Incidence of Insomnia in Type 2 Diabetes Mellitus patients in a Tertiary Care Centre in Southern Kerala

Incidence of Insomnia in Type 2 Diabetes Mellitus patients in a Tertiary Care Centre in Southern Kerala | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Incidence of Insomnia in Type 2 Diabetes Mellitus patients in a Tertiary Care Centre in Southern Kerala JOE P JOHN, V Abraham Varghese, Sajit Varghese This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6443080/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Insomnia refers to difficulty falling asleep or staying asleep, often resulting in poor sleep quality. Around 10% of the general population experience insomnia to the extent that it is considered a medical condition. Recently, insomnia has been recognized as a potential modifiable risk factor in the onset of type 2 diabetes (T2DM). OBJECTIVES (1) To estimate the incidence of insomnia in type 2 diabetes mellitus patients. (2) To determine the correlation between demographic and clinical variables with the occurrence of insomnia in type 2 diabetes mellitus patients. MATERIALS AND METHODS A cross-sectional study was done at a tertiary care center in Thiruvalla from 2022-2025 period. Convenience sampling was used to study 250 patients attending the hospital for consultation. A predesigned proforma was used to collect details and history, IIRS to diagnose insomnia, ADA criteria for T2DM were used.Data was analyzed using statistical software SPSS Version 25. RESULTS This study in 250 T2DM individuals had higher representation of females (56.4%) than males (43.6%). Occupational distribution shows majority belongs to unskilled (43.2%) and skilled (22%) categories. A significant proportion of individuals suffer from hypertension (49.2%), OSA (34%), and peripheral neuropathy (20%). Hypothyroidism is present in 19.6% and hyperthyroidism in 0.8% patients. The Incidence of Insomnia is 40.4% in the study population with secondary insomnia (83.17%) being more common than Primary insomnia (16.83%). Among those with insomnia, 47.52% experience difficulty falling asleep, 24.75% struggle with maintaining sleep, and 29.70% wake up too early. The duration of T2DM (p= 0.006), PPBS and HbA1C levels (p=0.002 for both) show significant association with the occurrence of Insomnia and Age(p=0.079), Sex and Occupation (p= 0.191 for both) and FBS(p=0.194) levels not. CONCLUSION In this study of 250 T2DM patients, the incidence of insomnia (40.4%) found to be higher than in general population.56.4% were females and 43.6% were males. Secondary insomnia (83.17%) found to be more common than Primary insomnia (16.83%) in insomnia patients. The duration of T2DM, PPBS and HbA1C levels show significant association with the occurrence of Insomnia and Age, Sex, Occupation and FBS levels not. Endocrinology & Metabolism T2DM INSOMNIA IIRS ADA Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 SUMMARY In this study of 250 T2DM patients, 56.4% was females and 43.6 % was males. Occupational distribution shows that most participants belong to unskilled (43.2%) and skilled (22%) job categories. Incidence of Insomnia in study population is 40.4% Primary Insomnia = 16.83%, Secondary Insomnia = 83.17% In primary insomnia most common comorbidity associated is hypertension(29.41%), followed by hypothyroidism(17.65%). In secondary insomnia patients most common comorbidity associated is OSA (46.43%) followed by peripheral neuropathy (25.00%), respiratory and cardiac conditions (both 13.09%). In primary insomnia patients, 58.82% experience mild symptoms followed by 29.41%(moderate) and 11.77%(severe). In contrast, secondary insomnia has equal distribution of mild(47.62%) and moderate(47.62%) and only 4.76% experiencing severe symptoms. Among those with insomnia, 47.52% experience difficulty falling asleep, 24.75% struggle with maintaining sleep, and 29.70% wake up too early. Sleep onset problem is more in secondary insomnia(51.19%) than primary insomnia(29.41%). Sleep maintenance is disturbed more in primary insomnia(52.94%) than secondary insomnia(19.05%). Early awakening is more common in primary insomnia(41.18%) than secondary insomnia(27.38%). In contrast, sleep disturbances are even more prevalent among non-insomnia individuals, with 95.97% having difficulty falling asleep, 86.58% experiencing trouble maintaining sleep, and 3.36% reporting early awakening. The duration of T2DM, PPBS and HbA1C levels show statistically significant association with the occurrence of Insomnia and Age, Sex, Occupation and FBS levels do not influence insomnia. INTRODUCTION Insomnia is the complaint of poor sleep and usually presents as difficulty initiating or maintaining sleep.(1) About 10% of general population experience insomnia that qualifies as a medical condition.(2) Insomnia is of two types namely (i) Primary Insomnia and (ii) Secondary Insomnia. (3) According to DSM-5 Criteria, Primary Insomnia can be defined as a predominant complaint of dissatisfaction with sleep quantity or quality, associated with one or more of the following: Difficulty initiating sleep Difficulty maintaining sleep Waking up earlier than usual and unable to return to sleep. The criteria also include: The symptoms must occur at least three nights per week and persist for a minimum of three months. The sleep disturbance leads to significant distress or impairment in various aspects of life, such as social, occupational, educational, academic, behavioural, or other essential areas of functioning. The sleep disruption occurs despite having sufficient time for sleep, is not solely a result of another mental health disorder, and is not caused by the direct physiological effects of substances like drugs, medications, or general medical conditions. (4) Primary Insomnia can be diagnosed by using DSM-5 criteria or ICSD-3 criteria.DSM-5 is easy to use and is commonly used everywhere. Secondary insomnia is when symptoms of insomnia occur from a primary medical illness, mental disorders or other sleep disorders. It may also occur from the use, abuse or exposure to certain substances. Risk factors of insomnia can be older age, female gender, depression/anxiety or other psychiatric disorders, stressful lifestyle, irregular sleep schedule, painful health conditions and other medical conditions like GERD, Bronchial Asthma, Heart failure.(5,6) Sleep onset or initial insomnia means difficulty initiating sleep at bedtime(taking more than 20-30 minutes to fall asleep).(4) Sleep maintenance or middle insomnia involves frequent or prolonged awakenings throughout the night(remaining awake more than 20-30 min).(4) Late insomnia is early morning awakening with inability to return to sleep.(4) Early morning awakening means awakening at least 30 minutes before the scheduled time and before total sleep time reaches 6.5 hours. (4) Epidemiologic studies have shown that the quantity and quality of sleep are significant predictors for the risk of developing T2DM. Click or tap here to enter text. RESEARCH QUESTION What is the Incidence of Insomnia in Type 2 Diabetes Mellitus patients in a tertiary care Centre in South Kerala? AIM & OBJECTIVES Aim of the study: To study the incidence of insomnia in type 2 diabetes mellitus patients and their epidemiological aspects like age, sex, occupation, secondary causes and associated non communicable conditions. Objectives: (1) To estimate the incidence of insomnia in type 2 diabetes mellitus patients. (2) To determine the correlation between demographic and clinical variables with the occurrence of insomnia in type 2 diabetes mellitus patients. RELEVANCE OF STUDY Insomnia is becoming recognized as a potential modifiable risk factor for the development of type 2 diabetes (T2DM). In short-term laboratory studies, induced sleep deprivation led to hyperglycemia, which was reversed once normal sleep patterns were restored. (8) RATIONALE OF STUDY There are hardly any studies or data available regarding insomnia and its characteristics in this part of India. The present study is aimed at reducing this knowledge gap and understanding the epidemiology of insomnia in type 2 diabetes mellitus patients. FEASIBILITY The present study is a feasible study which can be conducted in department of general medicine and possess no burden for the patients and indeed is a cost-effective approach. BACKGROUND AND REVIEW OF LITERATURE Insomnia is diagnosed only when the symptoms last for at least 1 month. (9)Insomnia is typically diagnosed by interview and questionnaires prospectively and retrospectively. Insomnia disorder diagnosis is done only when there is daytime function impairment due to night time sleep difficulties.(10) Sleep physiology Sleep architecture as defined by electroencephalogram includes two types of sleep, dream/REM sleep and NREM sleep. REM sleep comprises 18-25 % of sleep period. NREM sleep further subdivided into stages 1,2, 3, 4. Stage 1 is light sleep includes 5% of sleep period. Stage 2 is considered “sleep” involves 60 % of sleep period. Stage 3 and 4 together known as deep sleep and 10 -15 % of sleep period. A night sleep contains sleep onset followed by stage 1 onset, then stage 2, 3, 4.REM Sleep occurs on or slightly before sleep onset. thus 4 cycles of this pattern occur during night.(11) Pathophysiology of Insomnia One of theories of recent is patient is in hyperarousal state over 24-hour period which leads to sleep problems. Hyper aroused brain of patients does not reduce its metabolic rate with sleep. It not only affects nervous system but also physiological system. There are various predisposing and precipitating factors.(9) DSM-V replaced “primary and secondary” insomnia with generalized term “insomnia disorder”.(9)Therapeutic approaches for insomnia include pharmacological and non- pharmacological like cognitive behavior therapy, biofeedback, sleep restriction, stimulus control therapy, progressive muscle relaxation and paradoxical intention.(11) Diabetes and Sleep Problems Type 2 diabetics suffer various sleep disturbances not only directly from nocturia, polyuria, diabetic neuropathy and neuropathic pain but also from chronic illness produced due to diabetes like cerebrovascular accident, depression, cardiovascular complications, OSA and hypertension. Type 2 diabetes mellitus and sleep has bidirectional relationship., diabetes can lead to poor sleep and poor sleep has risk of developing diabetes. Diabetes can cause short sleep length 9 hours per night. Sleep disturbances in T2DM patients impairs glycemic control. It causes unhealthy eating, less exercise leading to increase in body weight. Insufficient sleep causes hormonal imbalance resulting in insulin resistance worsens diabetes risk factors such as sleep apnea, restless leg syndrome and insomnia ending in a vicious cycle.(13) Obesity, Diabetes and Sleep disturbances Sleep disturbances cause overactivity of orexin system as well as sympathetic system resulting in overfeeding. Sympathetic overactivity also results in insulin resistance. There is increase in levels of ghrelin a hunger promoting hormone and decrease in leptin satiety factor occurring during this.(13) In sleep disordered breathing (SDB) including OSA intermittent hypoxia and sleep fragmentation occurs. This leads to glycemic dysregulation from increased sympathetic activity by reducing insulin sensitivity. The episodes of respiratory problem furthermore aggravate metabolic disturbances.(13) Diabetes and OSA SDB, impaired glucose tolerance, insulin resistance and obesity have strong correlation. OSA is the most common type of SDB. Besides OSA, central type apneas, periodic breathing also occurs in patients with autonomic diabetic neuropathy.(13) OSA is upper air way collapse resulting in airflow cessation during sleep. Symptoms include loud snoring, awakening from sleep, excessive day time sleep and morning headaches.(13)Severity of OSA is calculated by AHI (apnea-hypopnea index) number of complete(apnea) and partial(hypopnea) cessation in breathing per hour of sleep.AHI-5 to 15 events/hour -mild,15 to 30 events/hour-moderate, >30 events/hour-severe OSA.(14) Obesity is the strongest risk factor for OSA, with central adiposity has more impact than BMI.(14) OSA itself increases the risk of endocrine problems, hypertension, cardiovascular disease and insulin resistance.(13)Moderate and severe OSA needs CPAP. (15) OSA may be reason for ineffective treatment of diabetes. Treatment by continuous positive airway pressure may improve metabolic abnormalities in glucose metabolism and of course blood pressure control.(13) Evaluation of Insomnia Proper history taking, clinical examination and laboratory tests are sufficient for evaluation and treatment of insomnia.(13)history taking include history of snoring, apneic episodes, leg twitching, sleep waking episodes and excessive daytime sleep. Role of drug/substance misuse should be ruled out. Keeping a 2-week sleep diary will be helpful in assessing sleep patterns. When other medical illness and psychiatric causes ruled out it becomes Primary Insomnia. PSG is the gold standard for measuring sleep but done only in other sleep disorder pathology like periodic limb movements and sleep related breathing disorders.(10) Management of Insomnia Management includes relief of symptoms and other co-morbid conditions. Behavioral approaches like praticising good sleep hygiene, sleep restriction, cognitive behavioral therapy and relaxation techniques can be used.(13)Pharmacologic approaches include benzodiazepines like alprazolam, nitrazepam, BZDRAs like Zolpidem, Zaleplon, Melatonin, Melatonin agonists like ramelteon can be used. Anti-psychotics, Anti-histaminics, Anti-depressants are rarely used for primary insomnia unless there is secondary component.(10) Table 1: Sleep Hygiene-Do’s and Don’ts for diabetes patients (13) Do’s Don’ts Keep phone in silent/off mode Too much caffeine or alcohol Sleep in dark and quiet environment Sleeping hungry or late-night meal Regular bed and risetime Late night TV or Phone Relaxing measures before bed like washing feet, face Daytime naps Exercise late noon or evening Eating spicy foods in night Table 2: Treatment of Co-morbidities in diabetes patients. (13) Co-morbidities Measures Fluctuation in glucose Glucose control Prevent hypoglycaemia OSA Weight loss Identify upper airway causes CPAP Restless leg syndrome Treat thyroid /iron problems if present Dopamine agonists Benzodiazepines and gabapentin Opiates in severe cases Peripheral neuropathies Analgesics Antidepressants (tricyclics) GABAergic agents(gabapentin, pregabalin) In a study conducted by Zhang and et al 2019 among Han Chinese individuals in Shandong province, China showed that insomnia is independently and associated with northern Chinese population, especially in 40–59-year-old male age group. The study included 5078(2665,52% male). The prevalence of insomnia was found to be 20.2% (68/377) and 12.2% (578/4741) in diabetic and non-diabetic controls respectively.(16) Bhatia (2021) conducted a study on the development and validation of a questionnaire to diagnose insomnia in Indians. The study introduced the Indian Insomnia Rating Scale (IIRS), which demonstrated excellent sensitivity and specificity for diagnosing insomnia, making it a reliable tool for assessing and measuring the severity of insomnia in the Indian population.(17) Talwalkar et al. (2017) found that the prevalence of insomnia among “patients with type 2 diabetes” (T2DM) was higher than in the general Indian population. Approximately 71.4% of the cases were newly diagnosed, and insomnia may have been overlooked in many T2DM patients. Additionally, patients were often prescribed medications not approved for insomnia treatment in India, highlighting both the lack of awareness among healthcare professionals and patients regarding the condition. The study enrolled 706 patients, with 377 (53.4%) diagnosed with insomnia (mean age: 55.5 ± 10.87 years; 49.1% males, 50.9% females). Among the 79 insomnia patients, 69 had an HbA1c >6.5% (87.34%). The majority of patients were aged 45 years or older (84.9%). Common sleep issues included delayed sleep onset (93.9%), midnight awakenings (93.4%), early morning awakenings (89.5%), and insufficient total sleep duration (92.6%).