The reciprocal interaction between sleep and type 2 diabetes mellitus: facts and perspectives

Type 2 diabetes mellitus is a systemic disease characterized by intolerance to glucose and peripheral resistance to insulin. This endocrine disease affects fundamental mechanisms of the central nervous system and jeopardizes the balance of vital functions such as the cardiovascular and circadian rhythm. The increased prevalence of metabolic disorders in our society is aggravated by endemic voluntary postponement of bedtime and by the current sedentary lifestyle, leading to epidemic proportions of obese people. Diabetes and chronic loss of sleep share the fact that both affect millions and one is detrimental to the other. Indeed, sleep deficits have marked modulatory effects on glucose metabolism and insulin sensitivity and foster metabolic syndrome that culminates in sleep disorders like restless syndrome and sleep apnea, which in turn lead to poor sleep quality. We examine the hypothesis that these two worldwide emerging disorders are due to two interlinked cycles. In our paradigm, we establish an intimate relationship between diabetes and sleep disturbances and postulate possible mechanisms that provide support for this conjecture. In addition, we propose some perspectives about the development of the reciprocal interaction between predictor components of metabolic syndrome and sleep disturbances that lead to poor sleep quality. The ability to predict the development and identify or associate a given mode of sleep disturbance to diabetes would be a valuable asset in the assessment of both. Furthermore, major advances in care coupled with healthy lifestyles can ensure a higher quality of life for people with diabetes.

Relationship between the quality of life and the severity of obstructive sleep apnea syndrome

The effects of sleep disorders on the quality of life (QOL) have been documented in the literature. Excessive sleepiness and altered circadian rhythms may negatively affect ability to learn, employment, and interpersonal relations, and directly degrade QOL. The objective of the present study was to evaluate the impact of obstructive sleep apnea syndrome of varying severity on QOL. The study was conducted on 1892 patients aged 18 years or older referred by a physician to the Sleep Institute, São Paulo, with complaints related to apnea (snoring, excessive daytime sleepiness, hyperarousal, and fatigue). They were submitted to overnight polysomnography for the diagnosis of sleep disorders from August 2005 through April 2006. The patients completed the Epworth Sleepiness Scale and QOL SF-36 sleep questionnaires. They were classified as non-physically active and physically active and not-sleepy and sleepy and the results of polysomnography were analyzed on the basis of the apnea hypopnea index (AHI). The apneic subjects showed a reduction in QOL which was proportional to severity. There was a significant decrease in all domains (physical functioning, role physical problems, bodily pain, general health perceptions, vitality, social functioning, emotional problems, general mental health) for apneics with AHI >30, who generally were sleepy and did not participate in physical activities (P < 0.05). The present study provides evidence that the impact of sleep disorders on QOL in apneics is not limited to excessive daytime sleepiness and that physical activity can contribute to reducing the symptoms. Thus, exercise should be considered as an adjunct interventional strategy in the management of obstructive sleep apnea syndrome.

Sleep, ageing and night work

Studies have shown that the frequency or worsening of sleep disorders tends to increase with age and that the ability to perform circadian adjustments tends to decrease in individuals who work the night shift. This condition can cause consequences such as excessive sleepiness, which are often a factor in accidents that occur at work. The present study investigated the effects of age on the daytime and nighttime sleep patterns using polysomnography (PSG) of long-haul bus drivers working fixed night or day shifts. A total of 124 drivers, free of sleep disorders and grouped according to age (<45 years, N = 85, and ≥45 years, N = 39) and PSG timing (daytime (D) PSG, N = 60; nighttime (N) PSG, N = 64) participated in the study. We observed a significant effect of bedtime (D vs N) and found that the length of daytime sleep was shorter [D: <45 years (336.10 ± 73.75 min) vs N: <45 years (398 ± 78.79 min) and D: ≥45 years (346.57 ± 43.17 min) vs N: ≥45 years (386.44 ± 52.92 min); P ≤ 0.05]. Daytime sleep was less efficient compared to nighttime sleep [D: <45 years (78.86 ± 13.30%) vs N: <45 years (86.45 ± 9.77%) and D: ≥45 years (79.89 ± 9.45%) and N: ≥45 years (83.13 ± 9.13%); P ≤ 0.05]. An effect of age was observed for rapid eye movement sleep [D: <45 years (18.05 ± 6.12%) vs D: ≥45 years (15.48 ± 7.11%) and N: <45 years (23.88 ± 6.75%) vs N: ≥45 years (20.77 ± 5.64%); P ≤ 0.05], which was greater in younger drivers. These findings are inconsistent with the notion that older night workers are more adversely affected than younger night workers by the challenge of attempting to rest during the day.

