CHAPTER
9

The Importance of Sleeping and Coping with Stress

In This Chapter

• How sleep affects your blood glucose
• Improving your chances for a restful sleep
• The effects of stress on your body
• Relaxation and stress management techniques

If you check your blood glucose and the result is higher than usual, probably the first two things you think about are what you ate and if you took your medication as planned. However, you may not think about how you slept the night before or how stressed you are. You’d be surprised at the impact that sleep and stress can also have on your blood glucose.

Poor sleep and stress can contribute to high blood glucose individually and together, with lack of sleep feeding stress and vice versa. So in this chapter, we discuss how getting better sleep and taking time to relax can improve your overall health and diabetes management.

Why Sleep Is Important

When you were a child, you were probably reminded on a regular basis about the importance of rest and sleep with phrases like “get a good night’s sleep,” “night night, sleep tight,” and “sleep well.” As an adult, sleep is still very important, but if you’re like a lot of people, you probably don’t get enough. The CDC estimates that up to 70 million adults in the United States have sleep or wakefulness disorders. Lack of sleep has been linked to risks of becoming obese and getting type 2 diabetes. Fatigue may contribute to overeating due to the belief that eating will boost energy. Plus, the foods selected tend to be less nutritious options, providing empty calories and leading to weight gain. Some studies have also shown that lack of sleep leads to insulin resistance, which can turn into type 2 diabetes over time, if not treated. People who have diabetes may not sleep as much, or as well, as people without diabetes. High blood glucose can lead to frequent urination which can cause multiple trips to the bathroom in the middle of the night. Obesity and type 2 diabetes are also risk factors for sleep apnea, which causes poor sleep quality (more on that later in this chapter). As you age, sleep quality also declines.

So how much sleep should you get? It’s all about finding the right balance for yourself; you want a sleep that’s both restful and long enough without being too long. Let’s take a look at what you need to get a good night’s sleep.

Getting Enough Sleep

While not everyone needs the same amount of sleep, seven to nine hours seems to be about the right amount for the majority of adults. If you aren’t getting that amount of sleep, there are some things you can do to help yourself catch more shut-eye. The most important way to better control your sleep schedule is by getting to bed at a regular time. You have a built-in sleep-wake cycle that tells your body when to get up and when to go to bed, making it hard for your body to switch gears when you change up your sleep schedule. This could be due to sleeping in late on the weekends and getting up early on the weekdays, working varying shifts, or traveling across time zones. By going to bed and getting up close to the same time each day, you help yourself stay on track with your sleep.

Beyond a proper sleep schedule, here are some tips for getting enough sleep:

• Don’t participate in physical activity too close to your bedtime. While staying active is a plus for diabetes management, try to finish your exercise at least two to three hours before bed. That way, you’re not energized and awake when you go to bed.
• Kick the afternoon caffeine. It may take up to eight hours for caffeine to get out of your system, so any afternoon coffee, cola, or tea may still be having an effect when you go to bed.
• Don’t eat too much before bed. A small snack is fine, but eating a large meal may cause heartburn and discomfort that could keep you awake.
• Don’t nap too late or too long. While quick naps can help you feel rested and more focused, make sure you don’t nap after 3 P.M. and keep them to 30 minutes or less; otherwise, you may negatively affect your sleep at night.
• Make your room conducive to sleep. Because light makes your body think it’s time to get up, your room should be dark when you’re sleeping. Your room should also be comfortable in terms of noise and temperature—not uncomfortably hot, cold, or noisy.
• Create a bedtime routine. Make a plan to allow some time to unwind at the end of the day. Relax before bed by reading or listening to music (just not while in bed!).

DIABETES DECODED

Checking emails, browsing the internet, watching television, playing video games, texting, and other “screen” time before you go to bed can cause you to stay up later than you planned. Plus, the light exposure from the screen (computer, cell phones, tablet devices, and so on) can decrease the hormone melatonin, which tells your brain when it’s time to sleep. Sleep experts recommend making your bedroom a technology-free zone. If you can’t get away from it entirely, shut off the technology at least 15 minutes before you go to bed—an hour is better.

How Well Do You Sleep?

