Specialist article on sleep and metabolism
Diabetes, sleep and breathingWhat the night has to do with blood sugar
Blood sugar is regulated not only during the day but also at night. Here you will learn what studies show about lack of sleep, sleep apnoea and diabetes, what treating sleep apnoea changes in blood sugar, and why, in our view, breathing, swallowing and head balance are among the levers for a calm night.
Does this sound familiar?
Blood sugar is an issue, and your nights are restless?
What applies to you?
Tap whatever applies to you.
If several points apply, it is worth taking a look at your nights. Sleep and breathing during sleep are more closely linked to glucose metabolism than many people think. The treatment of diabetes remains the responsibility of your practice. What is in your hands is the pattern with which you breathe, swallow and hold your head.
Sleep apnoea and diabetesWhat has been tested and what has notThe key points at a glance
- In studies, lack of sleep and disturbed deep sleep reduce insulin sensitivity in healthy people, after just a few nights.
- Obstructive sleep apnoea and type 2 diabetes often occur together. Whether CPAP treatment lowers long-term blood sugar remains open according to the large studies.
- In our view, the chain of a restless night usually begins with the basic functions of breathing, swallowing and head balance. A stable basis of these functions is the best starting point for any metabolic disease. The training has not been studied for blood sugar itself, and it does not replace the treatment of diabetes.
Video
Diabetes: what exercise, oxygen and breathing have to do with metabolism
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Fundamentals
Diabetes in brief: insulin, sugar and the cells
Before we turn to sleep and breathing, it is worth taking a brief look at what gets out of step in metabolism with diabetes.
Every cell obtains energy from grape sugar, glucose. For it to get from the blood into muscle, liver and fat cells, the hormone insulin from the pancreas is needed. In diabetes mellitus, commonly known as sugar disease, too much sugar remains in the blood. In the long term, this puts a strain on blood vessels, nerves, eyes and kidneys.
This article is about type 2 diabetes. It develops slowly, and many factors play a part: diet, exercise, body weight, age and predisposition.
One factor is often overlooked: sleep. Whether you sleep calmly and deeply at night or whether your breathing repeatedly stalls leaves traces in your metabolism. These traces can be measured.
Sleep and metabolism
Sleep and blood sugar: the night plays its part
Sleep is not a break for the metabolism. In deep sleep, the body readjusts hormones and the nervous system, and this also affects how it handles sugar.
At the University of Chicago, eleven healthy young men were allowed to spend only four hours in bed for six nights. Afterwards, they processed sugar less well than after six nights of ample sleep. The stress hormone cortisol was higher in the evening, and the sympathetic nervous system, the activating part of the nervous system, was working harder1.
with four hours in bed each were enough to measurably worsen sugar utilisation in young, healthy men1
less sleep, and yet insulin sensitivity fell markedly when only deep sleep was selectively disrupted2
of later type 2 diabetes was found in people with difficulty staying asleep, in an analysis of 10 studies with 107,756 people3
The second tile comes from a particularly precise experiment. The same research group selectively disrupted deep sleep at night in healthy adults without shortening sleep duration. Insulin sensitivity fell, and the more deep sleep was lost, the greater the fall2.
So it is not only how long you sleep that counts, but also how undisturbed your sleep is.
Blood sugar is regulated at night, too.Anyone talking about metabolism should therefore ask about sleep, and about breathing during sleep.
Sleep apnoea
Diabetes and sleep apnoea: often a pair
One of the most common reasons for fragmented sleep is obstructive sleep apnoea. The throat repeatedly collapses during sleep, and breathing stalls.
In obstructive sleep apnoea, the upper airway narrows so much during sleep that the airflow decreases or stops for seconds. The brain responds with a brief arousal, and breathing resumes, often with a loud snore. This can happen many times an hour without you noticing. How this comes about is explained in our article on snoring and sleep apnoea.
of 306 people with overweight and type 2 diabetes had sleep apnoea, measured during sleep, in a US study. In just over half of them it was moderate or severe4
for new type 2 diabetes was found in people with moderate to severe sleep apnoea, in an analysis of six long-term studies5
The connection probably runs in both directions. Sleep apnoea can put a strain on sugar metabolism. Conversely, long-standing diabetes can damage nerves, including those that control breathing and reflexes in the throat, and so favour disordered breathing during sleep6. The International Diabetes Federation therefore advises professionals always to think of the other condition when one is present7.