(18) He et al. (2019) found a significant association between insomnia and high alcohol craving in their secondary analysis of data from a clinical trial on alcohol dependence. The Penn Alcohol Craving Scale (PACS) was used to assess alcohol craving, while the Short Sleep Index (SSI) measured insomnia symptoms. The mean PACS total score was 15.9 (SD 8.5), and the mean SSI score was 2.1 (SD 2.3). The study revealed that alcohol craving was linked to insomnia symptoms, specifically difficulty falling asleep (P = 0.03; effect size = -0.7), and was also associated with the total SSI score (P = 0.04; effect size = -0.7).(19) Uddin et al.2017 describes caffeine intake prior to bedtime delays sleep onset, alters sleep stages and causes sleep difficulties.(20) Hu et al.2021 found significant association between regular smoking and insomnia and no significant association for occasional smokers and ex-smokers. The systematic review contained 12,445 participants from six cohort studies. Quantitatively summarized results showed smoking increased incidence of insomnia (odds ratio {OR}: 95% CI: 1.02, 1.13). regular smoking had relation with incidence of insomnia (OR =1.07, 95% CI: 1.01,1.13). From pooled analysis no relation with insomnia for occasional and ex-smokers (occasional smoker: OR = 2.09, 95% CI: 0.44, 9.95; ex-smoker; OR = 1.02, 95% CI: 0.67, 1.54).(21) Hu et al.2021 indicates increased risk of hypertension and CAD in t2dm patients. They also mention cardiovascular disease alters the physiology of sleep and vice versa, inadequate sleep increases CVD. 354 patients were enrolled. They were divided into 3 groups, Group A with T2DM alone, Group B with T2DM longer than insomnia, Group C with insomnia longer than T2DM. Propensity Score Matching (PSM) for association of insomnia with HBP and CAD, univariate and multivariate logistic regression analysis to explore whether insomnia a risk factor for HBP and CAD in T2DM patients. 225 patients in Group A, 62 in Group B, 67 in Group C. Group A has lower prevalence than Group B and Group C for HBP and CAD (p0.05). In the univariate and multivariate logistic regression analysis, insomnia a risk factor for HBP [univariate: odds ratio (OR) = 3.376, 95% CI 2.290–6.093, p <0.001; multivariate: OR = 2.832, 95% CI 1.373–5.841, p = 0.005] and CAD (univariate: OR = 5.019, 95% CI 3.148–8.001, p <0.001; multivariate: OR = 5.289, 95% CI 2.579–10.850, p < 0.001).(22) Quan 2009 tell us there is substantial evidence for association between CVD and sleep disorders. The mechanism remains unclear but mention it likely due to increase in sympathetic activity.(23) Tan et al.2022 dictates poor sleep quality to be pervasive in CKD patients and kidney transplantation will solve sleep problems. The mechanism for poor sleep remains unclear and may due to inflammation resulting from uremia. The pooled prevalences for poor sleep for CKD without KRT, hemodialysis, peritoneal dialysis, and kidney transplantation were 59% (95% CI, 44%-73%), 68% (95% CI, 64%-73%),67% (95% CI, 44%-86%), and 46% (95% CI, 34%-59%), respectively. The corresponding prevalences of insomnia were 48% (95% CI, 30%-67%), 46% (95% CI, 39%-54%), 61% (95% CI,41%-79%), and 26% (95% CI, 9%-49%), respectively. Insomnia was more prevalent in patients aged 51-60 years and those aged >60 years than those aged <50 years.(24) Shah et al.2020 indicates sleep problems is common in CLD and occurs in various forms like EDS, delayed sleep onset, poor sleep quality. The causes are multifactorial and liver transplantation does not improve sleep problems. They also say OSA has close association with NAFLD.(25) Neumann et al.2021 shows that anemia and insomnia has close association. The mechanism remains unclear, probably due to shared gene MEIS1 or inflammation or defective myelination resulting from iron deficiency. This cross-sectional study, 12,614 Chinese adults who participated in an ongoing cohort, the Kailuan Study were included. Individuals with anemia had greater odds of having insomnia (adjusted odds ratio [OR]: 1.32; 95% confidence interval [CI]:1.03–1.70) compared to those without anemia. A significant association persisted even after exclusion of individuals with chronic inflammation, as suggested by C-reactive protein levels >1 mg/L (adjusted OR: 1.68; 95% CI: 1.22–2.32). The meta-analysis results of 22,134 participants found a positive association for anemia and insomnia (pooled OR: 1.39; 95% CI: 1.22–1.57).(26) Bahnasy et al.2018 shows that type 2 diabetes and non-obese individuals with dysautonomia have increased risk of sleep problems resulting in poor glycemic control. Study was conducted in 30 non-obese type 2 dm patients, 20 with clinically evident DPN and 10 without.10 age, sex, body mass index matching healthy control subjects also included. Sleep -apnea syndromes, predominantly OSA, less commonly mixed (OSA/central apnea) increasedly seen in diabetic neuropathy patients than those without and healthy subjects(p<0.0001).(27) Baylan et al.2020 indicates that insomnia and insomnia symptoms higher in post-stroke than general population. A total of twenty-two studies examining the prevalence of insomnia or insomnia symptoms in individuals with stroke were reviewed, with fourteen studies meeting the criteria for inclusion in the meta-analysis. Meta-analysis showed pooled prevalence of 38.2% (CI 30.1-46.5) with significantly higher prevalence for studies of non-diagnostic tools, 40.70% (CI 30.96-50.82) compared to those with diagnostic assessment tools 32.21% (CI 18.5–47.64). Greater insomnia symptoms were showed with comorbid depression and anxiety.(28) Liu et al.2022 indicates hypertension and insomnia has bidirectional relationship and baseline hypertension serves as risk factor for insomnia. From 23 prospective studies,20 cohort studies recorded or adjusted value with the outcome for hypertension (OR = 1.11, 95% CI: 1.07–1.16; I2 = 83.9%), and three cohort studies reported or adjusted value with the outcome for insomnia (OR = 1.20, 95%CI: 1.08–1.32; I2 = 35.1%). Subgroup analysis indicates early morning awakening and composite insomnia were significant with hypertension.(29) Isayeva et al.2020 showed that replacement of indapamide with amlodipine in antihypertensives significantly reduced the insomnia patient proportion. They mention that activation of sympathoadrenal system, associated anxiety and depression, increase markers of systemic inflammation may be the reason for insomnia in hypertensives. Study contained 120 hypertensive patients with and without insomnia. 60 were patients with insomnia. Study has 3 stages. First to establish relation between different antihypertensives and insomnia. Second and third prospective study whether change in antihypertensives improved insomnia proportion.(30) Green et al.2021 mentions that thyroid hormone levels are not markers of sleep dysfunction, but untreated thyroid dysfunction can hammer one attaining healthy sleep.(31) Addanki et al.2024 shows that thyroid dysfunction and sleep disorders may have bidirectional relationship due to hormone dysregulation, metabolic abnormalities and symptomatic manifestations.(32) Wang et al.2023 found that decreased F.T3 levels is associated with increased duration of sleep only when patient sleep duration is less than 7 hours.(33) Choudhary et al.2009 suggests negative relationship between sleep and respiratory diseases due to OSA, restless leg syndrome, sleep hypoventilation.(34) Budhiraja et al.2015 mentions that COPD is often associated with sleep related problems and primary sleep abnormalities. COPD is associated with increased odds of insomnia 1.9(1.5-2.5) adjusted for age, gender(p<0.001). COPD has low sleep efficiency <82% than those without COPD (44%v 31%, p = 0.04).(35) Cespedes et al.2016 showed that decreased sleep quantity and quality has increased risk for diabetes in Hispanics/Latinos with greater odds for short sleep and insomnia. baseline data of sleep ,15227 participants obtained from the Hispanic Community Health Study/Study of Latinos (mean age 41; range 18–74 years). In the population, 14% were diabetes, 28% were insomnia, 9% has short sleepers, and 19% has long sleepers. Compared with average sleep and no insomnia, those with short sleep and insomnia were more chance to have diabetes (odds ratio [OR] 1.46; 95% confidence interval [CI] 1.02, 2.11). Average sleepers with insomnia (1.28; 95% CI 1.02, 1.61) and long sleepers without insomnia (1.33; 95% CI 1.07, 1.65) also shows elevated odds of T2DM.(36) Batool et al.2021 indicates “patients with type 2 diabetes” mellitus often has sleep abnormalities and poor sleep quality.260 “patients with type 2 diabetes” ,197(76%) female was in study. The mean age of sample 55.7±9.89 years, only 54(20.8%) have normal BMI. >50% were poor sleepers and educational status have strong relation with sleep quality(p<0.05).(37) Narisawa et al.2017 indicates that T2 DM patients have sleep problems especially sleep maintenance. This study has 622 type-2 DM patients (mean 56.1±9.56 years) and 622 sex- and age-matched controls. 253 poor sleepers (43.9%) in the type-2 DM group as a result of dichotomization with the PSQI-J cutoff total score of 5.5. The type-2 DM group showed higher mean PSQI-J total score (P,0.01) and poorer sleep maintenance. (38) Otaka et al.2019 found out that 154 (30.6%) exhibited probable insomnia among the 504 T2DM subjects. Adjusting for confounders, being female, living alone, high BMI and “high neuroticism” were significantly related with insomnia. Relationships between insomnia and HbA1c or lifestyle factors, such as smoking, drinking alcohol, or exercise frequency, were not found.(39) METHODOLOGY STUDY DESIGN Cross-sectional study STUDY SETTING The study was conducted in the Department of General Medicine and Endocrinology, Pushpagiri Institute of Medical sciences And Research Centre, Thiruvalla STUDY PERIOD One and 3/4 years(21 months) from ethics committee clearance STUDY SAMPLE All the out patients in Department of General Medicine and Endocrinology, inpatients from Department of General Medicine in the Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla during the period of study formed the study sample SAMPLE SIZE In a study conducted by Otaka et al assessing the association between insomnia and personality traits among “patients with type 2 diabetes” mellitus, probable insomnia was observed in 30.6% of study subjects. Using this data, minimum sample size required for the current study is calculated using the formula Hence this study will be conducted in a minimum of 218 Type 2 Diabetes mellitus patients. INCLUSION CRITERIA Age: more than 18 years and less than 80 years “patients with type 2 diabetes” mellitus. Informed consent EXCLUSION CRITERIA Those with Type 2 diabetes mellitus with acute complications (hypoglycemia, DKA, DK, HHS) Substances or neuroleptic medications which affect sleep wake cycle (alcohol, narcotics) Painful or chronically discomforting health conditions (cancers, stroke) Critically ill patients Pregnant patients Psychiatric disorders Not willing for study SAMPLING TECHNIQUE All consecutive patients based on the inclusion and exclusion criteria during the period of study was included in study until sample size is attained. TOOLS FOR DATA COLLECTION Interviewer administered Proforma Table 3: “Indian Insomnia Rating Scale- Questionnaire to diagnose Insomnia 1. How often do you find difficulty in falling asleep? Never Once a week 2-4 days a week 4-7 days a week Scores-→ 0 1 2 3 2. How often do you have difficulty in staying asleep at night? Never Once a week 2-4 days a week 4-7 days a week Scores→ 0 1 2 3 3. How often do you wake up very early in morning? Never Once a week 2-4 days a week 4-7 days a week Scores→ 0 1 2 3 4. How often do you sleep at night for less than six hours? Never Once a week 2-4 days a week 4-7 days a week Scores→ 0 1 2 5. Since how long did you have sleep complaints? Never Less than 3 months Greater than 3 months Scores→ 0 1 3 6. How Sleep affect quality of Life? Not Affected Moderately affected Severely affected Scores→ 0 2 3 7. How often sleep problem impairs your mood during the day-e.g., feeling irritable / distressed? Never Once a week 2-4 days a week 4-7 days a week Scores→ 0 1 2 3 8. How often because of the sleep problem, do you feel tired/fatigue during the day? Never Once a week 2-4 days a week 4-7 days a week Scores→ 0 1 2 3 9. How often the sleep problem impairs your ability to concentrate, think & take decision? Never Once a week 2-4 days a week 4-7 days a week Scores→ 0 1 2 3 10. How often do you use sleeping aids to fall asleep?” Never Once a month Once in a week More than 3 per week Scores→ 0 1 2 3 Interpretation of Scores Total Score: 0-4: No Insomnia 11-20: Moderate Insomnia 5-10: Mild Insomnia 21-30: Severe Insomnia METHODS OF DATA COLLECTION Clinical history and clinical examination of the patient was collected for filling proforma and to find out if insomnia is present or not. FBS, PPBS, HbA1c of the patients as needed was collected from type 2 diabetes mellitus patients. Indian Insomnia Rating Scale questionnaire was used to diagnose and assess the severity of insomnia, its Malayalam version is verified by back translation. Table 4: Criteria for diagnosis of Diabetes mellitus (40) Fasting Plasma Glucose (FPG) ≥ 126 mg/dL (7.0 mmol/L): Fasting is defined as no caloric intake for at least 8 hours. OR 2-hour Plasma Glucose (2-h PG) ≥ 200 mg/dL (11.1 mmol/L) during an Oral Glucose Tolerance Test (OGTT). The test should be performed according to the World Health Organization (WHO) guidelines, using a glucose load of 75 g anhydrous glucose dissolved in water. OR A1C ≥ 6.5% (48 mmol/mol). This test should be conducted in a laboratory using a method that is NGSP certified and standardized to the Diabetes Control and Complications Trial (DCCT) assay. OR In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L). In the absence of clear hyperglycemia, diagnosis requires two abnormal test results from the same sample or from two separate test samples. DATA ANALYSIS Data was properly coded and entered in Microsoft excel and was analyzed using statistical software SPSS Version 25. PLAN OF ANALYSIS Qualitative variables were summarized as percentages and for quantitative variables mean with standard deviation will be calculated. Incidence of insomnia among study subjects was expressed as percentage along with 95% confidence interval. Association of insomnia with qualitative variables was assessed using chi square test and with quantitative variables was assessed using t test. Non parametric tests were applied where ever applicable. Statistical significance was set at a p value <0.05. OUTCOME MEASUREMENTS The incidence of insomnia in type 2 diabetes mellitus patients. The severity of insomnia in type 2 diabetes mellitus patients. The relationship between age, sex, FBS, PPBS or HbA1c levels, duration of diabetes with insomnia in type 2 diabetes mellitus patients. EXPECTED OUTCOME This study is expected to yield data on the incidence and epidemiology of insomnia in type 2 diabetes mellitus patients in this part of south India. This will pave the way for understanding the commonly encountered but ignored problem of insomnia in diabetes patients, for the treating physician and help in retarding the complications of insomnia in these subsets of patients. RESULTS Descriptive and Clinical Characteristics of the Study Participants Table 5.1:Mean Age Distribution Mean±SD Age 56.74 ± 10.74 The mean age of the study participants is 56.74 years, with a standard deviation (SD) of 10.74 years. Table 5.2:Percentage Distribution of Participants by Age Group Age Category Frequency Percentage < 35 8 3.2 35-45 26 10.4 45-55 57 22.8 55-65 99 39.6 ≥ 65 60 24 Table 5.3: Distribution of Demographic, Health Conditions and Sleep Patterns in study participants Variables Frequency Percent Sex Male 109 43.6 Female 141 56.4 Occupation Professional 3 1.2 Semi-professional 46 18.4 Clerical, Shop, Farm 38 15.2 Skilled 55 22 Unskilled 108 43.2 Respiratory Condition Present 18 7.2 Absent 232 92.8 Cardiac Condition Present 23 9.2 Absent 227 90.8 Chronic Kidney Disease Present 3 1.2 Absent 247 98.8 Chronic Liver Disease Present 3 1.2 Absent 247 98.8 Old disc Prolapse Present 1 0.4 Absent 249 99.6 Benign Prostatic Hyperplasia Present 3 1.2 Absent 247 98.8 Hypertension Present 123 49.2 Absent 127 50.8 Hypothyroidism Present 49 19.6 Absent 201 80.4 Hyperthyroidism Present 2 0.8 Absent 248 99.2 Absent 165 66 Peripheral Neuropathy Present 50 20 Absent 200 80 Sleep Onset Intact 59 23.6 Disturbed 191 76.4 