Sleep isn’t just about quantity, though; it’s also about quality. How do you know if you’re having quality sleep? The following lists some common signs of lack of sleep quality:

• It takes you over 30 minutes to fall asleep at bedtime.
• You wake up in the night and can’t get back to sleep.
• You wake up earlier than you want to.
• You fall asleep during the day at unplanned times. (This is especially dangerous if you’ve fallen asleep while driving.)
• You rely on caffeinated beverages to stay awake during the day.

There are a number of factors, both internal and external, which affect how well you sleep. Various medical conditions—such as chronic pain and anxiety—can disrupt your slumber. If you’re not sleeping well at night due to uncontrolled pain or anxiety, talk with your medical provider about potential treatment options. There are other nonpharmaceutical options for both pain control and anxiety, so don’t feel the only solution is to take another pill.

Medications may also be the cause of restless nights. If you’re taking a number of prescription medications and sleeping has become a problem, ask your medical provider or pharmacist if any of your prescriptions might be keeping you awake at night. Potential solutions include using a different drug with fewer side effects, or you may be able to take your medication earlier in the day to avoid wakefulness.

Certain behaviors can also lead to poor sleep. For instance, alcohol and quality sleep don’t mix. If you have more than one or two drinks, you may fall asleep but stay in the lighter stages of sleep, meaning you’re not getting the deep sleep you need. Drinking can also cause nighttime hypoglycemia or contribute to high fasting blood sugar. Waking up in the middle of the night is also a problem after drinking alcohol. Not only do you get up to go to the bathroom more, but once the effects of the alcohol wear off, you tend to wake up. If you really want a good night’s sleep, forgo the alcohol. Smoking is also bad for sleep. Nicotine is a stimulant, which can make it difficult for you to fall asleep. Like alcohol, smoking can also cause you to spend more time in light sleep than nonsmokers, affecting the quality of your sleep. Plus, nicotine withdrawal symptoms can happen overnight or just prior to waking, which if you recall can lead to discomfort and make you less likely to stay asleep. If sleep is important to you, this may be the reason for you to choose to quit smoking.

If you have any of the signs occur frequently, try all the tips for getting a better night’s sleep. If you’re still having reoccurring signs of sleep deprivation, you may need to talk with your medical provider about it.

Obstructive Sleep Apnea

Have you gone through all of the previous recommendations and still been unable to get a good night’s rest? If you have type 2 diabetes and you’re having difficulty sleeping, obstructive sleep apnea (OSA) is a prime suspect. A number of studies have shown a strong connection between type 2 diabetes and OSA. Most common in middle-aged, overweight men, people with OSA have double the risk of developing type 2 diabetes than those without OSA, and approximately half of men who already have diabetes also have OSA. Several recent studies have indicated that as OSA becomes more severe, insulin sensitivity decreases, causing insulin resistance. OSA causes lack of oxygen, increased levels of circulating stress hormones, and inflammation, which are triggers for insulin resistance.

DEFINITION

Obstructive sleep apnea (OSA) is a chronic condition that causes a temporary stoppage in breathing during sleep. Symptoms can include loud snoring with pauses and loud snorting or choking sounds when breathing starts again.

With OSA, the muscles at the base of your tongue and the back of your throat relax and block off the airway, temporarily stopping breathing. Snoring indicates that air is being forced through a partial blockage, while a stoppage in snoring usually indicates a complete blockage of the airway. This can happen repeatedly throughout the night, jolting you awake (or at least partially awake). You then end up staying in light sleep without beneficial deep, restorative sleep. When you wake up, you tend to still feel tired and sleepy, a feeling that carries throughout the day. This form of sleep deprivation may contribute to memory changes, depression, and irritability. Physically, OSA decreases oxygen in your blood, increases your blood pressure, and puts stress on your heart.

Not sure you have OSA or other sleep problems that should be checked out? The following are some signs that may mean you’re having more than just a bit of trouble sleeping:

• When you first wake up, you feel like you just can’t move.
• Your sleeping partner tells you that you make jerking movements with your legs or arms during sleep.
• You have vivid dreams when you’re falling asleep or even dozing.
• Your sleeping partner reports that you snore loudly, make choking noises, or snort in your sleep, or notices that you stop breathing for short periods.
• Even after sleeping seven or eight hours, you don’t feel well rested.