If you have diabetes and snore loudly, or someone has noticed pauses in your breathing, mention it at your practice. A measurement during sleep, at home or in a sleep laboratory, shows whether sleep apnoea is present and how pronounced it is.
Explanatory model
What happens in the body during breathing pauses
How can a disturbance in the throat affect blood sugar? Research mainly describes two pathways: intermittent oxygen deficiency and fragmented sleep.
The airway narrows
During sleep the throat gives way, and the airflow decreases or stops.
Oxygen falls
Oxygen saturation in the blood falls, and carbon dioxide rises.
The brain raises the alarm
A brief arousal reopens the airway. Deep sleep is interrupted.
The stress system kicks in
Pulse, blood pressure and the activating sympathetic nervous system rise, night after night, many times over.
Metabolism responds
The cells respond less well to insulin, and sugar stays in the blood for longer.
A research group at Johns Hopkins University recreated the second and fourth steps in the laboratory. Thirteen healthy volunteers, while awake, breathed air with intermittently lowered oxygen for five hours. Afterwards, their insulin sensitivity was lower than on a comparison day, and heart rate variability showed a predominance of the sympathetic nervous system8.
Like a night shift with constant alarms
Imagine a night shift in which an alarm goes off every few minutes. Each time you jump up, your pulse races, then you lie down again. In the morning you have been in bed, but you are not rested. The body experiences a night with many breathing pauses in a similar way, and the next day your metabolism works under stress conditions.
This does not mean that sleep apnoea causes diabetes. Diet, weight, exercise and predisposition remain the major factors. But the night is often overlooked.
Research
CPAP and blood sugar: what the studies show
If sleep apnoea puts a strain on metabolism, treating it ought to improve blood sugar. It is not quite that simple.
CPAP therapy keeps the throat open during sleep with slight positive pressure via a mask. It is the standard for moderate and severe sleep apnoea and reliably prevents breathing pauses as long as the device is worn. Whether it also lowers long-term blood sugar was examined in two randomised studies in 2016.
International study, 298 people
- Type 2 diabetes, relatively well controlled, newly detected sleep apnoea
- Six months of CPAP or usual care
- No difference in long-term blood sugar HbA1c, even with regular use9
- Less daytime tiredness, better quality of life
Spanish study, 50 people
- Type 2 diabetes, not optimally controlled, sleep apnoea
- Six months of CPAP or no CPAP, diabetes medication unchanged
- HbA1c fell more in the CPAP group than in the comparison group10
- Insulin resistance and inflammatory markers improved
A review from Chicago describes the results on blood sugar as contradictory and sees one reason in how regularly the device is actually worn6. In our view, there is a second point. CPAP supports the airway from the outside as long as the mask is in place. It does not change the pattern that lets the throat collapse during sleep.
The image of the crutch
A crutch takes the load off an injured leg and is important during that time. The bone itself has to do the healing. That is how we see CPAP and other aids. They take work off the body as long as they are worn. They do not train the control of the airway.
If you use a CPAP device or a splint for sleep apnoea, never stop using it on your own initiative. Whether and when anything about the treatment can change is decided by your sleep medicine specialist on the basis of a follow-up measurement. Training the basic functions can be combined with ongoing treatment.
Function instead of symptom
Where the chain begins: breathing, swallowing and head balance
Sleep apnoea and snoring are at the end of a chain. In our view, it usually begins with the basic functions, long before the first breathing pauses occur.
Breathing
With loosely closed lips and nasal breathing, a slight negative pressure develops in the mouth, which holds the tongue against the palate. If you breathe through your mouth, you lose this hold, and the lower jaw sinks back more easily during sleep.
Swallowing
Many hundreds to a thousand times a day, the tongue rests against the palate when you swallow. Each swallow integrates the tongue, soft palate and pharynx into one sequence. The starting point is the tongue reference position.
Head balance
When the head is balanced over the body, the space in the throat remains wide. If it moves forward, in our view the tension and width of the upper airways change.