Sleep Maintenance Intact 96 38.4 Disturbed 154 61.6 Early Awakening Present 35 14 Absent 215 86 This dataset represents a study on the incidence of insomnia in “patients with type 2 diabetes” mellitus (T2DM). The sample consists of 250 individuals, with a slightly higher representation of females (56.4%) than males (43.6%). Occupational distribution shows that most participants belong to unskilled (43.2%) and skilled (22%) job categories. A significant proportion of patients suffer from hypertension (49.2%), Obstructive Sleep Apnea (34%), and peripheral neuropathy (20%), all of which can contribute to sleep disturbances. Other notable comorbidities include cardiac conditions (9.2%) and respiratory conditions (7.2%), which may also impact sleep quality. Chronic kidney disease (1.2%) and chronic liver disease (1.2%) are relatively rare in this population. Additionally, hypothyroidism is present in 19.6% of individuals, while hyperthyroidism is less common (0.8%). The data reveals a striking prevalence of sleep disturbances, with 76.4% experiencing difficulty initiating sleep and 61.6% struggling with sleep maintenance, although early awakening is reported less frequently (14%). Table 6: Characteristics of Insomnia “patients with type 2 diabetes” Mellitus Characteristics Frequency Percent INSOMNIA Present 101 40.4 Absent 149 59.6 Type of Insomnia Primary 17 16.83 Secondary 84 83.17 Severity of Insomnia Mild 50 49.5 Moderate 45 44.56 Severe 6 5.94 The data highlights the prevalence and characteristics of insomnia among “patients with type 2 diabetes” mellitus (T2DM). Insomnia is present in 40.4% of the study population, indicating a significant burden of sleep disturbances in these individuals. Among those with insomnia, the majority (83.17%) suffer from secondary insomnia, suggesting that underlying health conditions, including diabetes-related complications, may contribute to sleep disturbances. In terms of severity, nearly half (49.5%) experience mild insomnia, while 44.56% report moderate symptoms, and a smaller proportion (5.94%) suffer from severe insomnia. Table 7: Characterization of Severity of Insomnia in Primary and Secondary Insomnia Severity of Insomnia Types of Insomnia Primary Secondary Mild 10 (58.82%) 40 (47.62%) Moderate 5 (29.41%) 40 (47.62%) Severe 2 (11.77%) 4 (4.76%) Total 17 84 The data compares the severity levels of insomnia between individuals with primary and secondary insomnia. Among those with primary insomnia, the majority (58.82%) experience mild symptoms, followed by 29.41% with moderate symptoms and 11.77% with severe symptoms. In contrast, individuals with secondary insomnia show a nearly equal distribution of mild (47.62%) and moderate (47.62%) cases, with only 4.76% experiencing severe symptoms. This suggests that while primary insomnia tends to have a higher proportion of mild cases, secondary insomnia has a more balanced distribution between mild and moderate levels, with fewer severe cases overall. Table 8: Percentage Distribution of Comorbidities Among Patients with Primary and Secondary Insomnia Patients with primary Insomnia (n=17) Frequency Percent Comorbidities Hypertension 5 29.41 Hypothyroidism 3 17.65 Hyperthyroidism 0 0.00 Patients with Secondary Insomnia (n=84) Comorbidities Obstructive Sleep Apnea 39 46.43 Peripheral Neuropathy 21 25.00 Respiratory Condition 11 13.09 Cardiac Condition 11 13.09 Benign Prostatic Hyperplasia 3 3.57 Chronic Kidney Disease 2 2.38 Chronic Liver Disease 2 2.38 Old disc Prolapse 0 0.00 Anaemia 2 2.38 Post Stroke 1 1.2 Other Reasons 1 1.2 Among patients with primary insomnia (n=17), the most common comorbidity was hypertension (29.41%), followed by hypothyroidism (17.65%), while no cases of hyperthyroidism were reported. In contrast, among patients with secondary insomnia (n=84), obstructive sleep apnea was the most prevalent comorbidity (46.43%), followed by peripheral neuropathy (25.00%), respiratory and cardiac conditions (both 13.09%), and benign prostatic hyperplasia (3.57%). Less common conditions included chronic kidney disease, chronic liver disease, and anaemia (each around 2.38%), while post-stroke and other reasons accounted for 1.2% each. No cases of old disc prolapse were observed. This suggests that secondary insomnia is often associated with multiple underlying health conditions, particularly respiratory and neurological disorders, whereas primary insomnia occurs more independently, with hypertension being a notable comorbidity. TABLE 9: Incidence of Sleep Disturbances in Insomnia and Non-Insomnia Patients Sleep Disorders Insomnia Present Absent Disturbed sleep onset 48 (47.52%) 143 (95.97%) Disturbed sleep maintenance 25 (24.75%) 129 (86.58%) Early Awakening 30 (29.70%) 5 (3.36%) The data indicates a significant difference in sleep disturbances between individuals with and without insomnia. Among those with insomnia , 47.52% experience difficulty falling asleep, 24.75% struggle with maintaining sleep, and 29.70% wake up too early. In contrast, sleep disturbances are even more prevalent among non-insomnia individuals, with 95.97% having difficulty falling asleep, 86.58% experiencing trouble maintaining sleep, and 3.36% reporting early awakening. Table 10: Incidence of Sleep Disturbances in Primary and Secondary Insomnia Patients Sleep Disorders Type of Insomnia Primary Secondary Disturbed sleep onset 5 (29.41%) 43 (51.19%) Disturbed sleep maintenance 9 (52.94%) 16 (19.05%) Early Awakening 7 (41.18%) 23 (27.38%) The data shows a comparison between primary and secondary insomnia concerning specific sleep disturbances. For disturbed sleep onset, secondary insomnia (51.19%) is more prevalent compared to primary insomnia (29.41%). When it comes to disturbed sleep maintenance, primary insomnia shows a higher percentage (52.94%) than secondary insomnia (19.05%). Early awakening is more common in primary insomnia, affecting 41.18% of individuals, while 27.38% of those with secondary insomnia experience this disturbance. Table 11:Association of Patient Characteristics with Insomnia using Chi- Square Analysis Patient Characteristics INSOMNIA p value Present Absent Sex Male 39 (35.8%) 70 (64.2%) 0.191 Female 62 (44%) 79 (56%) Occupation Professional 1 (33.3%) 2 (66.7%) 0.191 Semi-professional 14 (30.4%) 32 (69.6%) Clerical, Shop, Farm 19 (50%) 19 (50%) Skilled 18 (32.7%) 37 (67.3%) Unskilled 49 (45.4%) 59 (54.6%) Sleep Onset Intact 53 (89.8%) 6 (10.2%) 0.000 Disturbed 48 (25.1%) 143 (74.9%) Sleep Maintenance Intact 76 (79.2%) 20 (20.8%) 0.000 Disturbed 25 (16.2%) 129 (83.8%) Early Awakening Present 30 (85.7%) 5 (14.3%) 0.000 Absent 71 (33%) 144 (67%) The chi-square analysis reveals significant associations between sleep patterns and insomnia. Sleep onset disturbance (p = 0.000), sleep maintenance disturbance (p = 0.000), and early awakening (p = 0.000) are all strongly correlated with insomnia, indicating that individuals experiencing these disturbances are significantly more likely to have insomnia. While sex and occupation do not show statistically significant associations with insomnia (p = 0.191 for both), a higher proportion of females (44%) report insomnia compared to males (35.8%). Among occupations, the clerical, shop, and farm workers group show the highest proportion of insomnia (50%), whereas professionals report the lowest (33.3%). These findings suggest that sleep disturbances play a critical role in insomnia, whereas demographic factors such as sex and occupation may have a less pronounced impact. Table 12:Mann-Whitney U Test for the Association of Insomnia with Age Diabetes Duration, FBS, PPBS and HbA1C levels INSOMNIA Mean Rank Mann Whitney U Asymptotic Significance Age Present 135.24 6541.000 0.079 Absent 118.9 DM-Duration Present 140.77 5982.5 0.006 Absent 115.15 FBS Present 116.78 5167.000 0.194 Absent 105.44 PPBS Present 125.96 4359.500 0.002 Absent 99.28 HbA1C Present 125.96 4357.000 0.002 Absent 99.28 The Mann-Whitney U test results compare various factors between individuals with and without insomnia. Age shows no statistically significant difference between the two groups (p = 0.079), suggesting that age does not strongly influence insomnia. However, diabetes duration (DM-Duration) is significantly higher in those with insomnia (p = 0.006), indicating a potential link between longer diabetes duration and sleep disturbances. Similarly, postprandial blood sugar (PPBS) and HbA1C levels are significantly higher in individuals with insomnia (both p = 0.002), suggesting poorer glycaemic control in those experiencing sleep issues. In contrast, fasting blood sugar (FBS) does not show a significant difference (p = 0.194), implying that fasting glucose levels alone may not be a key factor distinguishing those with and without insomnia. Overall, the findings suggest that longer diabetes duration and poor glycaemic control, particularly PPBS and HbA1C levels, are associated with insomnia in diabetic individuals. DISCUSSION Totally 250 T2DM patients were enrolled in the study and 56.4% were females. A comparable female dominance was noted by Talwalkar et al and Batool et al.(18,37) The mean age of the study participants is 56.74 years, with a standard deviation (SD) of 10.74 years comparable to Talwalkar et al where the mean age was 55.5±10.87 years . (18) In this study 56.4% were females and 43.6% were males. It was similar in observation to Talwalkar et al where females were 50.9% and males were 49.1% ,whereas in Batool et al. female were the strong majority(76%).(18,37) In Zhang and et al males were predominant 52%. (16) Age and sex showed no statistical difference between insomnia and non-insomnia groups. Where Zhang et al noted significant incidence of T2DM in the age-group 40-59 and in males.(16) Occupational distribution in this study shows that most participants belong to unskilled (43.2%) and skilled (22%) job categories. As compared to Batool et al. it had majority of the patients were illiterate 146 (56.2%) while 38 (14.6%) were paid workers. (37) In this study a significant proportion of patients suffered from hypertension (49.2%), Obstructive Sleep Apnea (34%), and peripheral neuropathy (20%).Other notable comorbidities include cardiac conditions (9.2%) and respiratory conditions (7.2%).Chronic kidney disease (1.2%) and chronic liver disease (1.2%) are relatively rare in this population. Additionally, hypothyroidism is present in 19.6% of individuals, while hyperthyroidism is less common (0.8%). The data in this study reveals a striking prevalence of sleep disturbances, with 76.4% experiencing difficulty initiating sleep and 61.6% struggling with sleep maintenance, although early awakening is reported less frequently (14%). In this study the incidence of Insomnia in T2DM patients was 40.4%,with primary insomnia being 16.83% and secondary insomnia being 83.17%.Where Talwalkar et al found 53.4% with insomnia, Otaka et al showed 30.6% has insomnia, Batool et al with >50% insomnia and Narisawa et al with 43.9% insomnia in T2DM patients with different sample size and study characteristics.(18,37–39) In this study, nearly half (49.5%) experience mild insomnia, while 44.56% report moderate symptoms, and a smaller proportion (5.94%) suffer from severe insomnia. Among those with primary insomnia, the majority (58.82%) experience mild symptoms, followed by 29.41% with moderate symptoms and 11.77% with severe symptoms. In contrast, individuals with secondary insomnia show a nearly equal distribution of mild (47.62%) and moderate (47.62%) cases, with only 4.76% experiencing severe symptoms. In this study those patients with primary insomnia have the most common comorbidity as hypertension (29.41%), followed by hypothyroidism (17.65%).In contrast, among patients with secondary insomnia, obstructive sleep apnea was the most prevalent comorbidity (46.43%), followed by peripheral neuropathy (25.00%), respiratory and cardiac conditions (both 13.09%), and benign prostatic hyperplasia (3.57%). Less common conditions included chronic kidney disease, chronic liver disease, and anaemia (each around 2.38%), while post-stroke and other reasons accounted for 1.2% each. Among those with insomnia, 47.52% experience difficulty falling asleep, 24.75% struggle with maintaining sleep, and 29.70% wake up too early. Where Talwalkar et al noticed that majority of the T2DM individuals with insomnia experienced sleep-related problems as delayed sleep onset (93.9%); sleep maintenance (93.4%); early morning awakening (89.5%) and insufficient total sleep duration (92.6%).(18) In this Study, for disturbed sleep onset, secondary insomnia (51.19%) is more prevalent compared to primary insomnia (29.41%). When it comes to disturbed sleep maintenance, primary insomnia shows a higher percentage (52.94%) than secondary insomnia (19.05%). Early awakening is more common in primary insomnia, affecting 41.18% of individuals, while 27.38% of those with secondary insomnia experience this disturbance. The duration of T2DM, PPBS and HbA1C levels showed significant association with the occurrence of Insomnia whereas Age, Sex, Occupation and FBS levels not. As opposed Zhang et al found significant association of incidence of T2DM in 40–59-year age group and also in males.(16) Otaka et al found no association between insomnia and HbA1C levels, lifestyle factors such as exercise frequency. Whereas Batool et al found significant association between educational status and insomnia.(37,39) In contrast, this study found that sleep disturbances are even more common among individuals without insomnia, with 95.97% reporting difficulty falling asleep, 86.58% experiencing trouble maintaining sleep, and 3.36% experiencing early awakening. These findings highlight the need for increased awareness among healthcare professionals and patients regarding sleep issues. Such disturbances could potentially serve as an early indicator for uncontrolled blood sugar levels and may lead to the development of a more severe insomnia disorder in the future. It is crucial to emphasize the importance of addressing these concerns with the utmost care. LIMITATIONS AND RECOMMENDATIONS Limitations There were certain limitations to our study. Duration of study Single center study Sample size studied. Patient non-compliance in answering questions (smoking, alcohol) and reluctance in doing baseline investigations(fbs,ppbs,hba1c) Recommendations Further multi-center control studies of similar nature with a large number of cases are needed in this regard to accurately estimate the incidence and impact of insomnia in type 2 diabetes mellitus patients and vice versa CONCLUSION This study found the increased incidence of insomnia in T2DM patients than general population. It also showed significant co-relation between higher HbA1C, PPBS levels and insomnia. Treating physicians should consider and treat insomnia in T2DM patients which may be the unknown factor responsible for uncontrolled blood sugars in these patients. Declarations ACKNOWLEDGEMENT It is a genuine pleasure to express my deep sense of gratitude to everyone who made completion of this dissertation possible. I am extremely grateful for the God’s blessings throughout this work. This work would not have been possible without the expert guidance, constant motivation, timely advice, and whole-hearted support of my guide Dr. V Abraham Varghese, Professor of Department of General Medicine, to whom I am extremely grateful. I would like to thank Dr. Sajit Varghese, Additional Professor, Department of General Medicine, my Co-Guide for the research topic, expert advice, continued support, and motivation. I am thankful to Dr. C A Abdul Khader, HOD-Emeritus and Dr. Tomy Philip, current HOD for permitting me to utilize the facilities of the college and hospital for my study. I am also thankful to, Dr. Elsheba, Emeritus Professor Department of Community Medicine, for the timely help. My sincere thanks to Dr. Amal Dev Assistant Professor Department of Endocrinology, for his continued support, motivation and valuable suggestions provided during the preparation of this thesis. I am truly indebted to, Dr. Rajeev Philip Professor & HOD Department of Endocrinology for his timely help and advice. I sincerely thank Amala thomas and Ann Maria Sebastian, Biostatisticians, PIMS&RC, for helping me out with statistical analysis of this thesis work. I would also like to thank my seniors, co-postgraduates, juniors, and nursing staffs of my department for their valuable support and encouragement throughout the study. I also acknowledge the wholehearted support, encouragement and wise counseling given by my family in all times of need. Last but not the least, let me thank all our patients for their participation and co- operation throughout the study. References Krystal AD, Prather AA, Ashbrook LH. The assessment and management of insomnia: an update. Vol. 18, World Psychiatry. 