Table 2.
Clinical studies examining the association between sleep quality with obesity and diabetes
| Author (year) | Type of study/country or region | Study population (sample size) | Definition of sleep disturbances | Method of sleep assessment | Age (yr) and male (%) | Outcome |
|---|---|---|---|---|---|---|
| Sleep quality and weight gain/obesity | ||||||
| Lyytikäine et al. (2011)91 | Prospective study (follow-up: 5–7 yr)/Finland | Middle-aged municipal employees from the Helsinki Health Study (n=7,022) | Trouble falling asleep, waking up several times per night, trouble staying asleep, or waking up early feeling tired: the corresponding sleep problems ≥15 nights in the past 4 weeks | Self-reported (the Jenkins Sleep Questionnaire) | 40–60, 18.5% | Weight gain of ≥5 kg Female with trouble falling asleep: OR, 1.49; 95% CI, 1.09–2.03 Female with waking up several times per night: OR, 1.34; 95% CI, 1.09–1.65 Female with trouble staying asleep: OR, 1.29; 95% CI, 1.02–1.62 Female with waking up tired: OR, 1.04; 95% CI, 0.83–1.30 Male: NS |
| Huang et al. (2013)92 | Cross-sectional study/China | Patients with insomnia (n=141) | Slow wave sleep time and rapid eye movement sleep time | PSG | Insomnia: 42.2±9.8, 44% Healthy: 38.9±12.4, 51% |
BMI Slow wave sleep time (min): β, −0.013; 95% CI, −0.026 to −0.001; P=0.043 Rapid eye movement sleep time (min): β, 0.007; 95% CI, −0.008 to 0.023; P=0.352 |
| Piccolo et al. (2013)93 | Prospective study (follow-up: 4.8±0.6 yr)/the United States | General population from the Boston Area Community Health Survey (n=4,145) | Restless sleep: experiencing restless sleep much of the time during the past week | Self-reported | 30–79, NS | New-onset obesity Experiencing restless sleep: OR, 1.66; 95% CI, 1.10–2.49 |
| Sivertsen et al. (2014)94 | Prospective study (follow-up: 11 yr)/Norway | General population from the Nord-Trøndelag Health Studies (n=24,715) | Insomnia: “often” or “almost every night” had difficulties in initiating or maintaining sleep in the preceding month, in addition to reporting impaired work performance caused by insomnia during the preceding year | Self-reported | 32–66, 43.1% | New-onset obesity Insomnia: OR, 1.13; 95% CI, 0.96–1.33 |
| Vgontzas et al. (2014)70 | Prospective study (total follow-up: 7.5 yr; women: 4.5 yr; men: 10.5 yr)/the United States | General population (n=815) | Insomnia: a complaint of insomnia with a duration of ≥1 yr Poor sleep: a moderate-to-severe complaint of difficulty falling asleep, difficulty staying asleep, early morning awakening, or non-restorative sleep. Normal sleep: absence of either of these two categories. |
Self-reported | 48.9±13.4, 50.5% | New-onset obesity Insomnia with adjustment for subjective sleep duration: OR, 0.48; 95% CI, 0.15–1.53 Poor sleep with adjustment for subjective sleep duration: OR, 1.78; 95% CI, 1.02–3.13 Insomnia with adjustment for objective sleep duration: OR, 0.59; 95% CI, 0.20–1.77 Poor sleep with adjustment for objective sleep duration: OR, 1.76; 95% CI, 1.03–3.00 |
| Tan et al. (2015)95 | Cross-sectional study/Finland | Overweight middle-aged men (n=211) | OSA: an AHI of 5 or greater with EDS or an AHI of 15 or greater, regardless of associated symptoms Insomnia: DIS and/or DMS and/or NRS, and lasted for at least 1 month during the last 3 months Reference: overweight participants free from any sleep disorders |
Specialist physician diagnosis (through Vitalmed sleep questionnaire and PSG) | 30–65, 100% | BMI Reference, 15.8±4.3; OSA, 19.7±6.0 (P<0.05); insomnia, 18.5±5.9; OSA+insomnia, 19.7±7.1 (P<0.05) Waist circumference (cm) Reference, 98.0±7.6; OSA, 110.4±9.0 (P<0.05); insomnia, 106.5±10.2 (P<0.05); OSA+insomnia, 111.4±14.7 (P<0.05) Fat mass trunk (kg) Reference, 15.8±4.3; OSA, 19.7±6.0 (P<0.05); insomnia, 18.5±5.9 (P<0.05); OSA+insomnia, 19.7±7.1 (P<0.05) Fat mass android region (kg) Reference, 2.9±0.9; OSA, 3.7±1.1 (P<0.05); insomnia, 3.5±1.2 (P<0.05); OSA+insomnia, 3.8±1.4 (P<0.05) |