These three functions do not work separately, but as one pattern, which we call the triadic functional circuit. If it deviates from the reference order, for example through mouth breathing, a low-lying tongue or a forward head posture, the body compensates. The nervous system stores this compensation as a preferred pattern.
Muscles that are not involved in their function are not used and lose tension. In the throat, in our view, this means that the tissue gives way more easily during sleep.
The pattern deviates
Mouth breathing, low-lying tongue, disturbed head balance, often since childhood.
The body compensates
The nervous system stores the compensation, and it runs automatically.
The tissue changes
The throat loses tension and becomes narrower during sleep.
Complaints arise
Snoring, breathing pauses, restless nights. When and how severely depends on extent, duration and age.
There is also a second route. Nasal breathing brings nitric oxide from the paranasal sinuses into the air we breathe13. In diabetes, the availability of this messenger substance at the vessel wall is often reduced. If you follow this logic, the conclusion suggests itself that the form of breathing is not irrelevant for metabolism. This has not been studied for blood sugar, but in our view it is plausible and testable.
According to Dr. Berndsen’s model, there is a third route via the vagus nerve. It connects the control centres for breathing and swallowing in the brainstem with the stomach, intestine and pancreas, and already during eating it triggers an initial insulin release via this route. Whether an orderly swallowing pattern thereby helps determine glucose metabolism has not been studied. It is a model, not a substitute for antidiabetic medication, and it does not change anything about your prescribed diabetes therapy.
Context
The basic functions as an adjusting screw for the night
What does this mean for people with diabetes? It does not mean that training treats diabetes. It means that the night is a factor you can work on yourself.
Our explanatory model links two elements. The first is well documented: disturbed sleep and breathing pauses put a strain on sugar metabolism. The second is our approach: in our view, a stable pattern of breathing, swallowing and head balance is the prerequisite for an airway that stays open during sleep. Whether both elements together change blood sugar has not been investigated by anyone.
with 120 adults were analysed by researchers from Stanford on myofunctional therapy for sleep apnoea, that is, exercises for the tongue, palate and throat11
was the average reduction in breathing pauses per hour in the adults in these studies; snoring and daytime sleepiness decreased11
These studies do not examine the FaceFormer, but other exercise programmes, and they do not measure blood sugar. They do show, however, that the tension of the upper airways can be influenced by active training. The authors see the exercises as a complement to other treatments11, and that is how we understand the training too.
Which statement fits this article?
Honest evidence
What has been tested and what has not
With a condition like diabetes, what counts is clarity about what is known and what is merely assumed.
Well documented
- Lack of sleep and disturbed deep sleep reduce insulin sensitivity
- Sleep apnoea is common in type 2 diabetes
- Intermittent oxygen deficiency puts a strain on sugar metabolism
- Exercises for the upper airways can reduce breathing pauses
Not investigated
- Whether FaceFormer training changes blood sugar or HbA1c
- Whether nasal breathing influences glucose metabolism via nitric oxide
- Whether it affects the need for diabetes medication
- Whether it reduces breathing pauses in people with diabetes
- How large a possible effect via sleep would be
The absence of a study does not mean that the connection does not exist. It means that it has not been tested.That is why, with regard to blood sugar, we explain our model and say openly where it has not yet been tested.
Your practice treats the diabetes; the training does not replace any therapy. In our view, a stable basis of breathing, swallowing and head balance is the best starting point for any metabolic disease, because sleep, the airway and stress regulation build on it. There is no study on blood sugar itself; for sleep as a lever, there are the studies above. Reports from individual users about changed blood sugar values are individual observations, not systematically recorded.
If you use insulin or tablets that lower blood sugar, never change the dose on your own. Any change in everyday life, such as more exercise or different sleep, can shift your levels. Discuss changes with your practice or your diabetes team. What the overall body of research on the FaceFormer shows can be found on our page Studies and science.
Training
Training the pattern: breathing, swallowing and head balance
A breathing pattern does not change through a resolution. It is a stored sequence, and that changes through repetition.
In FaceFormer training, the FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. In the basic exercise, you close your lips around the lip wedge, the tip of your tongue rests on the small ridge behind the upper front teeth, and your head is balanced upright. You bite down briefly and swallow. In this way you practise lip closure, nasal breathing, the tongue reference position, the act of swallowing and head balance in one sequence.