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Prevalence, symptomatic features, and factors associated with sleep disturbance/insomnia in Japanese patients with type-2 diabetes. Neuropsychiatr Dis Treat. 2017;13. Otaka H, Murakami H, Nakayama H, Murabayashi M, Mizushiri S, Matsumura K, et al. Association between insomnia and personality traits among Japanese patients with type 2 diabetes mellitus. J Diabetes Investig. 2019 Mar 1;10(2):484–90. Classification and diagnosis of diabetes: Standards of medical care in diabetes-2021. Diabetes Care. 2021 Jan 1;44:S15–33. Additional Declarations The authors declare no competing interests. Supplementary Files ANNEXURES.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Population\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/137bd21d3fae5d53687cd1d8.png"},{"id":80780443,"identity":"cbf374c1-68e4-411c-9aa2-e37f2589a978","added_by":"auto","created_at":"2025-04-17 04:31:15","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":114572,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrevalence of Comorbidities in Type 2 Diabetes Mellitus Patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/3f479d30307af2c6dd3e2593.png"},{"id":80780475,"identity":"a19b16a8-1d7a-444b-af4f-36b1344eda32","added_by":"auto","created_at":"2025-04-17 04:31:17","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":59884,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Insomnia Among Type 2 Diabetes Mellitus Patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/6d8be83baff53405f6c0af2c.png"},{"id":80781298,"identity":"1b13fbe1-984b-4513-888a-9cc90d210a89","added_by":"auto","created_at":"2025-04-17 04:39:18","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":75849,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Primary and Secondary Insomnia\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/bb37c0fb0d561cd7c483d2e1.png"},{"id":80780503,"identity":"af30ad2f-3a87-4b17-8e3e-c20bb0b92616","added_by":"auto","created_at":"2025-04-17 04:31:18","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":48684,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Insomnia Severity\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/f8256fb841b9b72c78ee16a2.png"},{"id":80780439,"identity":"4737dfd3-e609-4f1b-8b69-7823f6875726","added_by":"auto","created_at":"2025-04-17 04:31:15","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":52724,"visible":true,"origin":"","legend":"\u003cp\u003eSeverity of Primary and Secondary Insomnia\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/3fcb2f0ae97d301588a16472.png"},{"id":80781300,"identity":"4fd56f71-cfcc-491a-8931-bd4860d41812","added_by":"auto","created_at":"2025-04-17 04:39:18","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":47778,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Comorbidities among Patients with Primary Insomnia\u003c/p\u003e","description":"","filename":"12.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/796ffd95c23071e2dccc8e98.png"},{"id":80780482,"identity":"a7a6c0b3-8a42-4d7c-9b98-ca9f7bba148c","added_by":"auto","created_at":"2025-04-17 04:31:17","extension":"png","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":87079,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Comorbidities Among Patients with Secondary Insomnia\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"13.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/5199014dfe8520ac1632a3f4.png"},{"id":80780450,"identity":"0e94021c-5fdf-46cb-8d27-c9a490036ba2","added_by":"auto","created_at":"2025-04-17 04:31:16","extension":"png","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":39985,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of Sleep Disturbances in Insomnia and Non-Insomnia Patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"14.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/628798ec02bfe5bd3a655075.png"},{"id":80780458,"identity":"21fe3750-dda3-44f8-adae-58e65a6ca177","added_by":"auto","created_at":"2025-04-17 04:31:16","extension":"png","order_by":15,"title":"Figure 15","display":"","copyAsset":false,"role":"figure","size":46559,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of Sleep Disturbances in Primary and Secondary Insomnia Patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"15.png","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/09471dea1ee9e1838241343c.png"},{"id":80782446,"identity":"c771ad54-a690-4ee5-acdf-cb19ad1f2829","added_by":"auto","created_at":"2025-04-17 05:03:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2977914,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/807e49d8-eabc-4672-b478-03d6edda718a.pdf"},{"id":80781297,"identity":"1e984bf5-705b-4bc4-94d2-8bba96966ca8","added_by":"auto","created_at":"2025-04-17 04:39:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":357699,"visible":true,"origin":"","legend":"","description":"","filename":"ANNEXURES.docx","url":"https://assets-eu.researchsquare.com/files/rs-6443080/v1/3ef3ce5b09a62fe569c07afb.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eIncidence of Insomnia in Type 2 Diabetes Mellitus patients in a Tertiary Care Centre in Southern Kerala\u003c/p\u003e","fulltext":[{"header":"SUMMARY","content":"\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eIn this study of 250 T2DM patients, 56.4% was females and 43.6 % was males.\u003c/li\u003e\n \u003cli\u003eOccupational distribution shows that most participants belong to unskilled (43.2%) and skilled (22%) job categories.\u003c/li\u003e\n \u003cli\u003eIncidence of Insomnia in study population is 40.4%\u003c/li\u003e\n \u003cli\u003ePrimary Insomnia = 16.83%, Secondary Insomnia = 83.17%\u003c/li\u003e\n \u003cli\u003eIn primary insomnia most common comorbidity associated is hypertension(29.41%), \u0026nbsp;followed by hypothyroidism(17.65%).\u003c/li\u003e\n \u003cli\u003eIn secondary insomnia patients most common comorbidity associated is OSA (46.43%) \u0026nbsp; followed by peripheral neuropathy (25.00%), respiratory and cardiac conditions (both 13.09%).\u003c/li\u003e\n \u003cli\u003eIn \u0026nbsp; primary insomnia patients, 58.82% experience mild symptoms followed by 29.41%(moderate) and 11.77%(severe).\u003c/li\u003e\n \u003cli\u003eIn contrast, secondary insomnia has equal distribution of mild(47.62%) and moderate(47.62%) and only 4.76% experiencing severe symptoms.\u003c/li\u003e\n \u003cli\u003eAmong those with insomnia, 47.52% experience difficulty falling asleep, 24.75% struggle with maintaining sleep, and 29.70% wake up too early.\u003c/li\u003e\n \u003cli\u003eSleep onset problem is more in secondary insomnia(51.19%) than primary insomnia(29.41%).\u003c/li\u003e\n \u003cli\u003eSleep maintenance is disturbed more in primary insomnia(52.94%) than secondary insomnia(19.05%).\u003c/li\u003e\n \u003cli\u003eEarly awakening is more common in primary insomnia(41.18%) than secondary insomnia(27.38%).\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;In contrast, sleep disturbances are even more prevalent among non-insomnia individuals, with 95.97% having difficulty falling asleep, 86.58% experiencing trouble maintaining sleep, and 3.36% reporting early awakening.\u003c/li\u003e\n \u003cli\u003eThe duration of T2DM, PPBS and HbA1C levels show statistically significant association with the occurrence of Insomnia and Age, Sex, Occupation and FBS levels do not influence insomnia.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eInsomnia is the complaint of poor sleep and usually presents as difficulty initiating or maintaining sleep.(1) About 10% of general population experience insomnia that qualifies as a medical condition.(2)\u003csup\u003e\u0026nbsp;\u003c/sup\u003eInsomnia is of two types namely (i) Primary Insomnia and (ii) Secondary Insomnia.\u0026nbsp;(3)\u003c/p\u003e\n\u003cp\u003eAccording to DSM-5 Criteria, Primary Insomnia can be defined as a predominant complaint of dissatisfaction with sleep quantity or quality, associated with one or more of the following:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDifficulty initiating sleep\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDifficulty maintaining sleep\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWaking up earlier than usual and unable to return to sleep.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe criteria also include:\u003c/p\u003e\n\u003cp\u003eThe symptoms must occur at least three nights per week and persist for a minimum of three months.\u003c/p\u003e\n\u003cp\u003eThe sleep disturbance leads to significant distress or impairment in various aspects of life, such as social, occupational, educational, academic, behavioural, or other essential areas of functioning.\u003c/p\u003e\n\u003cp\u003eThe sleep disruption occurs despite having sufficient time for sleep, is not solely a result of another mental health disorder, and is not caused by the direct physiological effects of substances like drugs, medications, or general medical conditions. (4)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrimary Insomnia can be diagnosed by using DSM-5 criteria or ICSD-3 criteria.DSM-5 is easy to use and is commonly used everywhere. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSecondary insomnia is when symptoms of insomnia occur from a primary medical illness, mental disorders or other sleep disorders. It may also occur from the use, abuse or exposure to certain substances. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRisk factors of insomnia can be older age, female gender, depression/anxiety or other psychiatric disorders, stressful lifestyle, irregular sleep schedule, painful health conditions and other medical conditions like GERD, Bronchial Asthma, Heart failure.(5,6)\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSleep onset or initial insomnia means difficulty initiating sleep at bedtime(taking more than 20-30 minutes to fall asleep).(4)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSleep maintenance or middle insomnia involves frequent or prolonged awakenings throughout the night(remaining awake more than 20-30 min).(4)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLate insomnia is early morning awakening with inability to return to sleep.(4) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEarly morning awakening means awakening at least 30 minutes before the scheduled time and before total sleep time reaches 6.5 hours. (4)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEpidemiologic studies have shown that the quantity and quality of sleep are significant predictors for the risk of developing T2DM.\u003cspan class=\"MsoPlaceholderText\"\u003eClick or tap here to enter text.\u003c/span\u003e\u003csup\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eRESEARCH QUESTION\u003c/h3\u003e\n\u003cp\u003eWhat is the Incidence of Insomnia in Type 2 Diabetes Mellitus patients in a tertiary care Centre in South Kerala?\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003eAIM \u0026 OBJECTIVES\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eAim of the study:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo study the incidence of insomnia in type 2 diabetes mellitus patients and their epidemiological aspects like age, sex, occupation, secondary causes and associated non communicable conditions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(1) To estimate the incidence of insomnia in type 2 diabetes mellitus patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(2) To determine the correlation between demographic and clinical variables with the \u0026nbsp; occurrence of insomnia in type 2 diabetes mellitus patients.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eRELEVANCE OF STUDY\u003c/h3\u003e\n\u003cp\u003eInsomnia is becoming recognized as a potential modifiable risk factor for the development of type 2 diabetes (T2DM). In short-term laboratory studies, induced sleep deprivation led to hyperglycemia, which was reversed once normal sleep patterns were restored.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e(8)\u003c/p\u003e\n\u003ch3\u003eRATIONALE OF STUDY\u003c/h3\u003e\n\u003cp\u003eThere are hardly any studies or data available regarding insomnia and its characteristics in this part of India. The present study is aimed at reducing this knowledge gap and understanding the epidemiology of insomnia in type 2 diabetes mellitus patients.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eFEASIBILITY\u003c/h3\u003e\n\u003cp\u003eThe present study is a feasible study which can be conducted in department of general medicine and possess no burden for the patients and indeed is a cost-effective approach.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eBACKGROUND AND REVIEW OF LITERATURE\u003c/h3\u003e\n\u003cp\u003eInsomnia is diagnosed only when the symptoms last for at least 1 month. (9)Insomnia is typically diagnosed by interview and questionnaires prospectively and retrospectively. Insomnia disorder diagnosis is done only when there is daytime function impairment due to night time sleep difficulties.(10)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSleep physiology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSleep architecture as defined by electroencephalogram includes two types of sleep, dream/REM sleep and NREM sleep. REM sleep comprises 18-25 % of sleep period. NREM sleep further subdivided into stages 1,2, 3, 4. Stage 1 is light sleep includes 5% of sleep period. Stage 2 is considered \u0026ldquo;sleep\u0026rdquo; involves 60 % of sleep period. Stage 3 and 4 together known as deep sleep and 10 -15 % of sleep period. A night sleep contains sleep onset followed by stage 1 onset, then stage 2, 3, 4.REM Sleep occurs on or slightly before sleep onset. thus 4 cycles of this pattern occur during night.(11)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePathophysiology of Insomnia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of theories of recent is patient is in hyperarousal state over 24-hour period which leads to sleep problems. Hyper aroused brain of patients does not reduce its metabolic rate with sleep.\u003c/p\u003e\n\u003cp\u003eIt not only affects nervous system but also physiological system. There are various predisposing and precipitating factors.(9)\u003c/p\u003e\n\u003cp\u003eDSM-V replaced \u0026ldquo;primary and secondary\u0026rdquo; insomnia with generalized term \u0026ldquo;insomnia disorder\u0026rdquo;.(9)Therapeutic approaches for insomnia include pharmacological and non- pharmacological like cognitive behavior therapy, biofeedback, sleep restriction, stimulus control therapy, progressive muscle relaxation and paradoxical intention.(11)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiabetes and Sleep Problems\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eType 2 diabetics suffer various sleep disturbances not only directly from nocturia, polyuria, diabetic neuropathy and neuropathic pain but also from chronic illness produced due to diabetes like cerebrovascular accident, depression, cardiovascular complications, OSA and hypertension. Type 2 diabetes mellitus and sleep has bidirectional relationship., diabetes can lead to poor sleep and poor sleep has risk of developing diabetes.\u003c/p\u003e\n\u003cp\u003eDiabetes can cause short sleep length \u0026lt;6 hours per night as well as long sleep \u0026gt; 9 hours per night. Sleep disturbances in T2DM patients impairs glycemic control. It causes unhealthy eating, less exercise leading to increase in body weight. Insufficient sleep causes hormonal imbalance resulting in insulin resistance worsens diabetes risk factors such as sleep apnea, restless leg syndrome and insomnia ending in a vicious cycle.(13)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObesity, Diabetes and Sleep disturbances\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSleep disturbances cause overactivity of orexin system as well as sympathetic system resulting in overfeeding. Sympathetic overactivity also results in insulin resistance. There is increase in levels of ghrelin a hunger promoting hormone and decrease in leptin satiety factor occurring during this.