Morning hyperglycemia, so high blood sugar in the morning, is a relatively difficult problem to interpret. Usually, when you come for regular check-ups, you determine your morning blood sugar. It is not unusual to be annoyed that you have high blood sugar, although you feel pretty good, not thirsty, do not urinate too much.
Why is my blood sugar high in the morning?
- Taking too little insulin in the evening. In these types of situations of repeated hyperglycemia at 24 o’clock, at 3 o’clock at night, and in the morning are high. Increased thirst during the night and frequent urination. The urine is light in color. What do we need to do? We increase the dose of insulin in the evening progressively, by 2-4 IU, and thus the morning glycemia is normalized; however, this needs to be discussed with your doctor and you need to follow your doctor’s advice
- Taking too much insulin in the evening. Blood glucose at 3 o’clock at night is low below 40-60 mg%, and the body defends itself by secreting counterregulatory hormones, which mobilize glucose reserves in the liver, then force the liver to produce glucose from lipids and proteins, but do not stop when the blood sugar is within range. This is called the Somogyi effect. There is also the possibility that feeling hypoglycemic during the night increases the need to consume more sugar than necessary and then you will have high blood sugar in the morning. What do we need to do? You will gradually decrease the evening dose by 2-3-4 units. When you have hypoglycemia at night, get up with headaches, dizziness. If you still feel hypoglycemia at night, take only 2 teaspoons of sugar;
- Insulin with too short an action in the evening. Your body may react in particular to certain types of insulin. instead of covering 12-10 hours, the action may disappear at 9-10 hours. Blood glucose at 24 and 3 o’clock is normal, but blood sugar rises in the morning; What do we need to do? Replace intermediate-stage insulin with a longer-acting insulin or take a fast-acting insulin (Humulin R or Actrapid HM) in the evening and an intermediate-acting insulin (Humulin N, Insulatard) or a long-acting insulin (21-22). Humulin L), or a long-acting insulin analogue (Lantus, Detemir); again, changing the treatment plan should only be made in concurrence with your doctor
- Dawn phenomenon (dawn). There are a large number of patients whose insulin requirements increase in the morning (4-8 hours). But insulin is absorbed relatively constantly, unable to cover this increased need. Blood glucose at 23 and 3.00 is normal, and morning blood sugar is high. If the evening insulin dose is increased, hypoglycemia occurs at night. The situation could be solved only by the insulin pump, by increasing the basal insulin between 4-8 in the morning, depending on the levels of blood sugar.
- Increased consumption of carbs does not influence too much morning blood sugar;
- In case of infections, intense and prolonged stress can lead to high blood glucose in the morning, but also during the day, resolved by temporarily increasing insulin doses.
So a high blood sugar in the morning is a complex situation and you need to discuss it with your doctor, in order to make the right decision.
The Somogyi phenomenon
The Somogyi phenomenon is a disputed interpretation for the rise in blood sugar in the morning. Also called the Somogyi effect or posthypoglycemic hyperglycemia, the phenomenon is described as high blood sugar in response to hypoglycemia. When blood glucose levels are controlled by insulin injections, this effect occurs in patients with hyperglycemia as a result of an overabundance of insulin at night.
The phenomenon was named after Professor Michael Somogyi, who prepared the first insulin treatment given to a child with diabetes in 1922 in the USA. Somogyi has shown that excess insulin destabilizes the diabetic.
The phenomenon is actually less common than the Dawn phenomenon, which is an abnormal increase in blood sugar in the morning due to natural changes in hormones.
What causes the Somogyi phenomenon?
The main causes of the Somogyi phenomenon are insulin in excess or given at the wrong time or the absence of evening meals.
Unawareness of hypoglycemic episodes due to hyperglycemia can lead to metabolic imbalance and hypoglycemic complications.
Although no frequency data is available, the Somogyi phenomenon is probably rare. It occurs in type 1 diabetes and less frequently in type 2 diabetes.
If recognized and treated correctly, the prognosis of the Somogyi phenomenon is excellent with no complications in the long-term.
How the mechanism works
The body’s ability to suppress insulin release is an important physiological response that people with insulin-dependent diabetes cannot develop.
Defense against hypoglycemia involves counterregulatory hormones, which stimulate gluconeogenesis and glycogenolysis and counteract the anabolic effects of insulin. This mechanism is dependent on a glucose-sensitive system in the brain, pancreas, and associated nerves.