Information processing in sleep-onset insomnia : a test of the neurocognitive model /

The present thesis study is a systematic investigation of information processing at sleep onset, using auditory event-related potentials (ERPs) as a test of the neurocognitive model of insomnia. Insomnia is an extremely prevalent disorder in society resulting in problems with daytime functioning (e.g., memory, concentration, job performance, mood, job and driving safety). Various models have been put forth in an effort to better understand the etiology and pathophysiology of this disorder. One of the newer models, the neurocognitive model of insomnia, suggests that chronic insomnia occurs through conditioned central nervous system arousal. This arousal is reflected through increased information processing which may interfere with sleep initiation or maintenance. The present thesis employed event-related potentials as a direct method to test information processing during the sleep-onset period. Thirteen poor sleepers with sleep-onset insomnia and 1 2 good sleepers participated in the present study. All poor sleepers met the diagnostic criteria for psychophysiological insomnia and had a complaint of problems with sleep initiation. All good sleepers reported no trouble sleeping and no excessive daytime sleepiness. Good and poor sleepers spent two nights at the Brock University Sleep Research Laboratory. The first night was used to screen for sleep disorders; the second night was used to investigate information processing during the sleep-onset period. Both groups underwent a repeated sleep-onsets task during which an auditory oddball paradigm was delivered. Participants signalled detection of a higher pitch target tone with a button press as they fell asleep. In addition, waking alert ERPs were recorded 1 hour before and after sleep on both Nights 1 and 2.As predicted by the neurocognitive model of insomnia, increased CNS activity was found in the poor sleepers; this was reflected by their smaller amplitude P2 component seen during wake of the sleep-onset period. Unlike the P2 component, the Nl, N350, and P300 did not vary between the groups. The smaller P2 seen in our poor sleepers indicates that they have a deficit in the sleep initiation processes. Specifically, poor sleepers do not disengage their attention from the outside environment to the same extent as good sleepers during the sleep-onset period. The lack of findings for the N350 suggest that this sleep component may be intact in those with insomnia and that it is the waking components (i.e., Nl, P2) that may be leading to the deficit in sleep initiation. Further, it may be that the mechanism responsible for the disruption of sleep initiation in the poor sleepers is most reflected by the P2 component. Future research investigating ERPs in insomnia should focus on the identification of the components most sensitive to sleep disruption. As well, methods should be developed in order to more clearly identify the various types of insomnia populations in research contexts (e.g., psychophysiological vs. sleep-state misperception) and the various individual (personality characteristics, motivation) and environmental factors (arousal-related variables) that influence particular ERP components. Insomnia has serious consequences for health, safety, and daytime functioning, thus research efforts should continue in order to help alleviate this highly prevalent condition.

A comparison of electrophysiological changes during the sleep onset period of psychophysiological insomniacs, psychiatric insomniacs and normal sleepers

The EEG of the sleep onset period of psychophysiological insomniacs, psychiatric insomniacs and controls was compared using power spectral analysis (FFT). Eighteen drug-free subjects were equally divided into three groups according to their responses in the Brock Sleep and Insomnia Questionnaire, the Minnesota Multiphasic Personality Inventory and the Sleep Disorders Questionnaire. Group 1 consisted of psychophysiological insomniacs, group 2 included insomniacs with an indication of psychiatric disturbances, and group 3 was a control group. EEG, EOG and EMG were recorded for two consecutive nights. Power spectral analysis (FFT) of EEG at C4 from the sleep onset period (defined as lights out to the first five minutes of stage 2) was performed on all standard frequency bands, delta: .5-4 Hz; theta: 4-8 Hz; alpha: 8-12 Hz; sigma: 12-15 Hz beta: 15-25 Hz. Psychophysiological insomniacs had less alpha during wakefulness than the other two groups and did not show the dramatic drop in alpha across the sleep onset period, which characterizes normal sleep. They also had less delta, especially during stage 2 on night 2. They also showed less delta in the last quartile of the chronological analysis of the sleep onset period. Psychiatric insomniacs showed lower relative beta power values overall while psychophysiological insomniacs showed higher relative beta power values during wakefulness. This microanalysis 11 confirms that the sleep onset period is generally similar for psychiatric insomniacs and normal sleepers. This may be due to the sample of psychiatric insomniacs being heterogeneous or may reflect a sleep onset system that is essentially intact. Psychophysiological insomniacs have higher cortical arousal during the sleep onset period than do the psychiatric insomniacs and the controls. Clear differences in the sleep onset period of psychophysiological insomniacs exist. The dramatic changes in power values in these two groups are not seen in the psychophysiological insomniacs, which may make the discrimination between wakefulness and sleep more difficult.