(13)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn sleep disordered breathing (SDB) including OSA intermittent hypoxia and sleep fragmentation occurs. This leads to glycemic dysregulation from increased sympathetic activity by reducing insulin sensitivity. The episodes of respiratory problem furthermore aggravate metabolic disturbances.(13)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiabetes and OSA\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSDB, impaired glucose tolerance, insulin resistance and obesity have strong correlation. OSA is the most common type of SDB. Besides OSA, central type apneas, periodic breathing also occurs in patients with autonomic diabetic neuropathy.(13)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOSA is upper air way collapse resulting in airflow cessation during sleep. Symptoms include loud snoring, awakening from sleep, excessive day time sleep and morning headaches.(13)Severity of OSA is calculated by AHI (apnea-hypopnea index) number of complete(apnea) and partial(hypopnea) cessation in breathing per hour of sleep.AHI-5 to 15 events/hour -mild,15 to 30 events/hour-moderate, \u0026gt;30 events/hour-severe OSA.(14)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eObesity is the strongest risk factor for OSA, with central adiposity has more impact than BMI.(14)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOSA itself increases the risk of endocrine problems, hypertension, cardiovascular disease and insulin resistance.(13)Moderate and severe OSA needs CPAP. (15) OSA may be reason for ineffective treatment of diabetes. Treatment by continuous positive airway pressure may improve metabolic abnormalities in glucose metabolism and of course blood pressure control.(13)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluation of Insomnia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProper history taking, clinical examination and laboratory tests are sufficient for evaluation and treatment of insomnia.(13)history taking include history of snoring, apneic episodes, leg twitching, sleep waking episodes and excessive daytime sleep. Role of drug/substance misuse should be ruled out. Keeping a 2-week sleep diary will be helpful in assessing sleep patterns.\u003c/p\u003e\n\u003cp\u003eWhen other medical illness and psychiatric causes ruled out it becomes Primary Insomnia.\u003c/p\u003e\n\u003cp\u003ePSG is the gold standard for measuring sleep but done only in other sleep disorder pathology like periodic limb movements and sleep related breathing disorders.(10)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManagement of Insomnia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eManagement includes relief of symptoms and other co-morbid conditions. Behavioral approaches like praticising good sleep hygiene, sleep restriction, cognitive behavioral therapy and relaxation techniques can be used.(13)Pharmacologic approaches include benzodiazepines like alprazolam, nitrazepam, BZDRAs like Zolpidem, Zaleplon, Melatonin, Melatonin agonists like ramelteon can be used. Anti-psychotics, Anti-histaminics, Anti-depressants are rarely used for primary insomnia unless there is secondary component.(10)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Sleep Hygiene-Do\u0026rsquo;s and Don\u0026rsquo;ts for diabetes patients\u003c/strong\u003e(13)\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eDo\u0026rsquo;s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eDon\u0026rsquo;ts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eKeep phone in silent/off mode\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eToo much caffeine or alcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSleep in dark and quiet environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSleeping hungry or late-night meal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eRegular bed and risetime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eLate night TV or Phone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eRelaxing measures before bed like washing feet, face\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eDaytime naps\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eExercise late noon or evening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eEating spicy foods in night\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Treatment of Co-morbidities in diabetes patients.\u003c/strong\u003e(13)\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eCo-morbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eMeasures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eFluctuation in glucose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eGlucose control\u003c/p\u003e\n \u003cp\u003ePrevent hypoglycaemia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eOSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eWeight loss\u003c/p\u003e\n \u003cp\u003eIdentify upper airway causes\u003c/p\u003e\n \u003cp\u003eCPAP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eRestless leg syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eTreat thyroid /iron problems if present\u003c/p\u003e\n \u003cp\u003eDopamine agonists\u003c/p\u003e\n \u003cp\u003eBenzodiazepines and gabapentin\u003c/p\u003e\n \u003cp\u003eOpiates in severe cases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003ePeripheral neuropathies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eAnalgesics\u003c/p\u003e\n \u003cp\u003eAntidepressants (tricyclics)\u003c/p\u003e\n \u003cp\u003eGABAergic agents(gabapentin, pregabalin)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIn a study conducted by Zhang and et al 2019 among Han Chinese individuals in Shandong province, China showed that insomnia is independently and associated with northern Chinese population, especially in 40\u0026ndash;59-year-old male age group. The study included 5078(2665,52% male). The prevalence of insomnia was found to be 20.2% (68/377) and 12.2% (578/4741) in diabetic and non-diabetic controls respectively.(16)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBhatia (2021) conducted a study on the development and validation of a questionnaire to diagnose insomnia in Indians. The study introduced the Indian Insomnia Rating Scale (IIRS), which demonstrated excellent sensitivity and specificity for diagnosing insomnia, making it a reliable tool for assessing and measuring the severity of insomnia in the Indian population.(17)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTalwalkar et al. (2017) found that the prevalence of insomnia among \u0026ldquo;patients with type 2 diabetes\u0026rdquo; (T2DM) was higher than in the general Indian population. Approximately 71.4% of the cases were newly diagnosed, and insomnia may have been overlooked in many T2DM patients. Additionally, patients were often prescribed medications not approved for insomnia treatment in India, highlighting both the lack of awareness among healthcare professionals and patients regarding the condition. The study enrolled 706 patients, with 377 (53.4%) diagnosed with insomnia (mean age: 55.5 \u0026plusmn; 10.87 years; 49.1% males, 50.9% females). Among the 79 insomnia patients, 69 had an HbA1c \u0026gt;6.5% (87.34%). The majority of patients were aged 45 years or older (84.9%). Common sleep issues included delayed sleep onset (93.9%), midnight awakenings (93.4%), early morning awakenings (89.5%), and insufficient total sleep duration (92.6%).(18)\u003c/p\u003e\n\u003cp\u003eHe et al. (2019) found a significant association between insomnia and high alcohol craving in their secondary analysis of data from a clinical trial on alcohol dependence. The Penn Alcohol Craving Scale (PACS) was used to assess alcohol craving, while the Short Sleep Index (SSI) measured insomnia symptoms. The mean PACS total score was 15.9 (SD 8.5), and the mean SSI score was 2.1 (SD 2.3). The study revealed that alcohol craving was linked to insomnia symptoms, specifically difficulty falling asleep (P = 0.03; effect size = -0.7), and was also associated with the total SSI score (P = 0.04; effect size = -0.7).(19)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUddin et al.2017 describes caffeine intake prior to bedtime delays sleep onset, alters sleep stages and causes sleep difficulties.(20)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHu et al.2021 found significant association between regular smoking and insomnia and no significant association for occasional smokers and ex-smokers. The systematic review contained 12,445 participants from six cohort studies. Quantitatively summarized results showed smoking increased incidence of insomnia (odds ratio {OR}: 95% CI: 1.02, 1.13). regular smoking had relation with incidence of insomnia (OR =1.07, 95% CI: 1.01,1.13). From pooled analysis no relation with insomnia for occasional and ex-smokers (occasional smoker: OR = 2.09, 95% CI: 0.44, 9.95; ex-smoker; OR = 1.02, 95% CI: 0.67, 1.54).(21)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHu et al.2021 indicates increased risk of hypertension and CAD in t2dm patients. They also mention cardiovascular disease alters the physiology of sleep and vice versa, inadequate sleep increases CVD. 354 patients were enrolled. They were divided into 3 groups, Group A with T2DM alone, Group B with T2DM longer than insomnia, Group C with insomnia longer than T2DM. Propensity Score Matching (PSM) for association of insomnia with HBP and CAD, univariate and multivariate logistic regression analysis to explore whether insomnia a risk factor for HBP and CAD in T2DM patients. 225 patients in Group A, 62 in Group B, 67 in Group C. Group A has lower prevalence than Group B and Group C for HBP and CAD (p\u0026lt;0.05). Group C has no difference in prevalence for HBP and CAD compared to Group B(p\u0026gt;0.05). In the univariate and multivariate logistic regression analysis, insomnia a risk factor for HBP [univariate: odds ratio (OR) = 3.376, 95% CI 2.290\u0026ndash;6.093, p \u0026lt;0.001; multivariate: OR = 2.832, 95% CI 1.373\u0026ndash;5.841, p = 0.005] and CAD (univariate: OR = 5.019, 95% CI 3.148\u0026ndash;8.001, p \u0026lt;0.001; multivariate: OR = 5.289, 95% CI 2.579\u0026ndash;10.850, p \u0026lt; 0.001).(22)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQuan 2009 tell us there is substantial evidence for association between CVD and sleep disorders. The mechanism remains unclear but mention it likely due to increase in sympathetic activity.(23)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTan et al.2022 dictates poor sleep quality to be pervasive in CKD patients and kidney transplantation will solve sleep problems. The mechanism for poor sleep remains unclear and may due to inflammation resulting from uremia. The pooled prevalences for poor sleep for CKD without KRT, hemodialysis, peritoneal dialysis, and kidney transplantation were 59% (95% CI, 44%-73%), 68% (95% CI, 64%-73%),67% (95% CI, 44%-86%), and 46% (95% CI, 34%-59%), respectively. The corresponding prevalences of insomnia were 48% (95% CI, 30%-67%), 46% (95% CI, 39%-54%), 61% (95% CI,41%-79%), and 26% (95% CI, 9%-49%), respectively. Insomnia was more prevalent in patients aged 51-60 years and those aged \u0026gt;60 years than those aged \u0026lt;50 years.(24)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eShah et al.2020 indicates sleep problems is common in CLD and occurs in various forms like EDS, delayed sleep onset, poor sleep quality. The causes are multifactorial and liver transplantation does not improve sleep problems. They also say OSA has close association with NAFLD.(25)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNeumann et al.2021 shows that anemia and insomnia has close association. The mechanism remains unclear, probably due to shared gene MEIS1 or inflammation or defective myelination resulting from iron deficiency. This cross-sectional study, 12,614 Chinese adults who participated in an ongoing cohort, the Kailuan Study were included. Individuals with anemia had greater odds of having insomnia (adjusted odds ratio [OR]: 1.32; 95% confidence interval [CI]:1.03\u0026ndash;1.70) compared to those without anemia. A significant association persisted even after exclusion of individuals with chronic inflammation, as suggested by C-reactive protein levels \u0026gt;1 mg/L (adjusted OR: 1.68; 95% CI: 1.22\u0026ndash;2.32). The meta-analysis results of 22,134 participants found a positive association for anemia and insomnia (pooled OR: 1.39; 95% CI: 1.22\u0026ndash;1.57).(26)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBahnasy et al.2018 shows that type 2 diabetes and non-obese individuals with dysautonomia have increased risk of sleep problems resulting in poor glycemic control. Study was conducted in 30 non-obese type 2 dm patients, 20 with clinically evident DPN and 10 without.10 age, sex, body mass index matching healthy control subjects also included. Sleep -apnea syndromes, predominantly OSA, less commonly mixed (OSA/central apnea) increasedly seen in diabetic neuropathy patients than those without and healthy subjects(p\u0026lt;0.0001).(27)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBaylan et al.2020 indicates that insomnia and insomnia symptoms higher in post-stroke than general population. A total of twenty-two studies examining the prevalence of insomnia or insomnia symptoms in individuals with stroke were reviewed, with fourteen studies meeting the criteria for inclusion in the meta-analysis. Meta-analysis showed pooled prevalence of 38.2% (CI 30.1-46.5) with significantly higher prevalence for studies of non-diagnostic tools, 40.70% (CI 30.96-50.82) compared to those with diagnostic assessment tools 32.21% (CI 18.5\u0026ndash;47.64). Greater insomnia symptoms were showed with comorbid depression and anxiety.(28)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLiu et al.2022 indicates hypertension and insomnia has bidirectional relationship and baseline hypertension serves as risk factor for insomnia. From 23 prospective studies,20 cohort studies recorded or adjusted value with the outcome for hypertension (OR = 1.11, 95% CI: 1.07\u0026ndash;1.16; I2 = 83.9%), and three cohort studies reported or adjusted value with the outcome for insomnia (OR = 1.20, 95%CI: 1.08\u0026ndash;1.32; I2 = 35.1%). Subgroup analysis indicates early morning awakening and composite insomnia were significant with hypertension.(29)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIsayeva et al.2020 showed that replacement of indapamide with amlodipine in antihypertensives significantly reduced the insomnia patient proportion. They mention that activation of sympathoadrenal system, associated anxiety and depression, increase markers of systemic inflammation may be the reason for insomnia in hypertensives. Study contained 120 hypertensive patients with and without insomnia. 60 were patients with insomnia. Study has 3 stages. First to establish relation between different antihypertensives and insomnia. Second and third prospective study whether change in antihypertensives improved insomnia proportion.(30)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGreen et al.2021 mentions that thyroid hormone levels are not markers of sleep dysfunction, but untreated thyroid dysfunction can hammer one attaining healthy sleep.(31)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAddanki et al.2024 shows that thyroid dysfunction and sleep disorders may have bidirectional relationship due to hormone dysregulation, metabolic abnormalities and symptomatic manifestations.(32)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWang et al.2023 found that decreased F.T3 levels is associated with increased duration of sleep only when patient sleep duration is less than 7 hours.(33)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChoudhary et al.2009 suggests negative relationship between sleep and respiratory diseases due to OSA, restless leg syndrome, sleep hypoventilation.(34)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBudhiraja et al.2015 mentions that COPD is often associated with sleep related problems and primary sleep abnormalities. COPD is associated with increased odds of insomnia 1.9(1.5-2.5) adjusted for age, gender(p\u0026lt;0.001). COPD has low sleep efficiency \u0026lt;82% than those without COPD (44%v 31%, p = 0.04).