Discussion on Dawn Phenomenon

As a person with type 2 diabetes, the following does affect me, but most of the time I have avoided it with adjustments to my insulin.  The biggest aid has been splitting my long acting insulin into two doses per the doctors instructions.

 

The dawn phenomenon is a normal, natural rise in blood sugar that occurs in the early morning hours, between roughly 4 and 8 a.m. The shift in blood sugar levels happens as a result of hormonal changes in the body.

 

All people experience the dawn phenomenon to one level or another, which can vary day by day. People without diabetes may never notice it happening, as a normal body's insulin response adjusts for the rise without intervention.

 

A person with diabetes is more likely to experience symptoms from the rise in blood sugar levels, however.

 

How does it affect people with diabetes?

Dawn phenomenon is a normal rise in blood sugar released by the liver. The release happens as the person's body is preparing to wake for the day.

 

The rise in blood sugar is normally handled with insulin. For people with diabetes, insulin is not produced in high enough quantities, or the body is unable to use the insulin properly.

 

As a result, a person with diabetes will feel the effects of having high sugar levels in the blood.

 

These effects can include: faintness, nausea, vomiting, weakness, disorientation, feeling tired, and extreme thirst.

 

Managing the dawn phenomenon

Managing blood sugar levels is nothing new to most people with diabetes. A combination of diet, exercise, and medication often help keep the symptoms and problems under control.

 

In the case of dawn phenomenon, there are some additional changes that may help prevent issues caused by the spike in blood sugar.

 

Some steps people with diabetes can take to manage the dawn phenomenon include:

•   changing medication entirely or making adjustments with a doctor on existing medication

•   avoiding skipping meals or medication doses

•   avoiding carbohydrates around bedtime

•   taking medication closer to bedtime and not at dinner time

Other steps include eating dinner earlier in the evening. After dinner, some light physical activity, such as going for a walk, jogging, or yoga, is encouraged.

It is likely that a person with diabetes will experience high morning blood sugar levels from time to time. Occasional, mild issues from dawn phenomenon are not too worrisome. However, if the frequency becomes much more regular, then it's time to call a doctor.

Complications

If blood sugar levels spike too high as a result of dawn phenomenon, the effects can range from mild to a life-threatening medical emergency.

Some complications that a person with diabetes may experience as a result of dawn phenomenon include:

•   nerve damage

•   damage to blood vessels

•   organ damage

•   ketoacidosis, an extremely dangerous buildup of acid in the bloodstream

People who experience repeated high blood sugar levels due to dawn phenomenon should see a doctor to prevent these consequences.

Do options differ between type 1 and type 2 diabetes?

Differences in dealing with dawn phenomenon depends more on the individual person than what type of diabetes they have or what their treatment plan is.

A person with type 1 diabetes may adjust the dosage or type of insulin to account for any changes overnight. In other cases where the person wears an insulin pump, they may adjust the pump to deliver extra insulin in the morning.

Dawn Phenomenon Affects Up to Half T2DM

This was a bit of a shock for me when I read that approximately half of type 2 diabetes patients are affected by the dawn phenomenon. I knew that there had to be a large number by what I read on many of the diabetes forums, but half was even larger that I had guessed. No wonder this is such a problem and concern for type 2 patients.

The study by Louis Monnier, MD, from University Montpellier, France, and colleagues reveals that the dawn phenomenon has a significant impact and is present in some patients treated by diet alone. This effect is not prevented by oral diabetes medications. The dawn phenomenon refers to a spontaneous rise in blood glucose that occurs at the end of the night in patients with type 2 diabetes. This does not occur in individuals without diabetes, because endogenously produced insulin prevents this.

The one medication that does prevent this is insulin (Lantus or Levemir) when given at bedtime. In patients whose HbA1c is approaching 7% that are demonstrating evidence of the dawn phenomenon, insulin use should be considered earlier than it is traditionally, because insulin can eliminate this effect.

"We have defined the frequency of the dawn phenomenon in type 2 diabetes, which in the present paper occurs in around 50% of patients, and this definition is more accurate than previous ones due to our use of continuous glucose monitoring [CGM] systems," Dr. Monnier told Medscape Medical News.

Dr. Monnier agrees with Geremia B Bolli, MD, from the University of Perugia, Italy, that the new findings indicate that insulin use should be considered earlier for type 2 diabetes patients showing evidence of the dawn phenomenon. Presently doctors are unable to control the dawn phenomenon with the current array of oral hypoglycemic agents, even though metformin is probably the one that has the highest potency for reducing it. Currently insulin should be considered for the treatment of type 2 diabetes as soon as the HbA1c becomes greater than 7% when patients are already treated with maximal tolerated doses of oral agents.

Dr. Bolli states, “This new research confirms that the dawn phenomenon is a common occurrence among type 2 diabetes patients, independent of oral therapy and in a real-world setting. The work also reaffirms what should be a primary objective of type 2 diabetes therapy, he says, that is, treatment of the dawn phenomenon — the normalizing of blood sugar around breakfast time. I think if A1c is greater than 7.0% and the postprandial blood glucose is okay, one has to work on the fasting blood glucose, and the best approach is basal insulin in the evening."

My advice to patients is to talk to your doctor if you are having problems with the dawn phenomenon to prevent problems of hyperglycemia in the morning. Be careful, but don't let your doctor put you off, as this is important in your management of diabetes.

David Mendosa has posted an excellent blog here about the dreaded dawn phenomenon. He covers the same study, but has more background for your reading.