Sleep and information processing in individuals who have sustained a traumatic brain injury

Individuals who have sustained a traumatic brain injury (TBI) often complain of t roubl e sleeping and daytime fatigue but little is known about the neurophysiological underpinnings of the s e sleep difficulties. The fragile sleep of thos e with a TBI was predicted to be characterized by impairments in gating, hyperarousal and a breakdown in sleep homeostatic mechanisms. To test these hypotheses, 20 individuals with a TBI (18- 64 years old, 10 men) and 20 age-matched controls (18-61 years old, 9 men) took part in a comprehensive investigation of their sleep. While TBI participants were not recruited based on sleep complaint, the fmal sample was comprised of individuals with a variety of sleep complaints, across a range of injury severities. Rigorous screening procedures were used to reduce potential confounds (e.g., medication). Sleep and waking data were recorded with a 20-channel montage on three consecutive nights. Results showed dysregulation in sleep/wake mechanisms. The sleep of individuals with a TBI was less efficient than that of controls, as measured by sleep architecture variables. There was a clear breakdown in both spontaneous and evoked K-complexes in those with a TBI. Greater injury severities were associated with reductions in spindle density, though sleep spindles in slow wave sleep were longer for individuals with TBI than controls. Quantitative EEG revealed an impairment in sleep homeostatic mechanisms during sleep in the TBI group. As well, results showed the presence of hyper arousal based on quantitative EEG during sleep. In wakefulness, quantitative EEG showed a clear dissociation in arousal level between TBls with complaints of insomnia and TBls with daytime fatigue. In addition, ERPs indicated that the experience of hyper arousal in persons with a TBI was supported by neural evidence, particularly in wakefulness and Stage 2 sleep, and especially for those with insomnia symptoms. ERPs during sleep suggested that individuals with a TBI experienced impairments in information processing and sensory gating. Whereas neuropsychological testing and subjective data confirmed predicted deficits in the waking function of those with a TBI, particularly for those with more severe injuries, there were few group differences on laboratory computer-based tasks. Finally, the use of correlation analyses confirmed distinct sleep-wake relationships for each group. In sum, the mechanisms contributing to sleep disruption in TBI are particular to this condition, and unique neurobiological mechanisms predict the experience of insomnia versus daytime fatigue following a TBI. An understanding of how sleep becomes disrupted after a TBI is important to directing future research and neurorehabilitation.

The Association of Sleep Disorder, Obesity Status, and Diabetes Mellitus among US Adults—The NHANES 2009-2010 Survey Results

To examine the association between sleep disorders, obesity status, and the risk of diabetes in adults, a total of 3668 individuals aged 40+ years fromtheNHANES 2009-2010 withoutmissing information on sleep-related questions,measurements related to diabetes, and BMI were included in this analysis. Subjects were categorized into three sleep groups based on two sleep questions: (a) no sleep problems; (b) sleep disturbance; and (c) sleep disorder. Diabetes was defined as having one of a diagnosis from a physician; an overnight fasting glucose > 125 mg/dL; Glycohemoglobin > 6.4%; or an oral glucose tolerance test > 199mg/dL. Overall, 19% of subjects were diabetics, 37% were obese, and 32% had either sleep disturbance or sleep disorder. Using multiple logistic regression models adjusting for covariates without including BMI, the odds ratios (OR, (95% CI)) of diabetes were 1.40 (1.06, 1.84) and 2.04 (1.40, 2.95) for those with sleep disturbance and with sleep disorder, respectively. When further adjusting for BMI, the ORs were similar for those with sleep disturbance 1.36 (1.06, 1.73) but greatly attenuated for those with sleep disorders (1.38 [0.95, 2.00]). In conclusion, the impact of sleep disorders on diabetes may be explained through the individuals’ obesity status.

