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kaz044
Conclusion This study provides a process account of the importance of daily sleep quality of adults with TD, as well as one potential mechanism—self-regulation—
that may explain the effect of sleep quality on diabetes outcomes.
Keywords Blood glucose ∙ Daily diary ∙ Self-care behaviors Self-regulation ∙ Sleep ∙ Quality ∙ Type 1 diabetes
Type 1 diabetes (TD) is a chronic autoimmune disorder in which a person’s pancreas stops producing insulin. The goal of daily management is to mimic a functioning pancreas [
1
,
2
] by engaging in a complex daily self-regula- tion process that requires checking blood glucose (BG) levels, injecting insulin, monitoring diet and exercise, and adjusting insulin based on these activities [
3
]. Such self- care behaviors are related to numerous self-regulatory factors in late adolescents, including one’s daily sleep quality, as well as one’s ability to regulate one’s cogni- tions, emotions, and behaviors [
4–6
]. Sleep in adults with TD has not been well studied in relation to self-regula- tory factors.
Sleep, a process that restores the body’s ability to self-
regulate, maybe one important factor affecting self-care behaviors [
7–9
]. It has been well established that sleep is important for glycemic control, because sleep issues may adversely affect insulin sensitivity, disease progression, and development of complications [
10
,
11
]. However, the majority of diabetes-related sleep studies have been conducted with people with type 2 diabetes
[
12–14
], with comparatively few researchers focusing on
Eunjin Lee Tracy eunjin.lee@psych.utah.edu
1 Department of Psychology, University of Utah, Salt Lake City, UT 84112 2 College of Nursing, University of Utah, Salt Lake City, UT
84112 3 Department of Psychology, Carnegie Mellon University, Pittsburgh, PA 15213 ann. behav. med. (2020) 54:249–257
DOI: 10.1093/abm/kaz044

sleep for adults with TD [
15
,
16
]. In addition, previous diabetes-related sleep studies predominantly focus on the between-person (interindividual) effects of sleep quality
[
12–14
]. Fewer studies have focused on both within- person (intraindividual) and between-person variability predicting diabetes outcomes [
17
]. Sleep quality and diabetes outcomes (i.e., self-care behaviors and BG levels) are likely to vary on a daily basis. Therefore, the present study addressed these limitations of previous research by examining within-person and between-person associations of daily sleep quality with daily diabetes outcomes among adults with T1D.
Sleep quality, an individual’s overall perceived satisfaction with sleep [
18
], is essential for metabolic health
[
19
,
20
], yet little attention has been focused on the benefits of sleep as a potential variable in improving self- care and subsequent BG levels in persons with TD. Unfortunately, persons with TD experience unique barriers to good sleep quality as a result of the symptoms
(e.g., hyperglycemia, hypoglycemia, glucose variability) and management of TD [
21
]. Persons with TD are generally more likely to report sleep issues than individuals without TD [
22
]. In one study, 35% of persons with TD reported poor subjective sleep quality compared with 20% of participants without TD [
11
]. Furthermore, persons with TD face substantially higher risk for obstructive sleep apnea (17.2%) than those without TD
(5.15%) [
22
]. These sleep issues among persons with TD may adversely affect the development of complications, and diabetes-related stress experiences [
11
,
19
]. Insulin sensitivity has been shown to diminish after only a single night of partial sleep restriction compared to a night of normal sleep duration [
10
]. In 2017, the American Diabetes Association Standards of Medical Care in Diabetes established new recommendations to evaluate sleep patterns and sleep duration while evaluating how well persons with TD adhere to their medication regimens and routine sleep assessment recommendations continues presently The link between sleep quality and diabetes outcomes such as blood glucose and self-care behaviors may occur by sleep altering daily self-regulation (Turner SL, unpublished data. Self-regulation is conceptualized as the modulation of emotions, behaviors, and cognitions toward a particular goal [
25
,
26
]. In this study, we focused on self-regulation failures, which are defined as failures in self-regulation involving cognitive, behavioral, and emotional control in the context of monitoring blood glucose levels. Poorer sleep is associated with a range of self-regulation failures including memory failures, failures to initiate a behavior and motivate to engage in a behavior [
27
]. Persons with TD must manage competing demands on their time and resources to complete diabetes management tasks [
1
,
8
]. Poor sleep quality may disrupt one’s ability to regulate emotions, cognitions, and behaviors. Self-regulation failures may further disrupt daily diabetes-related self-care behaviors, which are themselves self-regulatory in nature [
26
]. The relation between sleep and self-regulation failures is especially important for persons with TD because self-regulation failures are important in diabetes-related self-care behaviors such as remembering to check blood glucose levels, initiating behaviors to address hypo- and hyperglycemia, such as injecting insulin and monitoring diet and exercise
[
3
]. Thus, poor sleep quality may affect daily blood glucose levels through daily self-regulation failures, which impedes the person’s ability to engage in self-care behaviors, leading to poor blood glucose This study examined potential underlying within- person and between-person mechanisms between sleep quality and diabetes outcomes (self-care behaviors and BG levels) by focusing on the mediating role of self-regulation failures. Persons with TD completed a day diary that assessed their daily sleep quality, self-regulation failures, self-care behaviors, and BG levels. First, we examined whether sleep quality of persons with TD affected self-care behaviors in terms of daily variability (within-person effects, or deviation from one’s average across the 14 days) and average effects
(between-person effects, averaged across the 14 days [
28
]) and then explored the potential mediating role of daily self-regulation failures in these relations. We hypothesized that better sleep quality would be associated with higher self-care behavior at both the daily and average levels. We also hypothesized that better sleep quality would be associated with fewer self-regulation failures at both the daily and average levels and that fewer self-regulation failures would explain the link of better sleep quality to better self-care. Then, we examined whether better sleep quality was associated with BG levels at both the daily and average levels and explored the potential, sequential mediating roles of self-regulation failures and self-care behaviors on the relation between daily sleep quality and daily BG levels at both the daily and average levels. We hypothesized that better sleep quality would be associated with healthier/better BG levels and that this association would be explained by lower self-regulation failures and better diabetes self-care behavior at both the daily and average levels.

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