(35)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCespedes et al.2016 showed that decreased sleep quantity and quality has increased risk for diabetes in Hispanics/Latinos with greater odds for short sleep and insomnia. baseline data of sleep ,15227 participants obtained from the Hispanic Community Health Study/Study of Latinos (mean age 41; range 18\u0026ndash;74 years). In the population, 14% were diabetes, 28% were insomnia, 9% has short sleepers, and 19% has long sleepers. Compared with average sleep and no insomnia, those with short sleep and insomnia were more chance to have diabetes (odds ratio [OR] 1.46; 95% confidence interval [CI] 1.02, 2.11). Average sleepers with insomnia (1.28; 95% CI 1.02, 1.61) and long sleepers without insomnia (1.33; 95% CI 1.07, 1.65) also shows elevated odds of T2DM.(36)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBatool et al.2021 indicates \u0026ldquo;patients with type 2 diabetes\u0026rdquo; mellitus often has sleep abnormalities and poor sleep quality.260 \u0026ldquo;patients with type 2 diabetes\u0026rdquo; ,197(76%) female was in study. The mean age of sample 55.7\u0026plusmn;9.89 years, only 54(20.8%) have normal BMI. \u0026gt;50% were poor sleepers and educational status have strong relation with sleep quality(p\u0026lt;0.05).(37)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNarisawa et al.2017 indicates that T2 DM patients have sleep problems especially sleep maintenance. This study has 622 type-2 DM patients (mean 56.1\u0026plusmn;9.56 years) and 622 sex- and age-matched controls. 253 poor sleepers (43.9%) in the type-2 DM group as a result of dichotomization with the PSQI-J cutoff total score of 5.5. The type-2 DM group showed higher mean PSQI-J total score (P,0.01) and poorer sleep maintenance. (38)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOtaka et al.2019 found out that 154 (30.6%) exhibited probable insomnia among the 504 T2DM subjects. Adjusting for confounders, being female, living alone, high BMI and \u0026ldquo;high neuroticism\u0026rdquo; were significantly related with insomnia. Relationships between insomnia and HbA1c or lifestyle factors, such as smoking, drinking alcohol, or exercise frequency, were not found.(39)\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003e\u003cstrong\u003eSTUDY DESIGN\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCross-sectional study\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTUDY SETTING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in the Department of General Medicine and Endocrinology, Pushpagiri Institute of Medical sciences And Research Centre, Thiruvalla \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTUDY PERIOD\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne and 3/4 years(21 months) from ethics committee clearance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTUDY SAMPLE\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the out patients in Department of General Medicine and Endocrinology, inpatients from Department of General Medicine in the Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla during the period of study formed the study sample\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSAMPLE SIZE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn a study conducted by Otaka et al assessing the association between insomnia and personality traits among \u0026ldquo;patients with type 2 diabetes\u0026rdquo; mellitus, probable insomnia was observed in 30.6% of study subjects. Using this data, minimum sample size required for the current study is calculated using the formula\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" width=\"662\" height=\"286\"\u003e\u003c/p\u003e\n\u003cp\u003eHence this study will be conducted in a minimum of 218 Type 2 Diabetes mellitus patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eINCLUSION CRITERIA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAge: more than 18 years and less than 80 years \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;patients with type 2 diabetes\u0026rdquo; mellitus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEXCLUSION CRITERIA\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThose with \u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eType 2 diabetes mellitus with acute complications (hypoglycemia, DKA, DK, HHS)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSubstances or neuroleptic medications which affect sleep wake cycle (alcohol, narcotics)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePainful or chronically discomforting health conditions (cancers, stroke)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCritically ill patients\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePregnant patients \u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePsychiatric disorders\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eNot willing for study \u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eSAMPLING TECHNIQUE\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll consecutive patients based on the inclusion and exclusion criteria during the period of study was included in study until sample size is attained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTOOLS FOR DATA COLLECTION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterviewer administered Proforma\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: \u0026ldquo;Indian Insomnia Rating Scale- Questionnaire to diagnose Insomnia\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e1.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eHow often do you find difficulty in falling asleep?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eOnce a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2-4 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e4-7 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores-\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e2.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eHow often do you have difficulty in staying asleep at night?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eOnce a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2-4 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e4-7 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e3.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eHow often do you wake up very early in morning?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eOnce a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2-4 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e4-7 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e4.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eHow often do you sleep at night for less than six hours?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eOnce a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2-4 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e4-7 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e5.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eSince how long did you have sleep complaints?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNever\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eLess than 3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eGreater than 3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e6.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eHow Sleep affect quality of Life?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNot Affected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eModerately affected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eSeverely affected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e7.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eHow often sleep problem impairs your mood during the day-e.g., feeling irritable / distressed?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eOnce a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2-4 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e4-7 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e8.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eHow often because of the sleep problem, do you feel tired/fatigue during the day?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eOnce a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2-4 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e4-7 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e\u0026nbsp; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e9.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eHow often the sleep problem impairs your ability to concentrate, think \u0026amp; take decision?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eOnce a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2-4 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e4-7 days a week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e10.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eHow often do you use sleeping aids to fall asleep?\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003eOnce a month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003eOnce in a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003eMore than 3 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.22311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0899%;\"\u003e\n \u003cp\u003eScores\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3852%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7303%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8411%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable style=\"width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100.0000%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpretation of Scores\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTotal Score:\u003c/p\u003e\n \u003cp\u003e0-4: No Insomnia \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 11-20: Moderate Insomnia\u003c/p\u003e\n \u003cp\u003e5-10: Mild Insomnia \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 21-30: Severe Insomnia\u003c/p\u003e\u003cbr\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS OF DATA COLLECTION\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical history and clinical examination of the patient was collected for filling proforma and to find out if insomnia is present or not. FBS, PPBS, HbA1c of the patients as needed was collected from type 2 diabetes mellitus patients. Indian Insomnia Rating Scale questionnaire was used to diagnose and assess the severity of insomnia, its Malayalam version is verified by back translation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Criteria for diagnosis of Diabetes mellitus\u003c/strong\u003e(40)\u003c/p\u003e\n\u003ctable style=\"width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100.0000%;\"\u003e\n \u003cp\u003eFasting Plasma Glucose (FPG) \u0026ge; 126 mg/dL (7.0 mmol/L): Fasting is defined as no caloric intake for at least 8 hours.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;2-hour Plasma Glucose (2-h PG) \u0026ge; 200 mg/dL (11.1 mmol/L) during an Oral Glucose Tolerance Test (OGTT). The test should be performed according to the World Health Organization (WHO) guidelines, using a glucose load of 75 g anhydrous glucose dissolved in water.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A1C \u0026ge; 6.5% (48 mmol/mol). This test should be conducted in a laboratory using a method that is NGSP certified and standardized to the Diabetes Control and Complications Trial (DCCT) assay.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose \u0026ge; 200 mg/dL (11.1 mmol/L).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIn the absence of clear hyperglycemia, diagnosis requires two abnormal test results from the same sample or from two separate test samples.\u003c/em\u003e\u003c/p\u003e\u003cbr\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eDATA ANALYSIS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Data was properly coded and entered in Microsoft excel and was analyzed using statistical software SPSS Version 25.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePLAN OF ANALYSIS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative variables were summarized as percentages and for quantitative variables mean with standard deviation will be calculated. Incidence of insomnia among study subjects was expressed as percentage along with 95% confidence interval. Association of insomnia with qualitative variables was assessed using chi square test and with quantitative variables was assessed using t test. Non parametric tests were applied where ever applicable. Statistical significance was set at a p value \u0026lt;0.05.\u003c/p\u003e\n\u003ch3\u003eOUTCOME MEASUREMENTS\u003c/h3\u003e\n\u003cp\u003eThe incidence of insomnia in type 2 diabetes mellitus patients.\u003c/p\u003e\n\u003cp\u003eThe severity of insomnia in type 2 diabetes mellitus patients.\u003c/p\u003e\n\u003cp\u003eThe relationship between age, sex, FBS, PPBS or HbA1c levels, duration of diabetes with insomnia in type 2 diabetes mellitus patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEXPECTED OUTCOME\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is expected to yield data on the incidence and epidemiology of insomnia in type 2 diabetes mellitus patients in this part of south India. This will pave the way for understanding the commonly encountered but ignored problem of insomnia in diabetes patients, for the treating physician and help in retarding the complications of insomnia in these subsets of patients.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eDescriptive and Clinical Characteristics of the Study Participants\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.1:Mean Age Distribution\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"255\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.5294%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56.4706%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.5294%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56.4706%;\"\u003e\n \u003cp\u003e\u0026nbsp;56.74 \u0026plusmn; 10.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u0026nbsp;\u003cp\u003eThe mean age of the study participants is 56.74 years, with a standard deviation (SD) of 10.74 years.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.2:Percentage Distribution of Participants by Age Group\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"367\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 39.8907%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.9617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 39.8907%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 35\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.9617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 39.8907%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e35-45\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.9617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e26\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 39.8907%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e45-55\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.9617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e57\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e22.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 39.8907%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e55-65\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.9617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e99\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e39.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 39.8907%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge; 65\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.9617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.3:\u003c/strong\u003e \u003cstrong\u003eDistribution of Demographic, Health Conditions and Sleep Patterns in study participants\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e43.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e56.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eSemi-professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eClerical, Shop, Farm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eSkilled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eUnskilled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e43.