1. By Jessica Moehling BS, Bradley University
Is there a significant difference in nutrient intake between subjects with diabetes with short sleep duration vs average sleep duration ages 18 and older?
RESULTS FROM NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY (NHANES)
By Jessica Moehling
BS, Bradley University

2. Background
Sleep duration and quality has long been suggested as an important factor in overall health
More recently, research is being conducted looking at sleep deprivation and the possible effect it plays on nutrition intake
Obesity and inadequate sleep duration are major health problems in the United States
According to Depner et al, 1 sleep deprivation results in significantly increased total energy expenditure; but also significantly increased total calorie intake as well, which exceeded the increase in total energy expenditure
Thus, long-term sleep deprivation is thought to contribute to weight gain
In a study by Kant et al. 2 researchers looked at the overall eating patterns in association with sleep duration
Short duration sleepers were more likely to skip meals and have a greater percentage of calorie intake from snacks than average duration sleepers

3. Background
Studies suggest that inadequate sleep duration may increase a person’s risk for developing type 2 diabetes 3
In a study by Van Cauter et al. 4, 11 healthy, young men ages years old participated in a 16 consecutive day research study examining the effects of sleep debt on metabolic and endocrine function
For 6 days, researchers induced sleep deprivation in these subjects
Researchers found glucose clearance was 40% slower when subjects were sleep deprived
Sleep deprivation effectively induced symptoms of prediabetes in otherwise young, healthy subjects
Obesity and poor glycemic control are real problems for the more than 20 million adults in the United States living with diabetes and, likely sleep deprivation is further aggravating these issues 5
Currently, there are no large epidemiological studies which look at the differences in diet quality, glycemic control, age of diabetes diagnosis and body measures between short-duration and average-duration sleepers with diabetes

4. Research Question
Is there a significant difference in nutrient intake between subjects with diabetes with short sleep duration vs average sleep duration ages 18 and older in NHANES , , , and cycles?
If so, do these differences result in a significant difference in hemoglobin A1c, body mass index (BMI), waist circumference and age of diabetes diagnosis between these groups?

5. Objectives
To determine if there is a significant difference in macronutrient composition of diet recalls between subjects with diabetes with short sleep duration vs average sleep duration
To determine if there is a significant difference in dietary intake of MyPyramid equivalents between subjects with diabetes with short sleep duration vs average sleep duration
To determine if there is a significant difference in hemoglobin A1c, body mass index (BMI), waist circumference, use of insulin and age of diabetes diagnosis between subjects with diabetes with short sleep duration vs average sleep duration

6. Methods: Data Collection
NHANES cycles , , , and (n=40,790)
Data files
Demographic variables
First and second day total nutrient intake
MyPyramid equivalents for first and second day recalls
Diabetes questionnaire variables
Sleep Disorder questionnaire variables
Body measures
Hemoglobin A1c laboratory values

7. Methods: Population Selection
Total sample: NHANES 2012 (n=40,790)
Dietary Interview: Two reliable 24-hour recalls (n= 31,733)
Subjects with Diabetes: Self-report from Diabetes questionnaire and/or hemoglobin A1c ≥ 6.5% (n= 2,625)
Sleep Disorders Questionnaire (n=2,601)
Age: Subjects ≥ 18 years old (n=2,591)
Short Sleepers: <7 hours (n=1,108)
Average Sleepers: ≥7 hours (n=1,483)

8. Methods: Variables Demographic variables Nutrient analysis Diabetes
Age, race, gender and education level were used to describe sample
Nutrient analysis
First and second day averages for nutrient recalls were calculated
MyPyramid equivalents, milligrams sodium, grams fiber and milligrams cholesterol were adjusted per 1000 calories
Percent of calories from protein, carbohydrate, sugar, fat and saturated fat were calculated
Diabetes
Age of diabetes diagnosis, insulin use, and hemoglobin A1c (%)
Diabetes duration was calculated as “Age at time of screening” minus “age of diabetes diagnosis”
Sleep
Sleep duration collapsed to short-duration sleepers (<7 hours sleep) and average-duration sleepers (≥7 hours sleep)
Body Measures
BMI (kg/m2) and waist circumference (cm)

9. Methods: Statistical Analysis
Statistical analyses were performed using SPSS® (Version 22, copyright 2013, Chicago, IL)
Continuous data were tested for normality
Non-normally distributed data were reported as median (IQR) and categorical data were reported as frequency distributions
Independent t-tests: Difference in percent of calories from carbohydrate and fat between short- duration sleepers vs average- duration sleepers
Mann Whitney U: Difference in age, sleep duration, percent calories from protein, sugar and saturated fat, BMI, waist circumference, hemoglobin A1c , diabetes duration, age of diabetes diagnosis and adjusted intake of fiber, sodium, cholesterol, MyPyramid equivalents
Chi square analysis: Difference in insulin use, race and education level between short- duration sleepers vs average- duration sleepers
A p value of < 0.05 was set at a level of significance.