The good thing is that OSA and other sleep disorders can be treated, so don’t avoid the discussion just because you think it can’t be helped. If you have any of the preceding signs of OSA (or suspect you have some other sleep disorder), schedule an appointment with your medical provider and share that you have difficulty sleeping. Generally, your provider will order a sleep study to determine if you have OSA or another sleep disorder and then, based on the results, together with your provider, you can determine the best treatment option for you.

Fighting Stress

Stress; where would you be without it? While picturing a life without stress sounds wonderful, having no stress at all would actually be quite boring. And stress doesn’t just happen with the bad stuff—it happens with the good things, too. While having to take a test, getting stuck in traffic, and getting sick or injured are probably the kinds of stressors you would just as soon do without, getting married, having a baby, and buying a new house are sources of positive stress.

Having to live with stress, both positive and negative, is something everyone does. What varies is how people cope with stress, or how they manage it. Some coping techniques don’t help actually manage the stress—or improve blood glucose control. For example, reaching for a cigarette, alcohol, or half-gallon of ice cream (or candy bars, chips, donuts, and so on) isn’t the most effective coping technique, but it tends to be what people do. So learning effective strategies to better manage your stress not only helps you deal with day-to-day challenges, it also helps with your overall health and diabetes control.

DID YOU KNOW?

While many think of stress as simply emotional, stress can be physical, too. Examples of physical stress include being sick with the flu or having surgery.

Why Stress Affects Blood Sugar

When it comes to stress, your body doesn’t know the difference between a real threat or an imagined one. Therefore, your body prepares you to face the threat by releasing “stress hormones” called epinephrine and cortisol. These hormones make your heart beat faster, increase your blood pressure, make you breathe more quickly, and raise your blood glucose so you have enough energy to either meet the danger head on or get away from it (also known as “fight or flight”). When you don’t have diabetes, your body is able to respond by lowering your blood glucose when it’s not really needed. But with diabetes, your body doesn’t compensate as well to get your blood glucose back down; instead, your blood glucose stays elevated, even when the perceived threat is over.

So does that mean all stress is bad? No; short bursts of stress are actually helpful. For instance, the stress of a deadline may help you get your work done sooner and help you stay focused on your task. Stress can also help you avoid danger like when you pull your hand away from a hot stove. However, it’s important for you to understand what stress feels like to you and to note physical and emotional symptoms. If you’re in tune to how stress affects you, you can take steps to manage it before it gets out of control. Taking note of your stress level when you test your blood glucose will help you discover what stressors cause elevations.

Even when you’re monitoring your stress levels, chronic stress can still sneak up on you, and you don’t always realize the negative effects it’s having on you until you become overwhelmed. Stress may trigger high blood glucose and high blood pressure, increase the risk of heart attack and stroke, and suppress your immune system. Emotionally, you may have increased anxiety and depression. But it’s hard to say how much stress is too much. Everyone’s stress limit is different. Some people will feel completely overloaded with a situation that others might actually seek out. However, if you’re developing some of the following symptoms, it’s a signal that your stress level is out of control and you need to take action to regain control. Symptoms of uncontrolled stress include the following:

• Worried and anxious thoughts
• Changes in appetite (eating too much or not enough)
• Significant weight loss or gain
• Teeth grinding
• Trouble with memory and concentration, and difficulty completing tasks
• Sleeping too much or not enough
• Irritability, anger, and frustration
• Stomach problems (such as nausea, constipation, and diarrhea)
• Headaches
• Trembling and shakiness
• Profuse sweating
• Depression

If you’re experiencing symptoms of uncontrolled stress, talk with your medical provider. Your medical provider can make referrals to the appropriate specialist if needed.

DIABETES DECODED

Depression is common with diabetes and directly linked to type 2 diabetes. If you’re unsure whether you’re depressed, you can use these two questions as a screening tool to check for depression risk:

1. During the past month, have you often been bothered by feeling down, depressed, or hopeless?
2. During the past month, have you found you have little interest or pleasure in doing things?