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eRespiratory Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e92.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eCardiac Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e90.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eChronic Kidney Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e98.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eChronic Liver Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e98.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eOld disc Prolapse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e99.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eBenign Prostatic Hyperplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e98.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e49.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e50.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eHypothyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e19.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e80.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eHyperthyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e99.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePeripheral Neuropathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eSleep Onset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eIntact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e23.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eDisturbed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e76.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eSleep Maintenance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eIntact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e38.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eDisturbed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e61.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eEarly Awakening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThis dataset represents a study on the incidence of insomnia in \u0026ldquo;patients with type 2 diabetes\u0026rdquo; mellitus (T2DM). The sample consists of 250 individuals, with a slightly higher representation of females (56.4%) than males (43.6%). Occupational distribution shows that most participants belong to unskilled (43.2%) and skilled (22%) job categories. A significant proportion of patients suffer from hypertension (49.2%), Obstructive Sleep Apnea (34%), and peripheral neuropathy (20%), all of which can contribute to sleep disturbances. Other notable comorbidities include cardiac conditions (9.2%) and respiratory conditions (7.2%), which may also impact sleep quality. Chronic kidney disease (1.2%) and chronic liver disease (1.2%) are relatively rare in this population. Additionally, hypothyroidism is present in 19.6% of individuals, while hyperthyroidism is less common (0.8%). The data reveals a striking prevalence of sleep disturbances, with 76.4% experiencing difficulty initiating sleep and 61.6% struggling with sleep maintenance, although early awakening is reported less frequently (14%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Characteristics of Insomnia \u0026ldquo;patients with type 2 diabetes\u0026rdquo; Mellitus\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"351\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 93px;\"\u003e\n \u003cp\u003eINSOMNIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e40.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e59.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 93px;\"\u003e\n \u003cp\u003eType of Insomnia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e16.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e83.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSeverity of Insomnia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e49.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e44.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe data highlights the prevalence and characteristics of insomnia among \u0026ldquo;patients with type 2 diabetes\u0026rdquo; mellitus (T2DM). Insomnia is present in 40.4% of the study population, indicating a significant burden of sleep disturbances in these individuals. Among those with insomnia, the majority (83.17%) suffer from secondary insomnia, suggesting that underlying health conditions, including diabetes-related complications, may contribute to sleep disturbances. In terms of severity, nearly half (49.5%) experience mild insomnia, while 44.56% report moderate symptoms, and a smaller proportion (5.94%) suffer from severe insomnia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7: Characterization of Severity of Insomnia in Primary and Secondary Insomnia\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"488\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of Insomnia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 330px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTypes of Insomnia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e10 (58.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e40 (47.62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 158px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e5 (29.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e40 (47.62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 158px;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e2 (11.77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e4 (4.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 158px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e17\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e84\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe data compares the severity levels of insomnia between individuals with primary and secondary insomnia. Among those with primary insomnia, the majority (58.82%) experience mild symptoms, followed by 29.41% with moderate symptoms and 11.77% with severe symptoms. In contrast, individuals with secondary insomnia show a nearly equal distribution of mild (47.62%) and moderate (47.62%) cases, with only 4.76% experiencing severe symptoms. This suggests that while primary insomnia tends to have a higher proportion of mild cases, secondary insomnia has a more balanced distribution between mild and moderate levels, with fewer severe cases overall.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8: Percentage Distribution of Comorbidities Among Patients with Primary and Secondary Insomnia\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients with primary Insomnia (n=17)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 124px;\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e29.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHypothyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e17.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHyperthyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 493px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients with Secondary Insomnia (n=84)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"11\" style=\"width: 124px;\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eObstructive Sleep Apnea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e46.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003ePeripheral Neuropathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eRespiratory Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e13.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eCardiac Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e13.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eBenign Prostatic Hyperplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e3.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eChronic Kidney Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e2.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eChronic Liver Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e2.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eOld disc Prolapse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eAnaemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e2.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003ePost Stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003eOther Reasons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAmong patients with primary insomnia (n=17), the most common comorbidity was hypertension (29.41%), followed by hypothyroidism (17.65%), while no cases of hyperthyroidism were reported. In contrast, among patients with secondary insomnia (n=84), obstructive sleep apnea was the most prevalent comorbidity (46.43%), followed by peripheral neuropathy (25.00%), respiratory and cardiac conditions (both 13.09%), and benign prostatic hyperplasia (3.57%). Less common conditions included chronic kidney disease, chronic liver disease, and anaemia (each around 2.38%), while post-stroke and other reasons accounted for 1.2% each. No cases of old disc prolapse were observed. This suggests that secondary insomnia is often associated with multiple underlying health conditions, particularly respiratory and neurological disorders, whereas primary insomnia occurs more independently, with hypertension being a notable comorbidity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 9: Incidence of Sleep Disturbances in Insomnia and Non-Insomnia Patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"493\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep Disorders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsomnia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbsent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDisturbed sleep onset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e48 (47.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e143 (95.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDisturbed sleep maintenance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e25 (24.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e129 (86.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 258px;\"\u003e\n \u003cp\u003eEarly Awakening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e30 (29.70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5 (3.36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe data indicates a significant difference in sleep disturbances between individuals with and without insomnia. Among those with insomnia\u003cstrong\u003e, 47.52% experience difficulty falling asleep, 24.75% struggle with maintaining sleep,\u0026nbsp;\u003c/strong\u003eand\u003cstrong\u003e\u0026nbsp;29.70% wake up too early.\u0026nbsp;\u003c/strong\u003eIn contrast, sleep disturbances are even more prevalent among non-insomnia individuals, with\u003cstrong\u003e\u0026nbsp;95.97% having difficulty falling asleep, 86.58% experiencing trouble maintaining sleep,\u003c/strong\u003e and\u003cstrong\u003e\u0026nbsp;3.36% reporting early awakening.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 10: Incidence of Sleep Disturbances in Primary and Secondary Insomnia Patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"482\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" style=\"width: 239px;\"\u003e\n \u003cp\u003eSleep Disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 243px;\"\u003e\n \u003cp\u003eType of Insomnia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 239px;\"\u003e\n \u003cp\u003eDisturbed sleep onset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e5 (29.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e43 (51.19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 239px;\"\u003e\n \u003cp\u003eDisturbed sleep maintenance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e9 (52.94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e16 (19.05%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 239px;\"\u003e\n \u003cp\u003eEarly Awakening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e7 (41.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e23 (27.38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe data shows a comparison between primary and secondary insomnia concerning specific sleep disturbances. For disturbed sleep onset, secondary insomnia (51.19%) is more prevalent compared to primary insomnia (29.41%). When it comes to disturbed sleep maintenance, primary insomnia shows a higher percentage (52.94%) than secondary insomnia (19.05%). Early awakening is more common in primary insomnia, affecting 41.18% of individuals, while 27.38% of those with secondary insomnia experience this disturbance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 11:Association of Patient Characteristics with Insomnia using Chi- Square Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 257px;\"\u003e\n \u003cp\u003ePatient Characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eINSOMNIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003ePresent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e39 (35.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e70 (64.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.191\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e62 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e79 (56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.191\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eSemi-professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e14 (30.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e32 (69.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eClerical, Shop, Farm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e19 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e19 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eSkilled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e18 (32.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e37 (67.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eUnskilled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e49 (45.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e59 (54.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eSleep Onset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eIntact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e53 (89.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e6 (10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eDisturbed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e48 (25.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e143 (74.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eSleep Maintenance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eIntact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e76 (79.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e20 (20.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eDisturbed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e25 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e129 (83.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eEarly Awakening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e30 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e5 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e71 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e144 (67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe chi-square analysis reveals significant associations between sleep patterns and insomnia. Sleep onset disturbance (p = 0.000), sleep maintenance disturbance (p = 0.000), and early awakening (p = 0.000) are all strongly correlated with insomnia, indicating that individuals experiencing these disturbances are significantly more likely to have insomnia. While sex and occupation do not show statistically significant associations with insomnia (p = 0.191 for both), a higher proportion of females (44%) report insomnia compared to males (35.8%). Among occupations, the clerical, shop, and farm workers group show the highest proportion of insomnia (50%), whereas professionals report the lowest (33.3%). These findings suggest that sleep disturbances play a critical role in insomnia, whereas demographic factors such as sex and occupation may have a less pronounced impact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 12:Mann-Whitney U Test for the Association of Insomnia with Age Diabetes Duration, FBS, PPBS and HbA1C levels\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eINSOMNIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eMean Rank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eMann Whitney U\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eAsymptotic Significance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e135.