|Year : 2013 | Volume
| Issue : 1 | Page : 59-62
Association between sleep duration and diabetes mellitus: Isfahan Healthy Heart Program
J Najafian1, N Mohamadifard2, ZD Siadat3, G Sadri3, MR Rahmati4
1 Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, Isfahan, Iran
2 Hypertension Research Center, Isfahan Cardiovascular Research Institute, Isfahan, Iran
3 Medicine School, Isfahan University of Medical Sciences, Isfahan, Iran
4 Arak Health Center, Arak University of Medical Sciences, Arak, Iran
|Date of Acceptance||14-May-2012|
|Date of Web Publication||2-Feb-2013|
Internist Cardiologist, Assistant Professor of Internal Medicine, Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Khoram Street, Sadigheh Tahereh Research Center, Po Box: 81465-1148, Isfahan
| Abstract|| |
Background: Recent studies revealed an association between sleep disturbance and metabolic disorders, such as obesity and metabolic syndrome. An aim of this study was to assess the relation between sleep duration and diabetes mellitus in a representative sample of the Iranian population.
Materials and Methods: Participants were 12514 individuals, (6123 men and 6391 women) studied in the baseline survey of a community based program entitled Isfahan healthy heart program (IHHP). Sleep time was obtained by validated questionnaire. Diabetes mellitus was defined as fasting glucose over 126 mg/dl or 2 hour post prandial glucose at glucose tolerance test over 200 mg/dl, or if the patient was on diabetic medication. The relation between the sleep time and diabetes was examined using categorical logistic regression with adjustment for sex, body mass index and waist circumference.
Results: Compared with those, sleeping 7-8 hours per night, the individuals with sleeping time of 5 hours or less and aged <60 years had an increased odd ratio for diabetes and an impaired glucose tolerance. (OR = 1.37 and 95% CI = 1.13, 1.67).
Conclusion: Sleep duration of 5 hours or less in individuals under age 60 years is associated with an increased prevalence of diabetes mellitus and an impaired glucose tolerance test. This finding should be confirmed in longitudinal studies.
Keywords: Diabetes mellitus, glucose tolerance, sleep
|How to cite this article:|
Najafian J, Mohamadifard N, Siadat Z D, Sadri G, Rahmati M R. Association between sleep duration and diabetes mellitus: Isfahan Healthy Heart Program. Niger J Clin Pract 2013;16:59-62
|How to cite this URL:|
Najafian J, Mohamadifard N, Siadat Z D, Sadri G, Rahmati M R. Association between sleep duration and diabetes mellitus: Isfahan Healthy Heart Program. Niger J Clin Pract [serial online] 2013 [cited 2014 Mar 12];16:59-62. Available from: http://www.njcponline.com/text.asp?2013/16/1/59/106756
| Background|| |
Sleep quantity and quality is reported to be associated with an increased morbidity and mortality. , Previous studies have demonstrated that experimental restriction of sleep to <4 hours per night for 6 nights resulted in an impaired glucose tolerance (IGT) in young healthy adults.  Most of these studies have been conducted in western countries with different ethnic background. Furthermore, this experience is limited to large community-based studies, , and it is not clear whether the results are applicable to the Asian population.
Results from the High-risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) study in Japan suggests that difficulty in initiating sleep, but not sleep duration or difficulty in maintaining sleep, is associated with a higher risk of diabetes in relatively healthy Asian workers, even after adjusting for a large number of possible confounders. 
In a number of cohort studies, ,,,,, it has been shown that sleep disturbances including either an increased or decreased length of nocturnal sleep may increase an incidence of type-2 diabetes, with a higher rate in men than in women.
The present study aims to investigate the relation between the sleep duration and existing diabetes in a large representative sample of the Iranian population.
| Materials and Methods|| |
This cross-sectional study was conducted as a part of Isfahan Healthy Heart Program. (IHHP). It is a 6 year comprehensive integrated community based program for cardiovascular disease (CVD) prevention and control via reducing CVD risk factors and improvement of cardiovascular healthy behaviors. ,
Participants were 12514 individuals aged over 19 years. 6123 men and 6391 women entered into the study. Sleep time was obtained by validated questionnaire.  The fasting blood glucose of all the participants and blood glucose of those without history of diabetes was measured 2 hours after giving a syrup containing 75 g of glucose powder using enzymatic method of oxidized glucose. Diabetes mellitus (DM) was defined as fasting glucose over 126-mg/dl, or 2-hour postprandial glucose (at glucose tolerance test) over 200 mg/dl, or if the subjects were on diabetic drug or on insulin medication. The 2-hour post-prandial glucose between 140 and 200 mg/dl and fasting glucose between 100 mg/dl and 126 mg/dl was considered as an IGT.