If you answered “yes” to either of these questions, make an appointment with your medical provider to get further assessment for depression. Depression can worsen diabetes control and high blood glucose can contribute to depression, leading to a vicious cycle. Therefore, it’s important to seek help to break this cycle.

The Four “A”s of Stress Management

In any given stressful situation, there are basically four things you can do. They are the four “A”s of stress management: avoid, alter, accept, or adapt. You may use any or all of these options successfully, depending on the scenario, in order to manage your stress level and in turn manage your health. Let’s take a look at each option and some examples of how they work.

Avoid: There are actually a number of stressors you can just choose to avoid so you don’t have to deal with them. The following are different ways you can avoid a stressful situation:

• If you really can’t take on another activity, it is okay to say no. For example, if you can’t coach your son’s Little League team, you can be a good cheerleader for him at the games. One of the best lines you can learn to use is “No, thank you; I’m overcommitted.”
• If busy traffic on your commute really annoys you, find an alternate route or leave earlier for work.
• If the ads on television bother you, shut the TV off and read a book. Or if you’re not ready to give up your show because of ads just yet, you can mute the sound on the ads and walk around your living room until your show is back on.

Alter: Of course, not all stress can be avoided. If possible, you can change your situation so it works for you. The following illustrate how a stressful situation can be altered:

• Prioritize and get just the important things done today. You don’t have to complete everything on your list every day. For instance, you can choose not to organize your desk today; it can wait until tomorrow.
• Practice good communication skills. Sometimes avoiding having a conversation just makes it blow way out of proportion. Using the describe, explain, specify, and consequence technique (see Chapter 5) can help you avoid conflict while still getting your point across.
• Find the positive people at work, where you volunteer, or in social situations and hang out with them. Being around people with optimistic outlooks can help you change your viewpoint for the better, too.

Accept: Sometimes you just have to accept the way things are. Remember, accepting is not the same thing as giving up; it’s simply acknowledging and dealing with the stressor at hand. The following are some ways you can manage stress through acceptance:

• Choose to let go of the negative feelings. Remember, no one can make you feel anything. You choose how you feel; there’s always a choice. Being caught up in the stress just makes it harder to see that.
• Talk about it. It is okay to vent your frustrations; it just has to be at the right time with the right person. Phone a friend to talk it out, or ask your walking buddy to walk it out with you.
• Ask yourself if you can change your situation that’s causing you stress. If the answer is no, it can help you move on. You can’t fix everything, and it’s okay to give yourself permission not to.

Adapt: An attitude adjustment can be just the thing to help you adapt to stressful situations. If you think you can’t, you can’t. If you think you can, who’s going to stop you? The following examples show how you can adapt:

• Stop the negative thoughts. Choose positive affirmation statements to say to yourself when the negative creeps in. If you hear things like “I’m such a failure,” turn it around as “I learned from this,” “I’m okay,” or “I’m on track.”
• Remember, you don’t have to be perfect. You probably don’t ask anyone else to be; why would you ask that of yourself? If something doesn’t go exactly as planned, will anyone else really notice?
• Make a list of all the things you’re grateful for—things that make you happy. You can then pull out your list and read it when you’re feeling down.

DID YOU KNOW?

One of the best things you can do to help put your stressful situation into perspective is to look outside the situation and ask yourself “Will this matter in a year or two from now?” The answer is usually “no.” If it is “no,” you can put it behind you more quickly.

Guided Imagery and Visualization

Guided imagery uses descriptions to direct your thoughts to create a visual image and experience that helps achieve a peaceful, focused, and relaxed state. In essence, guided imagery helps you learn the skill of creating a mental image. Usually, you listen to a recording of a script that walks you through some relaxation exercises like deep breathing and muscle relaxation. This technique has been used to help manage stress, decrease pain, promote sleep, support weight management, and even help control diabetes.

When listening to guided imagery to help you become more relaxed, you will hear a description and be asked to picture yourself in a comfortable, inviting setting, such as sitting by a cool lake or near a sandy beach. When you hear the description, try to also think of the sounds and smells you would experience in that setting. Once you’re able to visualize the scene and experience the scenario, your body responds as if you are actually in that place; you feel more relaxed and comfortable. It may also help you release negative, unwanted feelings and replace them with more positive, calm ones as you’re guided through the process.