10. Results Table 1: Demographic and sleep characteristics of adult subjects with diabetes in NHANES cycles dichotomized by self-reported sleep duration (n=2,591)
Demographic Data
Short Sleepers:
Less than 7 hours
(n=1,108)
Average Sleepers:
7 or more hours
(n=1,483)
P value1
Gender
Female
550 (49.6)
740 (49.9)
0.896
Age (yrs)
61 (50, 69)
64 (54, 73)
<0.001
Race
Non-Hispanic White
Non-Hispanic Black
Mexican American
Other Hispanic
Other Race
376 (33.9)
393 (35.5)
163 (14.7)
110 (9.9)
66 (6.0)
598 (40.3)
357 (24.1)
304 (20.5)
143 (9.6)
81 (5.5)
Education level
High school or less
Some college or AA degree
College graduate or more
n=1107
667 (60.3)
295 (26.6)
145 (13.1)
n=1480
925 (61.6)
340 (23.5)
215 (14.9)
0.085
Sleep Duration (hrs)
6.0 (5.0, 6.0)
8.0 (7.0, 8.0)
Nominal data are expressed as n (%) and continuous, non-normally distributed data are expressed as median (IQR). Significance was determined by Chi-square analysis for nominal variables and Mann Whitney U analysis for continuous, non-normally distributed variables. 1P value of <0.05 considered significant; 2Used RIDRETH1 variable; 3Includes multi-racial.

11. Results Table 2: Statistically significant differences in MyPyramid Equivalents in adult subjects with diabetes dichotomized by sleep duration
MyPyramid Equivalents1
Short Sleepers:
Less than 7 hours
(n=1,108)
Average Sleepers:
7 or more hours
(n=1,483)
P value2
Intact fruits (whole or cut); excluding citrus, melons, and berries (cup eq.)
0.1 (0.0, 0.5)
0.2 (0.0, 0.6)
<0.001
Total intact or cut fruits and fruit juices (cup eq.)
0.4 (0.1, 0.9)
0.5 (0.1, 0.9)
0.005
Other vegetables not in the vegetable components listed above (cup eq.)
0.2 (0.1, 0.4)
0.2 (0.1, 0.5)
0.046
Total meat, poultry, seafood, organ meats, cured meat, eggs, soy, and nuts and seeds; excludes legumes (oz. eq.)
3.2 (2.3, 4.3)
3.1 (2.2, 4.1)
0.044
Fluid milk and calcium fortified soy milk (cup eq.)
0.3 (0.1, 0.7)
0.3 (0.1, 0.6)
Total milk, yogurt, cheese, and whey (cup eq.)
0.6 (0.3, 0.9)
0.7 (0.4, 1.0)
Foods defined as added sugars (tsp. eq.)
5.6 (3.2, 9.1)
5.1 (2.9, 8.0)
Data are expressed as median (IQR). Significance was determined by Mann Whitney U analysis. 1All MyPyramid equivalents are an average of first and second day MyPyramid equivalents, adjusted per 1000 calories; 2P value of <0.05 considered significant.

12. Results Table 3: Differences in BMI, waist circumferences, hemoglobin A1c, age of diabetes diagnosis and insulin use in adult subjects with diabetes dichotomized by sleep duration
Characteristics
Short Sleepers:
Less than 7 hours
(n=1,108)
Average Sleepers:
7 or more hours
(n=1,483)
P value1
BMI (kg/m2)
32.2 (27.8, 37.7)
30.9 (27.3, 35.8)
<0.001
Waist Circumference (cm)
109.5 (100.0, 121.9)
107.2 (98.0, 117.5)
Hemoglobin A1c (%)
6.8 (6.3, 8.0)
6.9 (6.4, 7.9)
0.769
Diabetes duration
8 (3, 15)
9 (4, 16)
0.081
Age of diabetes diagnosis
50 (40, 60)
52 (40, 62)
0.003
Insulin Use
Yes
231 (20.8)
333 (22.5)
0.327
Nominal data are expressed as n (%) and continuous, non-normally distributed data are expressed as median (IQR). Significance was determined by Chi-square analysis for nominal variables and Mann Whitney U analysis for continuous, non-normally distributed variables. 1P value of <0.05 considered significant.