Data were presented as mean and percentiles. The association between diabetes mellitus or impaired glucose tolerance test and sleeping hours were tested with logistic regression models using 7-8 sleeping hours as the reference category. The analyzes were performed unadjusted and also with adjustments for possible confounding variables including age, sex, waist circumference (WC) and body mass index (BMI). Also, it was done separately for both the sexes and age groups over or below 60 years adjusted for BMI, and WC. P value below 0.05 was considered significant. All of the analyzes were performed by SPSS software version 15.00.
| Result|| |
The study populations consisted of 49.9% men and 51.1% women with a mean age of 38.89 (SD 14.93 years). In our study, 6.9% of the participants were diabetic, and 7.4% had an impaired glucose tolerance. Of the participants, 61% reported sleeping 7-8 hours per night, 30.3% reported sleeping 6 hours or less and 8.7% reported sleeping 9 hours or more. Subjects with lower sleep times were older and had a higher (BMI) and WC (P < 0.01) [Table 1]. Also, the frequency distribution of participants in different blood glucose level based on sleep duration categories was presented in [Table 1].
Compared with sleep times of 7-8 hours per night, sleep times of <5 hours were associated with a higher odds ratio for IGT and DM. This association remained significant even after an adjustment for age, sex, BMI and WC. However, in subjects with sleep times of 9 hours or more, there was no significant association with IGT or DM [Table 2].
|Table 2: Data for diabetes mellitus and impaired glucose tolerance by reported usual time in subjects|
Click here to view
Secondary analyzes after stratification for sex and age demonstrated that an association of sleep time of 5 hours or less with IGT and DM in men and women and in those subjects younger than 60 years was significant after an adjustment with age, sex, WC and BMI, but this association was not significant for the subjects aged 60 years or more [Table 3].
|Table 3: Diabetes mellitus or impaired glucose tolerance by reported usual sleep time|
Click here to view
| Discussion|| |
Sleep disturbances are common in general population. There are increasing evidence from large screening surveys about the role of sleep disorders as a new cardiovascular risk factor. Sleep disorders are not only independent risk factors, but also potentiate severity of the other risk factors, such as diabetes, hypertension obesity, mental stress and, etc. ,
In our study, sleep duration of 5 hours or less in people under the age 60 is associated with an increased prevalence of DM and IGT. However, sleep duration over 9 hours do not increase prevalence of these metabolic disturbances. In most recent studies, a U-shaped association is reported between the sleep duration and DM, sleep duration over 9 hours and under 5 hours is associated with an increased prevalence of IGT and DM. ,,,,
The differences between our study and other studies about an effect of sleeping longer than 9 hours may be explained by the role of sympathetic nervous system in stress, it is documented that sleep disorders are associated with an increased activity of the sympathetic nervous system, , this in turn could increase glycogen-breakdown and gluconeogenesis, and this would induce an insulin resistance. There are reports that poor glycemic control is associated with psychological distress. ,,, If in our population daily stress is strong enough to increase an insulin resistance, reducing daily awakening hours by increasing sleep hours may reduce an incidence of insulin resistance and this effect may compensate the effect of sleeping more than 9 hours. Our study revealed no significant relation between the DM and IGT in individuals aged 60 years. This may be due to the changes that take place in physiology of metabolic effect of sleep deprivation with aging. According to one recent study, decreased sleep-duration does not predict overweight or obesity (another metabolic effect of sleep deprivation) in older woman (aged >50 years) in contrast to younger woman.  It should be noted that our study has two potential limitations, first, as the study utilized a cross-sectional design, it cannot prove a casual relationship, second, sleep time was self-reported and was not directly measured, therefore, patient's co-operation could be a confounding factor.
As all of these associations have been documented by cross- sectional studies, they should be confirmed by longitudinal studies.
| Conclusion|| |
Sleep duration of 5 hours or less in individuals aged <60 years is associated with an increased prevalence of diabetes mellitus even after adjusting for body mass index, waist circumference and sex. Improvement of sleep quality and normalization of sleep length could lead to a better glucose tolerance and lower long-term risk for type-2 diabetes.
