Objective
Type 1 diabetes is gradually increasing in its prevalence throughout the United States and the world. The diagnosis carries with it significant burden, as constant monitoring of glucose levels, administration of insulin, and expensive therapies are required. Previously, the focus of type 1 diabetes management aimed at achieving tight glucose control using the available insulins and delivery methods. However, this does not address the burden on patients and their families. With a rise in mental health concerns and continued poor glucose control in people with type 1 diabetes, especially adolescents, more recognition has been placed on methods to improve mental health as a part of routine diabetes care. While it is only now becoming recognized as a critical component of health, sleep quality has been shown to significantly impact both mental and physical health, and adolescents are especially prone to significantly decreased sleep duration and frequent sleep disruptions.
The main objectives of this study are to: (1) Identify the causes of sleep disruptions in adolescents with type 1 diabetes who receive clinical care at the Barbara Davis Center for Diabetes; (2) Develop a useful and efficient sleep screening and intervention tool that can guide diabetes health care providers in the assessment of sleep health during routine clinical visits; (3) Obtain pilot data on the successful use and effectiveness of sleep interventions in adolescents with type 1 diabetes.
The ultimate goal of this project is to expand on the current understanding of the causes of sleep disruptions in adolescents with type 1 diabetes and to develop an efficient sleep screening and intervention tool that can be used during routine clinical visits. This project will thus help diabetes health care providers improve the overall health and wellbeing of adolescents with type 1 diabetes, a particularly vulnerable population.
Background Rationale
Quality sleep is essential for optimal physical and mental health, with deficient sleep linked to obesity, insulin resistance and metabolic syndrome, cardiac disease and high blood pressure, depression and anxiety, decreased cognitive abilities, and sedentary lifestyles. Adolescents in the general population often fail to achieve the recommended duration of sleep, with only around 25% meeting the goal, and this is especially true in adolescents with type 1 diabetes who achieve an average of 26 minutes less sleep than their peers. Adolescents with type 1 diabetes are also failing to meet glucose and hemoglobin A1c targets and are especially prone to high rates of depressive symptoms and mental health concerns. Deficient sleep in adolescents has been directly tied to hyperglycemia, elevated hemoglobin A1c, decreased diabetes self-management, and increased rates of depression and anxiety.
Deficient sleep is caused by a number of factors, including behavioral (e.g. timing of bed time, increased use of electronics at night, early wake times, etc) and physiologic (e.g. obstructive sleep apnea). Adolescents with type 1 diabetes are prone to the same factors faced by their peers, however, they also have additional unique sleep disruptors specifically related to diabetes. These disruptors include both hypo- and hyper-glycemia, rapid changes in glucose levels especially rapid drops, and the need for treatment of hypoglycemia during the night. Additionally, fear of hypoglycemia and nocturnal glucose testing during illnesses or medication changes result in deficient sleep. While diabetes devices have improved glucose outcomes, they also result in frequent nighttime disruptions due to device alarms.
Research has shown a significant link between sleep and type 1 diabetes health and wellbeing and routine assessment of sleep health during clinic visits is needed. To date, most health care providers do not address sleep in part due to time constraints during busy clinics, but also due to a lack of knowledge on how to approach sleep health and how to intervene when concerns have been identified. The purpose of this project is to fill a critical gap in the knowledge of causes of sleep disruptions in adolescents with type 1 diabetes and to develop an efficient tool to help diabetes health care providers identify significant sleep disruptors and provide guidance on intervention methods.
Description of Project
The overall goal of this project is to address the critical need to assess sleep health in youth with type 1 diabetes. Sleep is recognized as a modifiable factor in the health of adolescents with type 1 diabetes, impacting both mental and physical health, in addition to glycemic control. This study is relevant to the health of people with type 1 diabetes because the current research has overwhelmingly called for sleep health to be a part of routine type 1 diabetes care, however, to date, there is no clinical guidance on methods to assess or treat sleep concerns in this population. This project will focus on identification of causes of insufficient sleep in adolescents with type 1 diabetes and develop a cause-specific sleep screening and intervention tool to improve health care providers’ ability to assess sleep health during routine clinical visits. If the aims of this project are achieved, this study will significantly fill a critical gap in sleep knowledge and health in patients with type 1 diabetes.
Anticipated Outcome
This project has three phases with unique outcomes that are under investigation. The ultimate goal of this project is to develop an efficient sleep screening and intervention tool for health care provider use in routine clinical care of adolescents with type 1 diabetes. Phase 1 consists of identifying the causes of sleep disruptions in adolescents with type 1 diabetes. To complete this, adolescents aged 11-17 years will be asked to wear actigraphy watches and complete sleep diaries and sleep surveys. A subset will be invited to participate in qualitative interviews with a goal of further detailing the causes of deficient sleep, the impact on the daily activities of the individual, and identifying facilitators and barriers to improving sleep quality. We hypothesize that individuals with insufficient sleep duration will have modifiable sleep disruptors that can be targeted for intervention. Sleep disruptors will include both diabetes-specific and non-diabetes factors, as it is important to address all causes of sleep disruptions in this population.
The second phase of the project involves the development and feasibility testing of sleep screening questions and sleep interventions in a clinical setting. It is important to test the questions and interventions for clinical feasibility to ensure successful long term use. In addition, this will provide valuable insight in to the content of the screening questions and interventions and allow health care providers the opportunity to provide feedback on the content of the clinical tool. The feedback will lead to modifications and further testing to ensure improved content and efficiency. At the completion of this phase, we will have a clinically efficient sleep screening and intervention tool for use by health care providers.
The third phase will include pilot testing of the sleep screening and intervention tool in the clinic setting. Adolescents with type 1 diabetes who are identified as having sleep concerns and receive targeted interventions will be identified and invited to participate in follow up study visits. The adolescents will be followed over 3 months to obtain pilot data on the successful use of the sleep interventions, barriers to initiating recommendations, and efficacy of the sleep interventions. We hypothesize that the sleep screening and intervention tool will be feasible and will improve the health care provider’s ability to address sleep health as part of routine type 1 diabetes clinical care.
Relevance to T1D
The health of individuals with type 1 diabetes is significantly associated with sleep quality and duration. Sleep deficiency is linked to metabolic, cardiovascular, and mental health, all of which are significant concerns for people with type 1 diabetes. There is now substantial research indicating the importance of assessing sleep health as part of routine diabetes care, however, there is currently no guidance for health care providers on how to address sleep concerns or provide targeted treatment. It is therefore important to develop a method that is clinically efficient to assess sleep health during routine clinical visits. This project will be the first step in filling a critical gap in the management of type 1 diabetes in a particularly vulnerable population.