From around week 6, the breathing exercise is added. You breathe in through your nose for about six seconds, pause briefly, bite down and swallow, and then breathe out for six seconds.
Slow, calm nasal breathing engages the calming part of the nervous system. Our article on the vagus nerve explains more about this. You extend the breathing pause in small steps, only as far as feels comfortable.
- From day 1
Basic exercise
A few minutes three times a day with the FaceFormer ZERO; you increase the repetitions week by week.
- After 2 to 3 weeks
The night is added
Once the basic exercise is established, you also wear the ZERO at night, as a complement to daytime training, not as a replacement.
- After a few weeks
Switching to the ONE
During the day, you train with the FaceFormer ONE. It is the same size and shape as the ZERO, just made of firmer material.
- From around week 6
Breathing exercise
The breathing exercise combines the training with calm nasal breathing and breathing pauses that become longer over time.
- Over 6 to 12 months
The pattern runs by itself
The exercise manual allows six to twelve months until the new sequences run without thinking, even during sleep, followed by maintenance training.
The free FaceFormer app guides you through the basic exercises, and you can find all modules on the exercise pages. Wearing it only at night is not enough; the FaceFormer is a training device, not a passive support.
Safety
Limits and safety: when to consult first
The FaceFormer is a non-invasive Class I medical device made of medical-grade silicone. Some situations nevertheless call for patience or a consultation beforehand.
Sleep apnoea
If obstructive sleep apnoea has been diagnosed, you train alongside medical treatment, not instead of it.
Acute inflammation
Let inflammation in the mouth, throat or airways and a completely blocked nose subside first.
Recent surgery
After procedures in the mouth and in the case of an acute jaw joint lock with severe pain, only after consultation.
Neuromuscular disease
In degenerative diseases such as ALS, advanced Parkinson’s or bulbar palsy, only after medical consultation.
At the start, many users report muscle fatigue, pressure on the teeth or, after long-standing mouth breathing, irritated mucous membranes. At night, the device falls out more often at first. In that case, take a short break and continue with fewer repetitions or the softer ZERO.
The training replaces neither diabetes treatment nor the treatment of sleep apnoea. Never stop prescribed medication, insulin, CPAP or a splint on your own initiative. How the training can be combined with other therapies is described on the page FaceFormer and other treatments.
Everyday life
What you can do yourself for sleep and metabolism
The best-documented lever in type 2 diabetes lies in everyday life.
fewer new cases of diabetes occurred in a large US study of 3,234 people with elevated blood sugar levels when they lost weight and exercised for at least 150 minutes a week12
Exercise first
Regular exercise improves insulin sensitivity. Even brisk walking counts, ideally spread over the week.
Plan enough sleep
Give your sleep fixed times and enough hours. Studies show that both short and disturbed sleep are associated with a higher risk of diabetes.
Take snoring seriously
Loud snoring and observed breathing pauses are a reason to discuss a measurement during sleep, especially if you have diabetes.
Lips closed, nose open
Your lips rest lightly together, the tip of your tongue at the reference point. This keeps the oral cavity sealed, and the air takes the route through the nose by itself.
No mouth tape
We do not recommend taping your mouth shut at night. Tape closes the lips mechanically; it does not change the pattern. More on this in the article on mouth taping.
Keep what has been prescribed
Medication, insulin and CPAP stay as prescribed. Discuss any changes with your practice.
Questions
Frequently asked
Are diabetes and sleep apnoea connected?
Yes, they often occur together. In a US study, over 86 % of people with excess weight and type 2 diabetes had sleep apnoea. Long-term studies also show that moderate to severe sleep apnoea is associated with a higher risk of later developing type 2 diabetes. The connection probably runs in both directions.
Can lack of sleep raise blood sugar?
In studies, just one week with four hours of sleep per night worsened glucose utilisation in healthy young men. Even people who sleep for the same length of time but get hardly any deep sleep respond less well to insulin. How strongly this affects your values in an individual case depends on many other factors.
Does CPAP lower blood sugar?