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e6541.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e118.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eDM-Duration\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e140.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e5982.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e115.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eFBS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e116.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e5167.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.194\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e105.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003ePPBS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e125.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e4359.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e99.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eHbA1C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e125.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e4357.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e99.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe Mann-Whitney U test results compare various factors between individuals with and without insomnia. Age shows no statistically significant difference between the two groups (p = 0.079), suggesting that age does not strongly influence insomnia. However, diabetes duration (DM-Duration) is significantly higher in those with insomnia (p = 0.006), indicating a potential link between longer diabetes duration and sleep disturbances. Similarly, postprandial blood sugar (PPBS) and HbA1C levels are significantly higher in individuals with insomnia (both p = 0.002), suggesting poorer glycaemic control in those experiencing sleep issues. In contrast, fasting blood sugar (FBS) does not show a significant difference (p = 0.194), implying that fasting glucose levels alone may not be a key factor distinguishing those with and without insomnia. Overall, the findings suggest that longer diabetes duration and poor glycaemic control, particularly PPBS and HbA1C levels, are associated with insomnia in diabetic individuals.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTotally 250 T2DM patients were enrolled in the study and 56.4% were females.\u003c/p\u003e\n\u003cp\u003eA comparable female dominance was noted by Talwalkar et al and Batool et al.(18,37) \u003c/p\u003e\n\u003cp\u003eThe mean age of the study participants is 56.74 years, with a standard deviation (SD) of 10.74 years comparable to Talwalkar et al where the mean age was 55.5\u0026plusmn;10.87 years\u003csup\u003e.\u003c/sup\u003e(18)\u003c/p\u003e\n\n\u003cp\u003eIn this study 56.4% were females and 43.6% were males. It was similar in observation to Talwalkar et al where females were 50.9% and males were 49.1% ,whereas in Batool et al. female were the strong majority(76%).(18,37) In Zhang and et al males were predominant 52%. (16)\u003c/p\u003e\n\n\n\u003cp\u003eAge and sex showed no statistical difference between insomnia and non-insomnia groups. Where Zhang et al noted significant incidence of T2DM in the age-group 40-59 and in males.(16)\u003c/p\u003e\n\n\u003cp\u003eOccupational distribution in this study shows that most participants belong to unskilled (43.2%) and skilled (22%) job categories. As compared to Batool et al. it had majority of the patients were illiterate 146 (56.2%) while 38 (14.6%) were paid workers. (37)\u003c/p\u003e\n\n\u003cp\u003eIn this study a significant proportion of patients suffered from hypertension (49.2%), Obstructive Sleep Apnea (34%), and peripheral neuropathy (20%).Other notable comorbidities include cardiac conditions (9.2%) and respiratory conditions (7.2%).Chronic kidney disease (1.2%) and chronic liver disease (1.2%) are relatively rare in this population. Additionally, hypothyroidism is present in 19.6% of individuals, while hyperthyroidism is less common (0.8%). \u003c/p\u003e\n\n\u003cp\u003eThe data in this study reveals a striking prevalence of sleep disturbances, with 76.4% experiencing difficulty initiating sleep and 61.6% struggling with sleep maintenance, although early awakening is reported less frequently (14%).\u003c/p\u003e\n\n\n\u003cp\u003eIn this study the incidence of Insomnia in T2DM patients was 40.4%,with primary insomnia being 16.83% and secondary insomnia being 83.17%.Where Talwalkar et al found 53.4% with insomnia, Otaka et al showed 30.6% has insomnia, Batool et al with \u0026gt;50% insomnia and Narisawa et al with 43.9% insomnia in T2DM patients with different sample size and study characteristics.(18,37\u0026ndash;39)\u003c/p\u003e\n\n\u003cp\u003eIn this study, nearly half (49.5%) experience mild insomnia, while 44.56% report moderate symptoms, and a smaller proportion (5.94%) suffer from severe insomnia. Among those with primary insomnia, the majority (58.82%) experience mild symptoms, followed by 29.41% with moderate symptoms and 11.77% with severe symptoms. In contrast, individuals with secondary insomnia show a nearly equal distribution of mild (47.62%) and moderate (47.62%) cases, with only 4.76% experiencing severe symptoms.\u003c/p\u003e\n\n\n\n\u003cp\u003eIn this study those patients with primary insomnia have the most common comorbidity as hypertension (29.41%), followed by hypothyroidism (17.65%).In contrast, among patients with secondary insomnia, obstructive sleep apnea was the most prevalent comorbidity (46.43%), followed by peripheral neuropathy (25.00%), respiratory and cardiac conditions (both 13.09%), and benign prostatic hyperplasia (3.57%). Less common conditions included chronic kidney disease, chronic liver disease, and anaemia (each around 2.38%), while post-stroke and other reasons accounted for 1.2% each.\u003c/p\u003e\n\n\u003cp\u003eAmong those with insomnia, 47.52% experience difficulty falling asleep, 24.75% struggle with maintaining sleep, and 29.70% wake up too early. Where Talwalkar et al noticed that majority of the T2DM individuals with insomnia experienced sleep-related problems as delayed sleep onset (93.9%); sleep maintenance (93.4%); early morning awakening (89.5%) and insufficient total sleep duration (92.6%).(18)\u003c/p\u003e\n\n\u003cp\u003eIn this Study, for disturbed sleep onset, secondary insomnia (51.19%) is more prevalent compared to primary insomnia (29.41%). When it comes to disturbed sleep maintenance, primary insomnia shows a higher percentage (52.94%) than secondary insomnia (19.05%). Early awakening is more common in primary insomnia, affecting 41.18% of individuals, while 27.38% of those with secondary insomnia experience this disturbance.\u003c/p\u003e\n\n\u003cp\u003eThe duration of T2DM, PPBS and HbA1C levels showed significant association with the occurrence of Insomnia whereas Age, Sex, Occupation and FBS levels not. As opposed Zhang et al found significant association of incidence of T2DM in 40\u0026ndash;59-year age group and also in males.(16) Otaka et al found no association between insomnia and HbA1C levels, lifestyle factors such as exercise frequency. Whereas Batool et al found significant association between educational status and insomnia.(37,39)\u003c/p\u003e\n\n\u003cp\u003eIn contrast, this study found that sleep disturbances are even more common among individuals without insomnia, with 95.97% reporting difficulty falling asleep, 86.58% experiencing trouble maintaining sleep, and 3.36% experiencing early awakening. These findings highlight the need for increased awareness among healthcare professionals and patients regarding sleep issues. Such disturbances could potentially serve as an early indicator for uncontrolled blood sugar levels and may lead to the development of a more severe insomnia disorder in the future. It is crucial to emphasize the importance of addressing these concerns with the utmost care.\u003c/p\u003e\n\u003ch3\u003eLIMITATIONS AND RECOMMENDATIONS\u003c/h3\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThere\u0026nbsp;were\u0026nbsp;certain\u0026nbsp;limitations\u0026nbsp;to\u0026nbsp;our\u0026nbsp;study.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDuration\u0026nbsp;of\u0026nbsp;study\u003c/li\u003e\n \u003cli\u003eSingle\u0026nbsp;center\u0026nbsp;study\u003c/li\u003e\n \u003cli\u003eSample\u0026nbsp;size\u0026nbsp;studied.\u003c/li\u003e\n \u003cli\u003ePatient non-compliance in answering questions (smoking, alcohol) and reluctance in doing baseline investigations(fbs,ppbs,hba1c)\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003eRecommendations\u003c/h3\u003e\n\u003cp\u003eFurther multi-center control studies of similar nature with a large number of cases are needed in this regard to accurately estimate the incidence and impact of insomnia in type 2 diabetes mellitus patients and vice versa \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study found the increased incidence of insomnia in T2DM patients than general population. It also showed significant co-relation between higher HbA1C, PPBS levels and insomnia. Treating physicians should consider and treat insomnia in T2DM patients which may be the unknown factor responsible for uncontrolled blood sugars in these patients.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is a genuine pleasure to express my deep sense of gratitude to everyone who made completion of this dissertation possible.\u003c/p\u003e\n\u003cp\u003eI am extremely grateful for the God\u0026rsquo;s blessings throughout this work.\u003c/p\u003e\n\u003cp\u003eThis work would not have been possible without the expert guidance, constant motivation, timely advice, and whole-hearted support of my guide Dr. V Abraham Varghese, Professor of Department of General Medicine, to whom I am extremely grateful.\u003c/p\u003e\n\u003cp\u003eI would like to thank Dr. Sajit Varghese, Additional Professor, Department of General Medicine, my Co-Guide for the research topic, expert advice, continued support, and motivation.\u003c/p\u003e\n\u003cp\u003eI am thankful to Dr. C A Abdul Khader, HOD-Emeritus and Dr. Tomy Philip, current HOD for permitting me to utilize the facilities of the college and hospital for my study. I am also thankful to, Dr. Elsheba, Emeritus Professor Department of Community Medicine, for the timely help.\u003c/p\u003e\n\u003cp\u003eMy sincere thanks to Dr. Amal Dev Assistant Professor Department of Endocrinology, for his continued support, motivation and valuable suggestions provided during the preparation of this thesis.\u003c/p\u003e\n\u003cp\u003eI am truly indebted to, Dr. Rajeev Philip Professor \u0026amp; HOD Department of Endocrinology for his timely help and advice. \u003c/p\u003e\n\u003cp\u003eI sincerely thank Amala thomas and Ann Maria Sebastian, Biostatisticians, PIMS\u0026amp;RC, for helping me out with statistical analysis of this thesis work.\u003c/p\u003e\n\u003cp\u003eI would also like to thank my seniors, co-postgraduates, juniors, and nursing staffs of my department for their valuable support and encouragement throughout the study.\u003c/p\u003e\n\u003cp\u003eI also acknowledge the wholehearted support, encouragement and wise counseling given by my family in all times of need.\u003c/p\u003e\n\u003cp\u003eLast but not the least, let me thank all our patients for their participation and co- operation throughout the study. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKrystal AD, Prather AA, Ashbrook LH. 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American Academy of Sleep Medicine; 2015. p. 259\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eCespedes EM, Dudley KA, Sotres-Alvarez D, Zee PC, Daviglus ML, Shah NA, et al. Joint associations of insomnia and sleep duration with prevalent diabetes: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL). J Diabetes. 2016;8(3).\u003c/li\u003e\n\u003cli\u003eBatool SR, Hasan I, Dars JA, Batool R, Ahmed SM, Iqbal M. ASSESSMENT OF SLEEP QUALITY IN PATIENTS WITH TYPE 2 DIABETES MELLITUS:: A PROSPECTIVE OBSERVATIONAL STUDY FROM A TERTIARY CARE CENTRE. Pakistan Armed Forces Medical Journal. 2021;71(6).\u003c/li\u003e\n\u003cli\u003eNarisawa H, Komada Y, Miwa T, Shikuma J, Sakurai M, Odawara M, et al. Prevalence, symptomatic features, and factors associated with sleep disturbance/insomnia in Japanese patients with type-2 diabetes. Neuropsychiatr Dis Treat. 2017;13.\u003c/li\u003e\n\u003cli\u003eOtaka H, Murakami H, Nakayama H, Murabayashi M, Mizushiri S, Matsumura K, et al. Association between insomnia and personality traits among Japanese patients with type 2 diabetes mellitus. J Diabetes Investig. 2019 Mar 1;10(2):484\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eClassification and diagnosis of diabetes: Standards of medical care in diabetes-2021. Diabetes Care. 2021 Jan 1;44:S15\u0026ndash;33.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Pushpagiri Medical College","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"T2DM, INSOMNIA, IIRS, ADA","lastPublishedDoi":"10.21203/rs.3.rs-6443080/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6443080/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInsomnia refers to difficulty falling asleep or staying asleep, often resulting in poor sleep quality. Around 10% of the general population experience insomnia to the extent that it is considered a medical condition. Recently, insomnia has been recognized as a potential modifiable risk factor in the onset of type 2 diabetes (T2DM).\u003c/p\u003e\n\u003cp\u003eOBJECTIVES\u003c/p\u003e\n\u003cp\u003e(1) To estimate the incidence of insomnia in type 2 diabetes mellitus patients.\u003c/p\u003e\n\u003cp\u003e(2) To determine the correlation between demographic and clinical variables with the occurrence of insomnia in type 2 diabetes mellitus patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMATERIALS AND METHODS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was done at a tertiary care center in Thiruvalla from 2022-2025 period. Convenience sampling was used to study 250 patients attending the hospital for consultation. A predesigned proforma was used to collect details and history, IIRS to diagnose insomnia, ADA criteria for T2DM were used.Data was analyzed using statistical software SPSS Version 25.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study in 250 T2DM individuals had higher representation of females (56.4%) than males (43.6%). Occupational distribution shows majority belongs to unskilled (43.2%) and skilled (22%) categories. A significant proportion of individuals suffer from hypertension (49.2%), OSA (34%), and peripheral neuropathy (20%). Hypothyroidism is present in 19.6% and hyperthyroidism in 0.8% patients. The Incidence of Insomnia is 40.4% in the study population with secondary insomnia (83.17%) being more common than Primary insomnia (16.83%). Among those with insomnia, 47.52% experience difficulty falling asleep, 24.75% struggle with maintaining sleep, and 29.70% wake up too early. \u0026nbsp;The duration of T2DM (p= 0.006), PPBS and HbA1C levels (p=0.002 for both) show significant association with the occurrence of Insomnia and Age(p=0.079), Sex and Occupation (p= 0.191 for both) and FBS(p=0.194) levels not.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study of 250 T2DM patients, the incidence of insomnia (40.4%) found to be higher than in general population.56.4% were females and 43.6% were males. Secondary insomnia (83.17%) found to be more common than Primary insomnia (16.83%) in insomnia patients. The duration of T2DM, PPBS and HbA1C levels show significant association with the occurrence of Insomnia and Age, Sex, Occupation and FBS levels not.\u003c/p\u003e","manuscriptTitle":"Incidence of Insomnia in Type 2 Diabetes Mellitus patients in a Tertiary Care Centre in Southern Kerala","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-17 04:31:10","doi":"10.21203/rs.3.rs-6443080/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2f70a7fa-5c55-4b85-bb4e-f0488ffebce7","owner":[],"postedDate":"April 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":47286399,"name":"Endocrinology \u0026 Metabolism"}],"tags":[],"updatedAt":"2025-04-17T04:31:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-17 04:31:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6443080","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6443080","identity":"rs-6443080","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}