. https://www.sleephealth.org/sleep-health/the-state-ofsleephealth-in-america/. Accessed May 23, 2023.
Schipper SBJ, Van Veen MM, Elders PJM, et al. Sleep disorders in people with type 2 diabetes and associated health outcomes: a review of the literature. Diabetologia. 2021;64(11):2367-2377. doi:10.1007/s00125-021-05541-0
Antza C, Kostopoulos G, Mostafa S, et al. The links between sleep duration, obesity and type 2 diabetes mellitus. J Endocrinol. 2022;252(2):125-141. doi:10.1530/JOE-21-0155
American Diabetes Association Professional Practice Committee. 5. Facilitating positive health behaviors and well-being to improve health outcomes: Standards of Care in Diabetes—2024. Diabetes Care. 2024;47(1): S77-S110. doi: https://doi.org/10.2337/dc24-S005
Kothari V, Cardona Z, Chirakalwasan N, et al. Sleep interventions and glucose metabolism: systematic review and meta-analysis. Sleep Med. 2021;78:24-35. doi:10.1016/j.sleep.2020.11.035
Chattu VK, Chattu SK, Burman D, et al. The interlinked rising epidemic of insufficient sleep and diabetes mellitus. Healthcare (Basel). 2019;7(1):37. doi:10.3390/healthcare7010037
Wang C, Tan J, Miao Y, Zhang Q. Obstructive sleep apnea, prediabetes and progression of type 2 diabetes: a systematic review and meta-analysis. J Diabetes Investig. 2022;13(8):1396-1411. doi:10.1111/jdi.13793
Tong X, Yang L, Jiang C, et al. A review of the associations between obstructive sleep apnea and gestational diabetes mellitus and possible mechanisms of disease. Reproductive Sciences. 2022;30(1):81-92. doi:10.1007/s43032-022-00904-3
Reutrakul S, Mokhlesi B. Obstructive sleep apnea and diabetes: a state of the art review. Chest. 2017;152(5):1070-1086. doi:10.1016/j.chest.2017.05.009
Manin G, Pons A, Baltzinger P, et al. Obstructive sleep apnoea in people with type 1 diabetes: prevalence and association with micro- and macrovascular complications. Diabet Med. 2014;32(1):90-96. doi:10.1111/dme.12582
Suzuki YJ, Jain V, Park AM, Day RM. Oxidative stress and oxidant signaling in obstructive sleep apnea and associated cardiovascular diseases. Free Radic Biol Med. 2006;40(10):1683-1692. doi:10.1016/j.freeradbiomed.2006.01.008
Makarem N, Alcántara C, Williams N, et al. Effect of sleep disturbances on blood pressure. Hypertension. 2021;77(4):1036-1046. doi:10.1161/HYPERTENSIONAHA.120.14479
Yang XH, Zhang BL, Cheng Y, et al. Association of the coexistence of somnipathy and diabetes with the risks of cardiovascular disease events, stroke, and all-cause mortality: a systematic review and meta-analysis. J Am Heart Assoc. 2022;11(14):e024783. doi:10.1161/JAHA.121.024783
Choi Y, Choi JW. Association of sleep disturbance with risk of cardiovascular disease and all-cause mortality in patients with new-onset type 2 diabetes: data from the Korean NHIS-HEALS. Cardiovasc Diabetol. 2020;19(1):61. doi:10.1186/s12933-020-01032-5