The results are contradictory. A large international study found no difference in long-term blood sugar after six months, whereas a smaller Spanish study in people with poorer glucose control did. CPAP remains the standard for moderate and severe sleep apnoea because it reliably prevents breathing pauses for as long as it is worn.
Does FaceFormer training help with diabetes?
Your practice treats the diabetes; the training does not replace any therapy. In our view, a stable basis of breathing, swallowing and head balance is the best starting point for any metabolic disease, because sleep, the airway and stress regulation build on it. There is no study on blood sugar itself. Studies do show, however, that disturbed sleep puts a strain on glucose metabolism and that the upper airways can be trained.
Can I use the FaceFormer if I have diabetes?
Diabetes alone is not a reason against the training. At the beginning, watch out for pressure points in the mouth and take a break if the mucous membrane is irritated. In the case of acute inflammation, recent procedures in the mouth or degenerative neuromuscular diseases, consult a doctor beforehand. Do not change your diabetes medication on your own.
What can I do myself with type 2 diabetes?
The best evidence is for exercise and a healthier body weight. In a large study of people with elevated blood sugar levels, such a lifestyle programme reduced the number of new cases of diabetes by 58 %. Add to that enough calm sleep and, if you snore loudly, an assessment for sleep apnoea.
More articles from the knowledge section
Where to go next
Sources
- Spiegel K, Leproult R, Van Cauter E (1999). Impact of sleep debt on metabolic and endocrine function. The Lancet 354(9188):1435-1439. PMID 10543671. Source
- Tasali E, Leproult R, Ehrmann DA, Van Cauter E (2008). Slow-wave sleep and the risk of type 2 diabetes in humans. Proceedings of the National Academy of Sciences USA 105(3):1044-1049. PMID 18172212. Source
- Cappuccio FP, D’Elia L, Strazzullo P, Miller MA (2010). Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis. Diabetes Care 33(2):414-420. PMID 19910503. Source
- Foster GD, Sanders MH, Millman R et al., Sleep AHEAD Research Group (2009). Obstructive sleep apnea among obese patients with type 2 diabetes. Diabetes Care 32(6):1017-1019. PMID 19279303. Source
- Wang X, Bi Y, Zhang Q, Pan F (2013). Obstructive sleep apnoea and the risk of type 2 diabetes: a meta-analysis of prospective cohort studies. Respirology 18(1):140-146. PMID 22988888. Source
- Reutrakul S, Mokhlesi B (2017). Obstructive Sleep Apnea and Diabetes: A State of the Art Review. Chest 152(5):1070-1086. PMID 28527878. Source
- Shaw JE, Punjabi NM, Wilding JP, Alberti KG, Zimmet PZ; International Diabetes Federation Taskforce on Epidemiology and Prevention (2008). Sleep-disordered breathing and type 2 diabetes. Diabetes Research and Clinical Practice 81(1):2-12. PMID 18544448. Source
- Louis M, Punjabi NM (2009). Effects of acute intermittent hypoxia on glucose metabolism in awake healthy volunteers. Journal of Applied Physiology 106(5):1538-1544. PMID 19265062. Source
- Shaw JE, Punjabi NM, Naughton MT et al. (2016). The Effect of Treatment of Obstructive Sleep Apnea on Glycemic Control in Type 2 Diabetes. American Journal of Respiratory and Critical Care Medicine 194(4):486-492. PMID 26926656. Source
- Martínez-Cerón E, Barquiel B, Bezos AM et al. (2016). Effect of Continuous Positive Airway Pressure on Glycemic Control in Patients with Obstructive Sleep Apnea and Type 2 Diabetes. A Randomized Clinical Trial. American Journal of Respiratory and Critical Care Medicine 194(4):476-485. PMID 26910598. Source
- Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, Kushida CA (2015). Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Sleep 38(5):669-675. PMID 25348130. Source
- Knowler WC, Barrett-Connor E, Fowler SE et al., Diabetes Prevention Program Research Group (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine 346(6):393-403. PMID 11832527. Source
- Lundberg JO, Farkas-Szallasi T, Weitzberg E, Rinder J, Lidholm J, Anggård A, Hökfelt T, Lundberg JM, Alving K (1995). High nitric oxide production in human paranasal sinuses. Nature Medicine 1(4):370-373. PMID 7585069. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