| References|| |
|1.||Kripke DF, Garfinkel L, Wingard DL, Klauber MR, Marler MR. Mortality associated with sleep duration and insomnia. Arch Gen Psychiatry 2002;59:131-6. |
|2.||Enstrom JE, Kanim LE, Breslow L. The relationship between vitamin C intake, general health practices, and mortality in Alameda County, California. Am J Public Health 1986;76:1124-30. |
|3.||Spiegel K, Leproult R, Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet 1999;354:1435-9. |
|4.||Ayas NT, White DP, Al-Delaimy WK, Manson JE, Stampfer MJ, Speizer FE, et al. A prospective study of self-reported sleep duration and incident diabetes in women. Diabetes Care 2003;26:380-4. |
|5.||Yaggi HK, Araujo AB, McKinlay JB. Sleep duration as a risk factor for the development of type 2 diabetes. Diabetes Care 2006;29:657-61. |
|6.||Hayashino Y, Fukuhara S, Suzukamo Y, Okamura T, Tanaka T, Ueshima H. Relation between sleep quality and quantity, quality of life, and risk of developing diabetes in healthy workers in Japan: The High-risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) Study. BMC Public Health 2007;7:129. |
|7.||Resnick HE, Redline S, Shahar E, Gilpin A, Newman A, Walter R, et al. Sleep Heart Health Study. Diabetes and sleep disturbances: Findings from the Sleep Heart Health Study. Diabetes Care 2003;26:702-9. |
|8.||Nilsson PM, Rõõst M, Engstrõm G, Hedblad B, Berglund G. Incidence of diabetes in middle-aged men is related to sleep disturbances. Diabetes Care 2004;27:2464-9. |
|9.||Meisinger C, Heier M, Loewel H. MONICA/KORA Augsburg Cohort Study. Sleep disturbance as a predictor of type 2 diabetes mellitus in men and women from the general population. Diabetologia 2005;48:235-41. |
|10.||Bjõrkelund C, Bondyr-Carlsson D, Lapidus L, Lissner L, Mansson J, Skoog I, et al. Sleep disturbances in midlife unrelated to 32-year diabetes incidence: The prospective population study of women in Gothenburg. Diabetes Care 2005;28:2739-44. |
|11.||Mallon L, Broman JE, Hetta J. High incidence of diabetes in men with sleep complaints or short sleep duration: A 12-year follow-up study of a middle-aged population. Diabetes Care 2005;28:2762-7. |
|12.||Juuti AK, Hiltunen L, Rajala U, Laakso M, Härkönen P. Association of abnormal glucose tolerance with self-reported sleep apnea among a 57-year-old urban population in Northern Finland. Diabetes Res Clin Pract 2008;80:477-82. |
|13.||Sarraf-Zadegan N, Sadri G, Malek Afzali H, Baghaei M, Mohammadi Fard N, Shahrokhi S, et al. Isfahan healthy heart program: Comprehensive integrated community based program for cardiovascular disease prevention and control, designed, method and initial experience. Acta cardiol 2003;58:309-27. |
|14.||Sarrafzadegan N, Baghaei AM, Sadri GH, Kelishadi R, Malekafzali H, Boshtam M, et al. Isfahan Healthy Heart Program: Evaluation of comprehensive, community-based interventions for non-communicable disease. Prevention and Control J. 2006;2:73-84. |
|15.||Najafian J, Toghianifar N, Mohammadifard N, Nouri F. Association between sleep duration and metabolic syndrome in a population-based study: Isfahan Healthy Heart Program. J Res Med Sci. 2011 Jun;16:801-6. |
|16.||Najafian J, Mohammadifard N, Siadat ZD. Association between sleep duration and body mass index and waist circumference. IJMS 2010;35. |
|17.||Nakajima H, Kaneita Y, Yokoyama E, Harano S, Tamaki T, Ibuka E, et al. Association between sleep duration and hemoglobin A1C level. Sleep Med 2007;9:745-52. [Epub ahead of print]. |
|18.||Akerstedt T, Nilsson PM. Sleep as restitution: An introduction. J Intern Med 2003;254:6-12. |
|19.||Wiesli P, Schmid C, Kerwer O, Nigg-Koch C, Klaghofer R, Seifert B, et al. Acute psychological stress affects glucose concentrations in patients with type 1 diabetes following food intake but not in the fasting state. Diabetes Care 2005;28:1910-5. |
|20.||Lloyd CE, Dyer PH, Lancashire RJ, Harris T, Daniels JE, Barnett AH. Association between stress and glycemic control in adults with type 1 (insulin-dependent) diabetes. Diabetes Care 1999;22:1278-83. |
|21.||Surwit RS, van Tilburg MA, Zucker N, McCaskill CC, Parekh P, Feinglos MN, et al. Stress management improves long-term glycemic control in type 2 diabetes. Diabetes Care 2002;25:30-4. |
|22.||Stenstrom U, Wikby A, Hornquist JO, Andersson PO. Recent life events, gender, and the control of diabetes mellitus. Gen Hosp Psychiatry 1993;15:82-8. |
|23.||Kemmer FW, Bisping R, Steingruber HJ, Baar H, Hardtmann F, Schlaghecke R, et al. Psychological stress and metabolic control in patients with type I diabetes mellitus. N Engl J Med 1986;314:107. |
|24.||Chaput JP, Lord C, Aubertin-Leheudre M. Is overweight/obesity associated with short sleep duration in older women? Aging Clin Exp Res 2007;19:290-4. |
[Table 1], [Table 2], [Table 3]