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| Sleep quality and risk of diabetes | ||||||
| Nilsson et al. (2004)96 | Prospective study (mean follow-up: 14.8±2.4 yr)/Sweden | Healthy men from the Malmo Preventive Project (n=6,599) | Sleep disturbances: had either or both positive reply to difficulty in falling asleep or generally use sleeping pills more than 3 times a week | Self-reported questionnaire | 35–51, 100% | New-onset diabetes Sleep disturbances: OR, 1.52; 95% CI, 1.05–2.20 |
| Björkelund et al. (2005)97 | Prospective study (follow-up: 32 yr)/Sweden | Swedish women from the Population Study of Women in Gothenburg (n=661) | Sleep complaints: sleep problems (without specified time frame) and/or having consulted a doctor for sleep problems and/or hospital admission for this reason | Self-reported | 70–92, 0% | New-onset diabetes Sleep complaints: RR, 1.04; 95% CI, 0.91–1.18 |
| Mallon et al. (2005)74 | Prospective study (mean follow-up: 12 yr)/Sweden | General population (n=1,170) | DIS: had severe difficulties (scores 4 and 5) in initiating sleep DMS: had severe difficulties (scores 4 and 5) in maintaining sleep |
Self-reported (the Uppsala Sleep Inventory) | 45–65, 47.0% | New-onset diabetes Male with DIS: RR, 2.4; 95% CI, 0.7–8.6 Male with DMS: RR, 4.8; 95% CI, 1.9–12.5 Female with DIS: NS Female with DMS: RR, 1.8; 95% CI, 0.5–6.0 |
| Meisinger et al. (2005)98 | Prospective study (mean follow-up: 7.5 yr)/Germany | General population (n=8,269) | DIS: often had trouble falling asleep DMS: often woke up during the night |
Self-reported | 25–74, 49.9% | New-onset diabetes Male with DIS: HR, 1.10; 95% CI, 0.59–2.03 Female with DIS: HR, 1.42; 95% CI, 0.81–2.50 Male with DMS: HR, 1.60; 95% CI, 1.05–2.45 Female with DMS: HR, 1.60; 95% CI, 1.05–2.45 |
| Hayashino et al. (2007)77 | Prospective study (median follow-up: 4.2 yr)/Japan | Asian healthy workers from High-risk and Population Strategy for Occupational Health Promotion Study (n=6,509) |
DIS: sometimes or often had difficulties initiating sleeping DMS: sometimes or often had difficulties maintaining sleeping |
Self-reported | 38.2 (19–69), 73.9% | New-onset diabetes Sometimes DIS: HR, 1.42; 95% CI, 1.05–1.91 Often DIS: HR,1.61; 95% CI, 1.00–2.58 Sometimes DMS: HR, 1.31; 95% CI, 0.97–1.76 Often DMS: 1.37; 95% CI, 0.87–2.16 |
| Kita et al. (2012)81 | Prospective, occupational-based study (follow-up: 4 yr)/Japan | Local government employees (n=3,570) | Any sleep difficulties participants may have experienced ≥3 times a week during the previous month in sleep induction, awakening during the night, early morning awakening, self-perceived insufficient sleep duration, and overall quality of sleep | Self-reported questionnaire | 35–55, 79.0% | New-onset diabetes Awakening during the night: OR, 5.03; 95% CI, 1.43–17.64 Self-perceived insufficient sleep duration: OR, 6.76; 95% CI, 2.09–21.87 Unsatisfactory overall quality of sleep: OR, 3.71; 95% CI, 1.37–10.07 |
| Piccolo et al. (2013)93 | Prospective study (mean follow-up: 4.8±0.6 yr)/the United States | General population from the Boston Area Community Health Survey (n=4,145) | Restless sleep: experiencing restless sleep much of the time during the past week | Self-reported | 30–79, NS | New-onset T2DM Restless sleep: OR, 1.05; 95% CI, 0.67–1.64 |
| Sivertsen et al. (2014)94 | Prospective study (follow-up: 11 yr)/Norway | General population from the Nord-Trøndelag Health Studies (n=24,715) | Insomnia: “often” or “almost every night” had difficulties in initiating or maintaining sleep in the preceding month, in addition to reporting impaired work performance caused by insomnia during the preceding year | Self-reported | 32–66, 43.1% | New-onset T2DM Insomnia: OR, 1.07; 95% CI, 0.82–1.41 |
