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To Sleep, Perchance To Dream
Sleep apnea can threaten your diabetes control


A woman yawning and looking extremely tired.Jean, a person with well-controlled type 2 diabetes, worked long days for a small business that sold appliances. She was often on her feet for hours and did a little of everything—filling orders, inventory control, keeping the books, taking phone calls. She enjoyed her job and her good relationships with the owner of the business and his family.

But for the last few years, Jean had become increasingly fatigued. She found herself dragging through the afternoons, often falling asleep as soon as she got home. Worse, she was sometimes so tired during the day that she began making mistakes in her work. Finally, her boss told her he had noticed that she had changed, and urged her to see her doctor.

To Jean’s surprise, her doctor asked whether she snored. In fact, Jean’s loud snoring was something of a joke to her husband and two teenaged sons. Jean’s doctor told her that snoring can indicate a serious condition, and he arranged for her to spend the night in a sleep study center at a nearby hospital. When Jean arrived at the center to spend the night, a technician attached many wires to her head and body, and explained that these would monitor Jean’s heart, brain, breathing, and movements while she slept. Although at first Jean thought she would never be able to sleep with all these wires on, she was so tired that she fell asleep quickly.

Jean learned from her doctor that the results indicated she had sleep apnea, which means that as she snored, she stopped breathing about 40 times every hour. When she stopped breathing, her body roused itself from deeper levels of sleep. So even though she slept for many hours, it was not restful sleep, and she was tired all the time.

Stories like Jean’s are increasingly common in the U.S. and sleep apnea—temporary interruptions of breathing while a person is asleep—is closely related to type 2 diabetes. There are at least three major reasons for this connection:

The first is that sleep apnea and type 2 diabetes are both more common in people who are overweight. Most sleep apnea occurs when muscles of the airway at the back of the throat relax during sleep, and people who are overweight often have extra flabby or fatty tissue in the throat and neck. This leaves a narrower airway which is easily blocked when it’s not actively held open.

The next is that sleep apnea actually seems to change a person’s metabolism, causing weight gain. Researchers speculate that chronic sleep deprivation may affect levels of the hormones in the body that stimulate either the appetite or the feeling of fullness. So, even right after eating, a sleep-deprived person still feels hungry. Furthermore, fatigue makes it very hard to exercise. More weight gain follows, making the sleep apnea and deprivation even worse, leading to more weight gain, and so on into a negative spiral.

The third reason for the connection between sleep apnea and type 2 diabetes is that sleep apnea causes insulin resistance—an inability to use insulin effectively. This means that sleep apnea actually makes diabetes harder to control. The opposite is also true: when sleep apnea gets treated, diabetes often becomes easier to control, because the insulin resistance is decreased by deep, restorative sleep.

Besides the links to type 2 diabetes, sleep apnea has other dangers. The stress of interrupted breathing raises blood pressure, and is very hard on the heart and blood vessels. Untreated sleep apnea is a strong risk factor for heart attack and stroke, so it’s not only an inconvenience, it can be life-threatening. It’s important to have sleep issues diagnosed and treated.

There are several ways to treat sleep apnea, some more effective than others. Although the first piece of advice many people get is “try to lose weight,” most people who have sleep apnea find this advice very difficult to follow, for the reasons described above. So, while weight loss should remain an important goal, other treatments can restore restful sleep and the energy to lose weight.

For mild sleep apnea, some people find that a simple change of position can help avoid the closing of the throat that causes it. Sleeping on a side or stomach may allow the airways to remain open when the muscles relax. This is easier said than done since many people naturally roll to their backs during sleep. Some are able to prop themselves on their sides using pillows, and some have reported success by sewing a tennis ball to the back of their pajamas, so that lying on the back is uncomfortable. However, for moderate to severe sleep apnea, other treatments are available.

Most commonly, sleep apnea can be controlled using a “continuous positive airway pressure” or CPAP machine. It’s small, about the size of a toaster, and has a tube to carry air to a mask, which fits over the nose, or nose and mouth. There are a variety of designs for masks, and because a good fit is important, a respiratory therapist will usually fit the CPAP to make sure it is snug and comfortable.

A CPAP is worn during sleep, and constantly blows air which provides pressure to keep the airways open even when the muscles of the throat are relaxed. Although the CPAP mask often feels awkward at first, most people get used to it quickly. In fact, they often find that they feel so much better after getting good sleep that they cannot imagine sleeping without their CPAP.

Other options for treating sleep apnea include oral appliances (to position the jaw so the airways remain open) and surgery. Using a CPAP has a much stronger record of effectiveness, though, so these options are seldom used.

Although sleep apnea is the most common sleep disorder, there are many other types of sleep disorders. Some of the most common are: restless legs syndrome, periodic limb movements, and insomnia associated with anxiety, depression, caffeine, or certain medications. People who are tired all the time, regardless of whether they snore, should get a sleep evaluation. Most sleep disorders can be easily treated.

Fortunately, when sleep apnea or other sleep disorders are treated, life often improves dramatically. Blood sugar levels can improve almost immediately with restorative sleep. The appetite becomes more normally regulated, and the person can feel satisfied with less food. With more energy comes the stamina to exercise more. All of this can lead to weight loss, which improves diabetes control and sleep apnea. Now the spiral can lead upward.

If you never really feel rested, and especially if you know you snore, ask your doctor how you can get a sleep evaluation. If you do have sleep apnea, you may be surprised at how much better you feel once it is treated.

For more information, see:

• American Sleep Apnea Association.
Web site: www.sleepapnea.org
Phone: 202-293-3605

• National Sleep Foundation.
Web site: www.sleepfoundation.org
Phone: 202-347-3471

About the Author
Ann S. Williams is an RN, with a PhD in Psychology, and has worked as a diabetes educator for 20 years. She has specialized in teaching independent diabetes self-management for blind people and writes and speaks frequently on this topic for other health care professionals. She was the founder and past chair of the Disabilities Specialty Practice Group of the American Association of Diabetes Educators, and remains an active member of that group.