Rhythmic Masticatory Muscle Activity during Sleep: Etiology and Clinical Perspectives

L’activité rythmique des muscles masticateurs (ARMM) pendant le sommeil se retrouve chez environ 60% de la population générale adulte. L'étiologie de ce mouvement n'est pas encore complètement élucidée. Il est cependant démontré que l’augmentation de la fréquence des ARMM peut avoir des conséquences négatives sur le système masticatoire. Dans ce cas, l'ARMM est considérée en tant que manifestation d'un trouble moteur du sommeil connue sous le nom de bruxisme. Selon la Classification Internationale des Troubles du Sommeil, le bruxisme est décrit comme le serrement et grincement des dents pendant le sommeil. La survenue des épisodes d’ARMM est associée à une augmentation du tonus du système nerveux sympathique, du rythme cardiaque, de la pression artérielle et elle est souvent en association avec une amplitude respiratoire accrue. Tous ces événements peuvent être décrits dans le contexte d’un micro-éveil du sommeil. Cette thèse comprend quatre articles de recherche visant à étudier i) l'étiologie de l’ARMM pendant le sommeil en relation aux micro-éveils, et à évaluer ii) les aspects cliniques du bruxisme du sommeil, du point de vue diagnostique et thérapeutique. Pour approfondir l'étiologie de l’ARMM et son association avec la fluctuation des micro-éveils, nous avons analysé le patron cyclique alternant (ou cyclic alternating pattern (CAP) en anglais), qui est une méthode d’analyse qui permet d’évaluer l'instabilité du sommeil et de décrire la puissance des micro-éveils. Le CAP a été étudié chez des sujets bruxeurs et des sujets contrôles qui ont participé à deux protocoles expérimentaux, dans lesquels la structure et la stabilité du sommeil ont été modifiées par l'administration d'un médicament (la clonidine), ou avec l'application de stimulations sensorielles (de type vibratoire/auditif) pendant le sommeil. Dans ces deux conditions expérimentales caractérisées par une instabilité accrue du sommeil, nous étions en mesure de démontrer que les micro-éveils ne sont pas la cause ou le déclencheur de l’ARMM, mais ils représentent plutôt la «fenêtre permissive» qui facilite l'apparition de ces mouvements rythmiques au cours du sommeil. Pour évaluer la pertinence clinique du bruxisme, la prévalence et les facteurs de risque, nous avons effectué une étude épidémiologique dans une population pédiatrique (7-17 ans) qui était vue en consultation en orthodontie. Nous avons constaté que le bruxisme est un trouble du sommeil très fréquent chez les enfants (avec une prévalence de 15%), et il est un facteur de risque pour l'usure des dents (risque relatif rapproché, RRR 8,8), la fatigue des muscles masticateurs (RRR 10,5), les maux de tête fréquents (RRR 4,3), la respiration bruyante pendant le sommeil (RRR 3,1), et divers symptômes liés au sommeil, tels que la somnolence diurne (RRR 7,4). Ces résultats nous ont amenés à développer une étude expérimentale pour évaluer l'efficacité d'un appareil d'avancement mandibulaire (AAM) chez un groupe d'adolescents qui présentaient à la fois du bruxisme, du ronflement et des maux de tête fréquents. L'hypothèse est que dans la pathogenèse de ces comorbidités, il y a un mécanisme commun, probablement lié à la respiration pendant le sommeil, et que l'utilisation d'un AAM peut donc agir sur plusieurs aspects liés. À court terme, le traitement avec un AAM semble diminuer l'ARMM (jusqu'à 60% de diminution), et améliorer le ronflement et les maux de tête chez les adolescents. Cependant, le mécanisme d'action exact des AAM demeure incertain; leur efficacité peut être liée à l'amélioration de la respiration pendant le sommeil, mais aussi à l'influence que ces appareils pourraient avoir sur le système masticatoire. Les interactions entre le bruxisme du sommeil, la respiration et les maux de tête, ainsi que l'efficacité et la sécurité à long terme des AAM chez les adolescents, nécessitent des études plus approfondies.

