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Fig. 2. Multilevel mediation model to examine the relationship between sleep quality and BG mean and self-regulation failures and self-care behaviors as sequential multiple mediators. Within-person effect and between-person effect were examined simultaneously. Figure reports un- standardized coefficients with standard errors in parentheses and the 95% confidence intervals (CI) in brackets. *p < .05,
**
p < .01,
***
p < .001
ann. behav. med. (2020) 54:249–257 255

existed within-persons rather than between persons, which could account for the results found here. Such results provide caution in interpreting studies that rely on individual difference measures of these constructs as reflective of daily processes as well. Future research is needed, however, to examine the time course of these processes at the daily level assessing sleep quality after rising and self-regulation failures, self-care behaviors, and BG levels throughout the day to capture how self-regulation failures may disrupt self-care behaviors and BG sequentially by utilizing ecological momentary assessment.
The results of the current study must be interpreted in the context of limitations. First, data were mainly self-report with the exception of blood glucose levels provided by glucometer. Future research would benefit from objective measures of sleep. For example, participants can wear an actigraph device, which objectively monitors sleepover the study period to give additional insights into how other metrics of sleep, such as sleep duration, sleep disturbances, and obstructive sleep apnea [
39
] relate to diabetes outcomes [
40
]. Actigraphy monitors are noninvasive, portable, and easy to wear for extended periods of time and are uniquely suited to capture night-to-night variability in sleep in persons with TD simultaneously in an ecologically valid context (i.e., the persons with TD homes) [
41
,
42
]. In addition, participants completed the daily diary in the evening about the previous night’s sleep quality and that day self-regulation failures, self-care behaviors. Thus, the measurement of daily sleep quality maybe more affected by retrospective bias than those of self-regula- tion failures and/or self-care behaviors. Furthermore, we examined self-regulation failures in the context of BG monitoring. Future research is needed to examine daily self-regulation failures in the context of other behaviors, such as diet and exercise. The fact that the results held after controlling for factors such as CGM use, which may reduce the self-regulatory demands associated with TD may indicate that our measure of self-regulation failures is capturing self-regulation beyond behaviors associated with monitoring BG. Consistent with this idea, our measure of self-regulation failures has been related with broader measures of executive functioning in our work with adolescents These findings hold some useful clinical implications. Such process-oriented investigations between daily sleep quality and daily diabetes outcomes hold the potential to identify targets for prevention and intervention efforts to optimize daily sleep quality among persons with TD. Clinicians should assess sleep quality and duration and provide counsel about sleep hygiene, strategies to manage dietary self-care when tired, and address insulin adjustments and/or behaviors that may help to minimize overnight hypo- and hyperglycemia. In particular, among persons with TD who have sleep disorders, daily sleep quality can be monitored by clinicians or physicians using telemedicine, which is the delivery of healthcare services via virtual visits without an in-person visit. That is, clinicians or physicians and persons with TD can share information about sleep quality in real time by telephone or via the Internet and can potentially help persons with TD adhere to recommended treatment in an efficient and timely manner
[
43
]. Improvements in daily sleep quality may provide important reductions in self-regulatory failures, better self-care, and lower BG levels In conclusion, this study provides a window into the importance of daily sleep quality of adults with TD, as well as an illustration of self-regulation as an important underlying mechanism linking sleep quality to diabetes outcomes. More conclusive study is needed while addressing the limitations of our study. This study may encourage future research to identify daily antecedent factors that affect daily sleep quality of persons with TD. This study also may provide a foundation for future longitudinal research on persons with TD to examine the underlying physiological mechanisms of these associations as well.

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