Diabetes and Sleep Apnea

By Matt T. Bianchi, MD, PhD
Chief, Division of Sleep Medicine

In an era when advanced technologies, imaging, genetics, and personalized medicine is making heroic steps towards improving healthcare it may come as a surprise that a common and serious disorder with multiple available treatments remains largely undiagnosed. Yet such is the case for sleep apnea, which affects about 10% of adults but is diagnosed in fewer than half of these.  Sleep apnea is defined as repeated obstructions in breathing during sleep, each lasting typically 20-30 seconds.  These events can range from complete obstruction (apnea) to partial obstruction (hypopnea) and are often accompanied by drops in oxygen.

Sleep apnea is more common in people with diabetes, especially if other risks like obesity are present. Undiagnosed sleep apnea can increase risk of heart attack and stroke – which are already increased in those with diabetes. Sleep disturbances such as sleep apnea can also make it harder to keep blood sugars under control. Other risk factors include male sex, older age, smoking, and alcohol use. Those who have already had a heart attack or stroke, or who have poorly controlled blood pressure, are also at increased risk.

Diagnostic testing, performed in the laboratory or sometimes even at home, involves monitoring breathing and oxygen levels. Pauses in breathing (obstructions) occurring at 5 or more times per hour indicate sleep apnea is present. Increased pause rate means increased severity of the problem (15-30 is moderate; >30 is severe). This disorder often comes with snoring, sleepiness and being overweight – but not in every case.

There are many treatment options for those with sleep apnea. Wearing a mask known as continuous positive airway pressure (CPAP) while sleeping is the standard treatment. Although some initially find the prospect of this treatment daunting, there are dozens of different kinds of masks to help accommodate each person’s needs and comfort. Alternatives come in two categories: surgical and non-surgical. Surgeries include soft palate surgery and jaw advancement surgery, as well as a new stimulator device that acts like a pacemaker to prevent obstructions in sleep. Dental appliances can be made that pull the bottom jaw forward in sleep – these are made by specially trained dentists.

For some people, the sleep apnea is present mainly when they sleep on their back.  In these cases avoiding that position can be helpful. This can be accomplished with a shirt/vest that has a bumper on the back that makes back-sleeping uncomfortable. (The challenge is that some people end up sleeping on their back for some or all their sleep regardless.) Finally, weight loss can be helpful for those patients who are overweight. Whichever treatment pathways are chosen, alone or in combination, it is best to speak with your doctor about your choices and how to monitor your progress.


Gestational Diabetes

By Eileen B. Wyner, NP
Bulfinch Medical GroupEileen W

Let’s talk about pregnancy. Now, don’t leave me, WordPress didn’t get its wires crossed and bring you to Mommies 101. Diabetes is more familiar to us when we talk about Type 1 or Type 2, but there is another form of Diabetes that is particular to pregnant women only.

Gestational Diabetes (GDM) is Diabetes that occurs in pregnant women without a past history of Type 1 or Type 2.  It’s most commonly diagnosed between weeks 24-28 and disappears when the baby is born. GDM occurs in roughly 2-10% of pregnancies, but with the recent revised criteria from the American Diabetes Association (ADA), the incidence may be as high as 18%.

GDM occurs when pregnant women begin to develop insulin resistance (IR) during the second and third trimester. The same hormones released by the placenta to assist in fetal development are the same ones responsible for this IR. The mother’s pancreas works very hard to make enough insulin, but it doesn’t lower her glucose levels. The extra glucose in the mother’s blood crosses the placenta but insulin doesn’t, so the developing baby’s blood sugar becomes elevated.  The baby’s pancreas releases more insulin in response, which acts as a growth hormone and contributes to an increase in the baby’s birth weight.

Risk factors for developing GDM include: being overweight or obese at conception, being over age 35, positive family history of Diabetes, personal history of GDM with prior pregnancy, and being of African American, Hispanic, Native American or Asian ethnicity.


GDM is diagnosed with an oral glucose tolerance test, usually done around week 24 (though it may be done earlier for reasons of increased thirst, frequent urinary tract infections, or if sugar is found in the urine during monthly tests). The test starts with a fasting blood sugar, and then the mother is given a concentrated glucose drink.  Blood sugar is then checked at one hour and two hour intervals. According to the ADA guidelines, fasting range should be less than 92 mg/dL, the one hour range should be less than 180 mg/dL, and the two hour should be less than 153 mg/dL. GDM is diagnosed if just one test is elevated.

After diagnosis, it’s important to manage GDM as closely as possible–there are potential complications to both mother and baby which close monitoring can identify so the best treatment can be started as soon as possible. Women with GDM are at a greater risk for high blood pressure and preeclampsia.  The most common complication for the baby is increased birth weight (greater than 9 pounds) which may mean delivery via c-section will be required (though many vaginal deliveries occur as well).  Larger birth weight babies may face damage to their shoulders during birth—another reason a C-section may be needed.  Some babies may be born with hypoglycemia due to the extra insulin made by their pancreas, but this is very easily treated with sugar water or formula at birth and commonly corrects itself in 24 hours or less.  However, it is important to realize that many of these babies are born without any complications.

Managing GDM requires a close collaboration between mother and care team (obstetrician, diabetes educator, registered dietician, and endocrinologist). Diet modification and exercise are the most important aspects of Diabetes self management; it’s also important to check your blood sugar before meals and at bedtime. Many providers will also recommend women check their urine ketones each morning as a quick and easy way to see if the baby is receiving enough nutrition through the night. Occasional urinary ketones do not signal a problem but persistent elevations need to be reviewed with your care team.

There are times when lifestyle changes are not enough to keep blood sugar levels at goal. Human insulin is the gold standard for medical management and is one of the safest drugs to use in pregnancy. There is not definitive information on the safety in using oral agents or long acting insulin in pregnancy at this point, although there may be special circumstances where these medications are in use.

After Delivery

The great thing about gestational Diabetes is that it goes away as soon as the baby is born. However, because GDM is a risk factor for developing Type 2 Diabetes later in life, there are still several measures to take to ensure continued good health.  It’s important to monitor blood sugar values after delivery–approximately 1/3 to 2/3 of women who develop GDM with one pregnancy will have GDM with later pregnancies.  A glucose tolerance test 6 weeks after delivery needs to be done to be sure the mother hasn’t developed pre-diabetes or Type 2 (your primary care provider or obstetrician can set this up for you). If the results of this test are normal, the current recommendation is to obtain a fasting blood sugar every 3 years to screen for Type 2 Diabetes.   

The same lifestyle behaviors you adopted during pregnancy should be continued after delivery.  Stay active, follow a good diet, and try to keep your weight in a normal range to help prevent developing Type 2 Diabetes.  Remember, if you have any questions about your Diabetes management plan, you can always contact your health care provider.

Be well.