13. Results
Figure 1: Mann Whitney U analysis indicates there is a significant difference in body mass index in adult subjects with diabetes dichotomized as short-duration sleepers (<7 hours) or average-duration sleepers (≥7 hours)

14. Results
Figure 2: Mann Whitney U analysis indicates there is a significant difference in waist circumference in adult subjects with diabetes dichotomized as short- duration sleepers (<7 hours) or average-duration sleepers (≥7 hours)

15. Results
Figure 3: Mann Whitney U analysis indicates there is a significant difference in age of diabetes diagnosis in adult subjects with diabetes dichotomized as short-duration sleepers (<7 hours) or average-duration sleepers (≥7 hours)

16. Discussion
Short-duration sleepers were significantly younger than average duration sleepers
Suggests that age may play a role in sleep duration and risk for sleep debt
Short-duration sleepers had a larger percentage of non-Hispanic Blacks compares to average-duration sleepers, who in contrast had a higher percentage of non-Hispanic Whites and Mexican-Americans
Suggests that race may also play a role in sleep duration and risk for sleep debt
Dietary composition of subjects included in this study were similar to dietary composition of adult subjects with diabetes published in a study by Oza-Frank et al 8
Short-duration sleepers were more likely to have greater consumption of sugar compared to average duration sleepers, consistent with the study by Kant et al 2

17. Discussion
Intake of MyPyramid equivalents of average duration sleepers was more similar to nutrition recommendations for patients with diabetes detailed in the American Diabetes Association (ADA) position paper by Evert and colleagues 9
No difference in calories between the groups, though BMI and waist circumference were significantly higher in short-duration sleepers
Can be hypothesized that average-duration sleepers may have an overall better diet quality than short-duration sleepers
Differences in diet quality had no effect on glycemic control in this study
Difference in median age of diabetes diagnosis was significantly later in average-duration sleepers by approximately two years
Suggests that better diet quality resulted in delay of disease development

18. Clinical Significance
Statistical differences in MyPyramid equivalents seen between groups likely not clinically significant
Largest difference seen between groups was in foods defined as added sugars (tsp. eq.)
The difference was 0.5 teaspoon of sugar equivalent per 1000 calories
Median calorie intake in the population was 1679
Thus, this difference equates to a difference of approximately 0.8 teaspoon of sugar equivalent or approximately 13 calories
Despite differences seen in BMI, waist circumference and MyPyramid equivalents, suggesting greater calorie intake in short-duration sleepers there was no statistical difference in calorie intake between groups
In agreement with results of the study by Kant et al 2

19. Limitations
Significant differences in demographic characteristics between groups
Racial and age differences between the two groups may have contributed to the differences found in MyPyramid equivalents, BMI, and waist circumference
Temporal distribution of nutrient intake and eating patterns were not assessed
May have provided further insight into differences between groups
A more sophisticated statistical analysis needed to determine if differences in MyPyramid equivalents partially mediated the differences in BMI, waist circumference, and age of diabetes diagnosis between the two groups
Subjects are prone to underreporting in diet recalls, especially those with diabetes and who are obese
Differences between these two groups possibly masked by underreporting
Much of this analysis utilized non-parametric statistical tests due to non- normally distributed data which are
Not as powerful in determining differences between groups as parametric tests

20. Conclusion
Results of this study suggest that a relationship between sleep duration and diet quality exists
Also a likely relationship between sleep duration and body measures, such as BMI and waist circumference
Further research must be done to determine the if a triangular relationship exists between sleep duration, diet quality and body measure
Both diet quality and body measures have been found to play an important role in diabetes prevention as well as glycemic control 10
Sleep duration may be a future area of focus in counseling patient with diabetes to promote not only overall health and mental well-being 3, but possibly improved diet quality and body measures

21. References
1. Depner CM, Stothard ER, Wright Jr. KP. Metabolic consequences of sleep and circadian disorders. Curr Diabetes Rep. 2014;14(7). 2. Kant AK, Graubard BI. Association of self-reported sleep duration with eating behaviors of american adults: NHANES Am J Clin Nutr. 2014;100(3): Golem DL, Martin-Biggers JT, Koenings MM, Davis KF, Byrd-Bredbenner C. An integrative review of sleep for nutrition professionals. Adv Nutr. 2014;5(6): Van Cauter E, Polonsky KS, Scheen AJ. Roles of circadian rhythmicity and sleep in human glucose regulation. Endocr Rev. 1997;18(5): CDC - national diabetes statistics report, publications - diabetes DDT Accessed 10/17/2014, NHANES - about the national health and nutrition examination survey Accessed 12/2/2015, National sleep foundation recommends new sleep times - national sleep foundation recommends-new-sleep-times. Accessed 4/20/2015, Oza-Frank R, Cheng YJ, Narayan KMV, Gregg EW. Trends in Nutrient Intake among Adults with Diabetes in the United States: J Am Diet Assoc. 2009;109(7): Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2014;37(SUPPL.1):S120-S Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New Engl J Med. 2002;346(6):