| Lou et al. (2015)85 | Prospective study (follow-up: 5 yr)/China | General population (n=11,842) | Poor sleep: had difficulties with initiating and maintaining sleep ≥8 days per month on average during the previous year | Self-reported | 44.8±14.7, 45.4% | New-onset T2DM Poor sleep quality: RR, 1.91; 95% CI, 1.31–2.74 Poor sleep quality with short sleep duration (≤ 6 hr/night): RR, 6.21; 95% CI, 2.78–11.81 |
| Lee et al. (2016)99 | Prospective study (median follow-up period: 2.5 yr)/Korea | General population from the family cohort study in primary care (the FACTS) (n=563) | Poor sleep quality: the score of the PSQI ≥5 | Self-reported | 10–75, 45.6% | New-onset T2DM RR, 2.64; 95% CI, 1.03–6.78 |
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| Sleep quality and glycemic control | ||||||
| Knutson et al. (2006)87 | Cross-sectional study/the United States | African-American women and men with diabetes (n=161) | Modified PSQI score: PSQI score after removing the sleep duration component to assess sleep quality independently from sleep quantity | Self-reported questionnaire | 57±12, 26.1% | Glycemic control (lnHbA1c) Modified PSQI score in patients without diabetic complications: β, −0.014; P=0.16 Modified PSQI score in patients with at least 1 diabetic complications: β, 0.043; P=0.002 |
| Wan Mahmood et al. (2013)100 | Cross-sectional study/Ireland | Caucasian patients with T2DM (n=114) | Poor sleep quality: the score of PSQI >5 | Self-reported questionnaire | NS, 54.4% | Log HbA1c Poor sleep quality: β, 0.038; P=0.826 |
| Cho et al. (2014)101 | Cross-sectional study/Korea | Patients with T2DM (n=614) | Sleep apnea: SDQ-SA ≥36 for males and ≥32 for females; Poor sleep: PSQI score ≥5 Insomnia: any difficulty in falling asleep, maintaining sleep, early morning waking, and non-restorative sleep occurring at least three times per week over the preceding month |
Self-reported questionnaires | 59.7±11.1, 62.1% | Postprandial glucose Sleep apnea score (SDQ-SA): r=0.100, P=0.032 HbA1c No significant association between HbA1c values and poor sleep, insomnia |
| Nefs et al. (2015)102 | Cross-sectional study/the Netherlands | Dutch adults with T1DM (n=267) or T2DM (n=361), (total n=628) | Poor sleep quality: PSQI score >5 | Self-reported questionnaire | T1DM: 47±16, 41% T2DM: 62±9, 54% |
Most recent HbA1c, % (mmol/mol) In T1DM, good sleep quality vs. poor sleep quality: 7.5±0.9 (58±10) vs. 7.5±1.1 (59±12), P=0.68; In T2DM, good sleep quality vs. poor sleep quality: 7.1±1.3 (54±14) vs. 7.3±1.3 (57±14), P=0.09 |
| Osonoi et al. (2015)103 | Cross-sectional study/Japan | Patients with T2DM (n=724) | Poor sleep quality: PSQI score ≥9 Average sleep quality: PSQI score 6–8 Good sleep quality: PSQI score ≤5 |
Self-reported questionnaire | 57.8±8.6, 62.9% | Fasting blood glucose (mg/dL) Good sleep: 132±31; average sleep: 136±31; poor sleep: 141±32 (P>0.05) HbA1c (%) Good sleep: 6.9±1.0; average sleep: 7.1±1.1; poor sleep: 7.1±0.8; (P>0.05) |
Values are presented as range or mean± standard deviation.
OR, odds ratio; CI, confidence interval; NS, not specified; PSG, polysomnography; BMI, body mass index; OSA, obstructive sleep apnea; AHI, apnea hypopnea index; EDS, excessive daytime sleepiness; DIS, difficulty in initiating sleep; DMS, difficulty in maintaining sleep; NRS, nonrestorative sleep; RR, relative risk; HR, hazard ratio; T2DM, type 2 diabetes mellitus; PSQI: the Pittsburgh Sleep Quality Index; SDQ-SA, the Sleep Disorders Questionnaire Sleep Apnea subscale; T1DM, type 1 diabetes mellitus.