Sleep, ageing and night work

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Increasing trends of sleep complaints in the city of São Paulo, Brazil

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Sleep complaints and polysomnographic findings: A study of nuclear power plant shift workers

The literature widely recognizes that shift workers have more health complaints than the general population. The objective of this study was to describe the prevalence of sleep complaints and verify the polysomnographic (PSG) variables of shift workers in two Brazilian nuclear power plants. We carried out a subjective evaluation with a sleep questionnaire. Based on these results, the interviewees that reported sleep-related complaints were referred for polysomnographic evaluation. of the 327 volunteers initially evaluated by the sleep questionnaire, 113 (35%) reported sleep complaints; they were significantly older, had higher body mass index (BMI), and worked more years on shifts than those without sleep complaints. of these 113, 90 met criteria for various sleep disorders: 30 (9%) showed obstructive sleep apnea (OSA), 18 (5.5%) showed limb movement, and 42 (13%) evidenced both sleep problems and had a significantly higher proportion of sleep stage 1 and arousals compared with the 23 shift workers that had no indices of sleep problems. The present study found that 90 (27.5%) of the evaluated participants met the PSG criteria of some type of clinical sleep disorder. This high proportion should be investigated for associations with other aspects of work, such as working hours, working schedule, years performing shift work, and access to health services. Due to the strong association between sleep disorders and the incidence of fatigue and sleepiness, the evaluation of the sleep patterns and complaints of shift workers is essential and should be considered to be one of the basic strategies of industry to prevent accidents.

Effects of neuromuscular electrical stimulation, laser therapy and LED therapy on the masticatory system and the impact on sleep variables in cerebral palsy patients: a randomized, five arms clinical trial

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Treatment of snoring and sleep apnea syndrome with a removable mandibular advancement device in patients without TMD

INTRODUCTION: Among the sleep disorders reported by the American Academy of Sleep, the most common is obstructive sleep apnea-hypopnea syndrome (OSAHS), which is caused by difficulties in air passage and complete interruption of air flow in the airway. This syndrome is associated with increased morbidity and mortality in apneic individuals. OBJECTIVE: It was the objective of this paper to evaluate a removable mandibular advancement device as it provides a noninvasive, straightforward treatment readily accepted by patients. METHODS: In this study, 15 patients without temporomandibular disorders (TMD) and with excessive daytime sleepiness or snoring were evaluated. Data were collected by means of: Polysomnography before and after placement of an intraoral appliance, analysis of TMD signs and symptoms using a patient history questionnaire, muscle and TMJ palpation. RESULTS: After treatment, the statistical analysis (t-test, and the before and after test) showed a mean reduction of 77.6% (p=0.001) in the apnea-hypopnea index, an increase in lowest oxyhemoglobin saturation (p=0.05), decrease in desaturation (p=0.05), decrease in micro-awakenings or EEG arousals (p=0.05) and highly significant improvement in daytime sleepiness (p=0.005), measured by the Epworth Sleepiness Scale. No TMD appeared during the monitoring period. CONCLUSION: The oral device developed in this study was considered effective for mild to moderate OSAHS.

Behavior analysis of electromyographic activity of the masseter muscle in sleep bruxers

The effects of occlusal splint on the electric activity of masseter were studied in 15 women who presented sleep bruxism using surface electromyography. Sleep bruxism was defined by its clinical characteristics. The signal acquisition was done during mandible occlusion without clenching and maximum voluntary contraction in two situations. The first was after a workday without using the occlusal splint; and the second, after a sleeping night using occlusal splints. Evaluating masseter muscles during mandible occlusion without clenching, it could be observed that lower values were noticed after splint wearing in both sides. The same results were verified in maximum voluntary contraction (MVC). These results confirmed that the use of occlusal splints reduced the electromyographic activity of the right and left masseters, showing its myorelaxing effect. © 2009 Elsevier Ltd. All rights reserved.

Sleep quality and its associations with leisure-time exercise and excess weight among civil servants

O objetivo do estudo foi analisar a associação entre qualidade do sono, prática de exercícios físicos no lazer e obesidade entre servidores públicos de uma universidade. A amostra foi composta por 92 adultos de ambos os sexos. Qualidade do sono e atividade física foram coletadas por meio de questionário. O excesso de peso/obesidade foi diagnosticado pelo índice de massa corporal, o qual foi calculado com valores de peso e estatura relatados pelos avaliados. A prevalência de pessoas com sono alterado foi de 53,84%. Houve associação entre obesidade (OR= 7,22 [ORIC95%: 1,65-31,5]) e pior qualidade do sono, bem como, prática de atividade física e melhor qualidade do sono (OR= 0,19 [ORIC95%: 0,04-0,95]), independente de outros fatores de confusão. Concluiu-se que há alta ocorrência de distúrbios do sono, a qual foi associada de maneira independente com a prática de exercícios físicos e a obesidade.