A good resource for guided imagery CDs and downloadable recordings is Health Journeys (healthjourneys.com). If you’re not so sure that guided imagery is right for you, you can also listen to sample recordings available on the website to see what you think.

Other Relaxation Exercises for Stress Relief

There are many relaxation exercises or techniques that can help you manage your stress. Relaxation exercises typically work by helping you increase your awareness of your body. With practice, this awareness will help you pinpoint the physical sensations of stress, like muscle tension. This will allow you to notice your stress symptoms sooner and to stop the stress before it gets out of hand. There isn’t one best technique, so try out a few of the following, and then practice the ones you like best.

DID YOU KNOW?

Laughter really may be the best medicine. There is growing evidence that laughter isn’t just about your sense of humor; it provides many physical benefits, too. It helps lower your blood pressure, decreases your pain, improves your mood, and strengthens your immune system. This makes laughter ideal for coping with stressful situations. So look for humor in a situation and practice smiling. Let’s get you started with a joke: Why did the student eat his homework? Because the teacher told him it was a piece of cake!

Mindfulness meditation: This is an activity that focuses on awareness of breathing. To start, you sit on a cushion on the floor and, if possible, with your legs crossed and your back straight. If you can’t sit on the floor, you can use a chair; the main thing is keeping good posture with your back straight. You then focus on or “follow” your breathing in and out. If your thoughts wander away from concentrating on your breathing, just get back to it once you notice. For this exercise to be most effective, you need to find a place without distractions. Once you have a quiet place for this, you may want to just practice for 5 or 10 minutes to begin with. You can gradually increase the amount of time spent focusing on your breathing with practice.

Progressive muscle relaxation: With this technique, you focus on slowly tensing and then relaxing each muscle group. This allows you to become more aware of the difference between muscle tension and relaxation. You can start with your toes and gradually move up to your head, tensing and relaxing each muscle on the way. Or you can do the opposite and start with your head and work your way down.

Want a quick muscle relaxation exercise that’s easy to do? When you feel yourself tensing up at work or when you’re stuck in your car at an endless red light, try this “in-the-moment” relaxation exercise:

1. Sit up straight and tall.
2. Focus on breathing in through your nose and out through your mouth slowly. Say the word breathe or one each time you slowly breathe out.
3. Think positive thoughts, smile, and choose to let go of the stress.

Yoga: You can find different types of yoga classes for different skill levels at many locations. If you’re just starting out, look for hatha yoga, a general term that is usually applied to the more traditional type of yoga. Often, a local YMCA or parks and recreation department offers yoga classes if you’re not sure where to find them. You don’t have to already be flexible to start yoga; you’ll improve your flexibility and strength with practice. However, make sure if you’re just starting out to find out how to modify the moves for your fitness and flexibility level. If you’re not ready to join a yoga class yet, there are numerous yoga videos you can use in your own home.

Tai-chi: Based on Chinese martial arts, this is a low-impact exercise with a series of slow, focused movements. It can be adapted for beginners and is a great activity for fit healthy people, less fit older adults, and even people recovering from surgery. This mind-body activity is proving to have multiple health benefits, including better balance and improved muscle strength and function in older adults. Most communities have tai-chi classes available through the parks and recreation department, local health clubs, or the YMCA.

No matter which of these relaxation exercises you decide to use, if any, just keep practicing and you’ll get better at them. To gain the most benefit, practice the relaxation exercises in tandem with the other positive coping methods discussed in this chapter. Remember, everyone lives with stress. However, if you manage it well, it doesn’t create the same problems as uncontrolled stress.

DIABETES DECODED

If you don’t feel like yoga or tai-chi are for you, almost any physical activity is helpful for stress management and blood glucose control. In the end, being more active is always a good choice!

The Least You Need to Know

• Lack of sleep has been linked to risks of becoming obese and developing type 2 diabetes.
• Having a defined sleep schedule and not eating and drinking before bed are a couple ways you can ensure a good night’s sleep.
• Stress can lead to your blood glucose becoming and staying elevated when you have diabetes.
• Use the four As (avoid, alter, accept, and adapt) in conjunction with relaxation exercises to better manage your stress level.