The key goal of medicine should be to seek the most elegant solution to solve an imbalance of any kind. This thinking precisely reflects Occam’s razor’s assertion that the most simple way of explaining an issue should be the favoured option. Modern medicine is moving in the very opposite direction. With more complex and convoluted explanations, therapeutics and procedures about how and why disease occurs, there is a tendency to believe that simple solutions simply cannot bring about large changes.

I find myself more and more disengaged with the ever more elaborate ways in which textbooks and medical authorities alike are attempting to elucidate the underpinnings of disease. More often than not, these conversations and explanations proceed without the slightest of mentions regarding the world of context that surrounds the development and progression of disease states. Why not approach disease firstly by addressing the foundations of health, and then gradually seek more complex solutions as these contextually significant aspects of health (such as sleep and breathing mechanics) are remedied?


Consider the following scenario:

An individual, slightly overweight in a 9-5 office job. While not in the very best of health, they do their best to eat well and exercise. One month, their work gets very busy as they and their team prepare for a big pitch meeting. To compose a task of such importance, they rely more on coffee than they would normally to get through the long days. Once home, they can’t switch off and, still fuelled by the caffeine coursing through their veins, have great trouble sleeping over the next few weeks. Their sleep is restricted, and their water intake throughout the day is displaced by coffee. They then attend a routine check in with their family doctor that was booked months in advance. A blood draw was made and their fasting insulin and other relevant markers used for the diagnosis (HbA1c) are elevated. The doctor recommends a statin drug to remedy the high blood sugars and assures them that they will remain on this drug for the rest of their life.

 

Were they truely diabetic, or just extremely over-tired and under-hydrated?

Many publications have outlined the relationship between transient sleep-deprivation, dehydration and their effects on blood sugar and insulin levels. Sleep disruption in the form of obstructive sleep apnoea (OSA) has also been strongly associated with the development of type 2 diabetes (T2D) as well as cardiovascular disease[1]. OSA also leads to chronic mouth-breathing, further impacting on hydration through vasopressin and loss of moisture through over-breathing  [2][3] . Should addressing these simple abnormalities be the first steps in attending to insulin resistance and high blood sugars in patients? I would suggest that not only would it be the cheapest, most accessible and long-lasting, but also far more effective for not just diabetic symptoms, but for all aspects of health simultaneously.


Sleep, Breathing and Diabetes:

One of the most brilliant examples of these ideas was demonstrated in a lovely study that demonstrated that mere loss of sleep can induce a diabetic condition [4]. Simply restricting sleep in healthy men for a single week induced a diabetic condition. This has huge implications as these men would have been considered metabolically healthy at the onset of the study. A mere week where the men were only allowed 5 hours of sleep per night rendered them in a diabetic condition. Most of us would no doubt know someone who brags about continually living off this amount of sleep, sometimes for years on end.
While the cause and effect relationship of OSA and diabetes has not been established in the literature, I am not opposed to going out on a limb and saying that it is quite clear that chronic OSA causes T2D. The evidence appears far too strong to reach any other conclusion [5]. During OSA, the individual is knocked out of sleep sometimes over 100 times each night, severely disrupting the cycling nature of sleep patterns. This generated chronic hypoxia (oxygen deprivation) as well as chronic sleep deprivation, both of which have demonstrated a powerful effect in modulating diabetic symptoms [6][7].


The Dehydration Connection:

Most people simply do not consume enough water to stay hydrated on a daily basis. Thirst is often misinterpreted as hunger, and in a vein attempt to hydrate, people habitually eat to mask the body’s cry for water [8]. To make things worse, consumption of diuretic substances (agents that promote water excretion) such as tea, coffee and blood pressure medications are at an all time high. Even beyond this, chronic mouth-breathing is becoming more common, leading to even greater water loss through the breath (particularly while sleeping). This perfect storm of sleep deprivation leading to an increased intake of diuretics, leading to further dehydration is likely to be a significant contributor to the diabetes epidemic.
It is well known that dehydration indirectly effects blood sugars via its influence on copeptin and vasopressin [9]. As these molecule’s regulation is heavily reliant on hydration, it is not hard to conceptualise that chronic dehydration (from various sources) can lead to elevated vasopressin levels, resulting in chronically elevated blood sugar/T2D [10][11].

While this is an oversimplified summary (and purposefully so), it highlights the basic biochemistry of how sleep and hydration play enormous roles in metabolic health. Attending to these aspects of health first may prove to be a much more sustainable, powerful and cost-effective approaches to treating and maintaining metabolic health. Establishing adequate rest and hydration are not invasive or even difficult to prioritise in most cases. This should be standard of care for those presenting with diabetic or pre-diabetic symptoms and bloodwork; well before medication is considered.

I am scared to thing about how many times a scenario such as the one I outlined above has actually occurred, resulting in the prescription of diabetic medication; likely in the absence of any conversation surrounding the sleeping, breathing and drinking habits of the individual. Hopefully this information is more widely recognised and utilised by practitioners who are seeking lasting positive change with their patients.


References
:

  1. https://erj.ersjournals.com/content/49/4/1700179.full
  2. https://pubmed.ncbi.nlm.nih.gov/12169769/
  3. https://pubmed.ncbi.nlm.nih.gov/21035477/
  4. https://diabetes.diabetesjournals.org/content/59/9/2126
  5. https://pubmed.ncbi.nlm.nih.gov/25145320/
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3220834/pdf/2551.pdf
  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5099401/
  8. Your Body’s Many Cries For Water: You’re Not Sick, You’re Thirsty
  9. https://pubmed.ncbi.nlm.nih.gov/20439785/
  10. https://pubmed.ncbi.nlm.nih.gov/3886209/
  11. https://www.karger.com/Article/Fulltext/488304

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