Counterregulatory hormones include the following:
- glucagon acts on the liver to stimulate glycogenolysis and gluconeogenesis and is probably the first and most important hormone in the Somogyi phenomenon
- adrenaline increases nutrient intake in the periphery, decreases insulin release, stimulates glucagon release, inhibits glucose utilization in certain tissues, and stimulates the alarm system through sweating, anxiety, and tachycardia
- cortisol can help in prolonged and severe cases of the Somogyi phenomenon by blocking glucose utilization and stimulating hepatic glucose release
- Growth hormones are similar to cortisol.
Studies have sparked controversy over the importance of counterregulatory hormones in mediating glycemic rebound. Hypoinsulinemia (absence of an insulin dose), insulin resistance and hypersensitivity to the effects of counter-hormones may also play a role.
A person with type 1 diabetes needs to balance their insulin intake to control their blood sugar. Occasionally, insufficient insulin may cause hyperglycemia. The appropriate answer is to take a corrective dose of insulin to reduce your blood sugar and reconsider adjusting your insulin regimen to release extra insulin to prevent hyperglycemia. Conversely, excessive insulin release may cause hypoglycaemia. The correct answer is to treat hypoglycemia and consider adjusting the regimen to reduce insulin in the future.
Somogyi argued that untreated prolonged hypoglycemia causes a hyperglycemic rebound due to hypoglycemic stress. The physiological mechanism that triggers the rebound is a defensive one. When blood sugar drops below normal, the body responds by releasing the hormone glucagon as well as the stress hormones adrenaline, cortisol, and growth hormones. Glucagon facilitates the release of glucose from the liver by immediately increasing blood sugar, and stress hormones lead to insulin resistance for several hours supporting increased blood sugar.
Signs and symptoms
Patients with Somogyi’s phenomenon have excessive morning hyperglycemia compared to normal blood glucose control. Nocturnal hypoglycemia is asymptomatic or not felt due to sleep, and posthypoglycemic hyperglycemia is not considered or is confused with the Dawn phenomenon.
The most common cause of morning hyperglycemia is hypoinsulinemia. Patients have an increased need for insulin in the morning especially due to the release of growth hormone, which antagonizes the action of insulin. Cortisol may have a supporting role.
Patients may experience hypoinsulinemia due to absorption or incorrect doses of insulin given the night before. The phenomenon develops as the need for insulin increases (Dawn phenomenon) and causes a rapid rise in blood sugar at 4-8 in the morning. The phenomenon is found in both people with type 1 or 2 diabetes.
The Somogyi phenomenon is identified by performing: fasting blood sugar,
nocturnal blood glucose test, A1C, and the usual blood sugar tests.
In the case of Dawn, the body releases hormones that cause the liver to release glucose during sleep. If there is not enough insulin in the body to counteract this, then the blood glucose level rises during the night, resulting in high blood sugar in the morning.
How do we make a difference between Dawn and Somogyi?
The only way to distinguish the two phenomena is to test your blood sugar at night. Wake up several nights in a row, between 2:00 and 3:00, and check your blood sugar. If at that time its value is below 70 mg/dl, it could be the Somogyi effect.
If it is within normal or high limits, then the Dawn phenomenon may be to blame. A more convenient option may be to use a continuous glucose monitoring (CGM) device or a small device that measures blood sugar in real-time, 24 hours a day.
How can we treat the Dawn effect?
To counteract hyperglycemia in the morning, there are two important steps you should take:
If you are being treated with insulin, monitor your blood sugar before bed. If it is too low, for example, less than 100 mg/dl, you may need a snack before bedtime that contains more protein than carbohydrates. You could eat some nuts or cheese.
Keep a diary of medications, food, and blood sugar for a few days so you can deduce a pattern of how your body reacts.
This information is extremely useful in trying to find out what is happening and the doctor can use it to make changes in the treatment schedule, in the recommended insulin doses, the time of administration of the drugs, the exercise regime, or the meal plan.
Tips to combat the Dawn phenomenon
If Dawn causes your blood sugar to rise during the morning, consider these additional tips:
- Eat dinner earlier, thus avoiding carbohydrates late at night.
- Exercising in the evening can help keep your blood sugar levels in a better range.
- Have breakfast, even if your blood sugar is high. Consumption of food at breakfast will effectively stop the process of the Dawn phenomenon and will allow the glycemia to return to normal.
Talk to your doctor. You may need to adjust the time you take your medicine or the type of medicine you are taking. Never adjust the medication or treatment plan without consulting your doctor!