IS YOUR MORNING GLUCOSE TOO HIGH?

Rise & Shine: How to lower morning highs. Allison Nimlos. Find out why blood glucose can rise overnight and how to manage it.; Why they happen and what to do about them.     E ver head to bed with a respectable blood glucose reading only to wake up with a fasting level that's unexpectedly high? With no food in your system for several hours, you might wonder what could cause a blood glucose rise of 20, 30, even 50 points or more. The answer is likely the dawn effectwhen an increase in hormone levels during the early morning hours causes a surge in blood sugar. The body naturally produces a bit of glucose around the clock. It's one of the reasons people on insulin need a long-acting, or basal, insulin. But in the early hours, usually between 4 and 8 a.m., that glucose production goes into overdrive. The hormones cortisol, glucagon, and epinephrine are highest in early morning. They cause the liver to produce glucose and also cause insulin resistance, which spikes blood sugar. About half of people with type 1 and type 2 diabetes experience morning highs. Overnight blood sugar levels can have a big effect on your A1C because you can spend six to eight hours of your day above your target blood glucose range. If your A1C is above target and your fasting blood sugar is higher than your bedtime blood sugar, you're probably experiencing the dawn effect. Morning Highs in Early Type 2 For people in the early years of type 2 diabetes, the hormones that control blood sugar can be particularly unbalanced. Here's what happens during sleep to a person with type 2 diabetes: "Overnight, the liver and muscles get the message from excess glucagon to ramp up the glucose supply because the person is sleeping, not eating, and needs glucose from stored sources like the liver," says pharmacist Marty Irons, R.Ph., CDE, a member of the Diabetic Living advisory board. "There is not enough of the incretins, insulin, or amylin hormones to stem the tide of excess glucose from the liver and muscles, essentially throwing this feedback loop out of whack. High fasting blood sugar levels, particularly in the earlier years of type 2 diabetes, result from this hormonal imbalance that drives the production of glucose from the liver and less so from the muscles. Evening meals and snacks often get the blame for morning highs, but hormones are the likely cause. If you're on a non-insulin medication Metformin works by reducing the amount of glucose produced by the liver, and it's likely going to be the best defense against the dawn phenomenon. But if your morning blood sugar is still too high, your A1C is lingering above the American Diabetes Association recommended guideline for most adults of 7 percent, and you're taking the maximum dose of metformin (2,000 milligrams a day), talk to your health care provider. Research has shown that adding a basal insulin, either Levemir or Lantus, is your best option because oral medications and other injectable medications don't adequately lower fasting blood sugar. Increasing some oral medications, like sulfonylureas (glipizide and glyburide), may cause low blood sugar later in the day. Incretins (Byetta and Victoza) work mostly on postmeal blood sugars, so increasing those doses also may not have much impact first thing in the morning. Being physically active in the afternoon or evening may be another trick to lower early morning blood sugar. Exercise increases your body's sensitivity to glucose, and the effect on your blood glucose can be long-reaching, even 1218 hours later. If you use an Insulin pump One of the biggest benefits to using an insulin pump is the ability to change your basal rates or background insulin doses throughout the day. Increasing your basal rate just before your dawn phenomenon begins prevents those blood sugar excursions. How do you know when you need a different basal rate to manage the dawn effect? Doing several overnight basal rate tests can help you determine your needs. After eating dinner at least four hours before bed, Smith suggests checking blood sugar at bedtime and then twice overnight, around 3 a.m. and 5 a.m., to see if and when your blood sugar starts to rise. A continuous glucose monitor, or CGM, also can help in this instance. Ask your health care provider if a loaner is available to try. If you take Multiple daily injections Basal insulin (Lantus or Levemir) is a 24-hour peakless insulin. While it can keep blood sugar stable for most of the day, people experiencing the dawn effect may need an extra boost to get them through the 24 hours. Incorporating a midrange long-acting insulin, such as NPH or N, may provide a peak of insulin at the right time to keep the dawn phenomenon at bay. "By taking NPH or N at night, you can expect it to peak within six to eight hours," Smith says. "If you take it at 10 p.m., it will peak around 4 a.m., possibly when the dawn phenomenon is going to kick in. The use of NPH and N fell out of favor for many years after 24-hour basal insulins became available, but they are starting to make a comeback. Try a snack before bed A small bedtime snack containing some carbohydrate, but no more than 20 grams, may help you wake up with better fasting blood glucose. A bedtime snack shortens the time span that the liver is in overdrive producing glucose while you sleep.  Recommended tasty treats: Low-fat yogurt One serving of tortilla chips and fresh salsa Frozen grapes Edamame (soybeans) and hummus Small piece of fruit