Understanding the Somogyi effect and dawn phenomenon

Diabetes nurse educator, Christine Manga, explains the causes behind elevated fasting blood glucose readings in the morning: Somogyi effect and dawn phenomenon.


Both the Somogyi effect and dawn phenomenon will lead to elevated fasting blood glucose (glucose level after an overnight fast) readings in the morning. The target for fasting blood glucose levels is <= 7mmol/L. This said, the causes are very different.

Dawn phenomenon

The dawn phenomenon occurs in everyone. However, people without diabetes will not notice it because their body is able to counteract the effects. It is caused by natural body changes during sleep.

During the night, less insulin is produced and in the early hours of the morning, hormones, such as cortisol, growth hormone, epinephrine and glucagon, are all released. These hormones all act in the opposite way to insulin, resulting in elevated blood glucose levels.

Towards the early hours of the morning, the body releases stored glucose from the liver into the bloodstream to provide energy for the coming day. This will cause a further rise in blood glucose levels. According to the American Diabetes Association, the dawn phenomenon occurs between 5:00am – 8:00am. The dawn phenomenon is a natural phenomenon.

Somogyi effect

The Somogyi effect is usually management related and is a rebound hyperglycaemia (high blood glucose). It happens in response to a nocturnal hypoglycaemia (low blood glucose).

This hypoglycaemia can be caused by giving too much insulin at night, not having an evening snack, or from doing vigorous exercise in the evening hours. In response to the hypo, the body releases hormones to raise the blood glucose levels. These include cortisol, growth hormone, glucagon and adrenaline. When you wake, you will have elevated fasting blood glucose level.

So, which one do you have: Somogyi effect and dawn phenomenon?

Due to the causes being different, the management will also differ. To establish what is causing your elevated fasting reading, you will need to do some extra blood glucose testing.

Testing your blood glucose levels between 2:00am – 3:00am on a few consecutive nights will give you an answer. If you are experiencing hypos at this time of night, then you are experiencing the Somogyi effect.

If on the other hand, your blood glucose levels are normal at this time, then you are experiencing the dawn phenomenon.

The use of continuous glucose monitoring (CGM) would be extremely useful in detecting the cause of your elevated blood glucose readings. CGM is now becoming more affordable, but definitely is still not cheap. Speak to your doctor about wearing a sensor to assist you in making management decisions.

Prevention

Dawn phenomenon

To prevent the dawn phenomenon, you could:

  • Increase the amount of vigorous physical exercise in the evening hours.
  • Wear an insulin pump to administer extra insulin in the early morning hours. This would work well.
  • Reduce the amount of carbs and evening snacks.
  • Change insulin formulations to more concentrated ones. This can lead to improved fasting blood glucose levels.
  • Administer insulin later at night. This may also be beneficial.
  • There may be a need to change some of your diabetes medications, or possibly even add more.

Somogyi effect

Here are ways to prevent the Somogyi effect from occurring:

  • Reduce the amount of insulin given in the evening.
  • Once again, changing your insulin to a stronger concentration can prevent nocturnal hypos.
  • Giving the insulin earlier may also prove helpful.
  • Getting assistance with carb counting will help you to match the amount of insulin to the amount of carbs you eat, preventing overdosing of insulin.
  • Your doctor may need to assess your medication and reduce, or discontinue some.
  • Try to reduce the amount of vigorous physical activity in the evening.
  • It may also be necessary to have an evening snack before bedtime. The down side to this is that it may cause long-term weight gain.

The most important thing is that you know which one, the dawn phenomenon or the Somogyi effect, is causing your elevated fasting readings. You can only manage what you know.

eating time budget

MEET OUR EXPERT


Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.


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Understanding the steps to diabetes self-management

We explore ways to help you learn and implement self-management practices.


The diagnosis of diabetes

If you or a loved one have just been diagnosed with diabetes, you may be feeling an overwhelming amount of mixed emotions. Diabetes is a complex and serious condition, and living with it every day can be challenging1. Part of that challenge is due to the fact that the management of diabetes will largely rest in your hands. This can be daunting. Be kind to yourself and remember that small positive steps every day will make a difference in the long run.

Getting started with self-management

Ideally, on diagnosis, you should have access to a team of healthcare professionals. This may include the treating doctor, a diabetes educator or coach, and possibly a dietitian.

However, in many cases you might only have access to a doctor and your time spent with him or her in consultation will be limited.

In the beginning, you may feel overloaded with information about what to eat, how much to exercise, when to take your medicine, how to test as well as confusing terminology, such as HbA1c, hyperglycaemia, hypoglycaemia, glycaemic control etc.

To help make sense of it all, diabetes educators have developed some key areas to focus on1:

  1. Healthy eating

Having diabetes does not mean you must give up your favourite foods. Over time and through experience, you’ll learn how the foods you eat affect your blood sugar. You should eat regular meals and make food choices that will help control your diabetes better1.

Work with a dietitian or diabetes educator to develop a healthy, balanced eating plan that suits your lifestyle. Remember that it is okay to treat yourself once in a while. You can also visit the Accu-Chek website and download the Accu-Chek portion plate which will give you some practical tips on healthy eating.

  1. Being active

Guidelines for the management of Type 2 diabetes refer to studies that have proven that regular physical activity significantly improves blood sugar control, reduces cardiovascular risk factors, and may reduce chronic medication dosages2. Regular physical activity may also improve symptoms of depression and improve health-related quality of life2. Try to include a combination of cardio and resistance training into your weekly exercise routine.

  1. Self-monitoring of blood glucose (SMBG)

The International Diabetes Federation (IDF) recommends SMBG as an effective means for patients with diabetes to understand more about their condition and the influence of events – such as exercise, stress, food and medication – on blood sugar levels3.

However, for SMBG to be effective, it’s recommended that you practice structured testing using a tool, such as the Accu-Chek 360 3-Day Profile Tool3 which can be found on www.accu-chek.co.za

Structured testing is testing at the right times, in the right situations, and frequently enough to generate useful information3. Always agree with your doctor or diabetes educator what your individual structured SMBG testing plan is.

Another aspect you should discuss with your doctor will be your target range for your blood sugar levels. In the beginning, understanding this range and what is considered out of range may be confusing, so you may want to make use of a meter such as the Accu-Chek Instant Meter which offers a support tool called the target range indicator (TRI)4.

A study done on the TRI showed that 94% of study participants were able to easily interpret their blood sugar values through the use of the target range indicator4. Furthermore, 94% felt that the support tool will help them discuss their blood sugar values with their doctor4.

  1. Taking medication

You may need to take medication to help keep your blood sugar (glucose) level steady. Diabetes can increase your risk for other health conditions, such as heart or kidney related problems, so you may need to take medicine to help with those too1.

  1. Problem solving

When you have diabetes, you learn to plan ahead to be sure you maintain blood sugar levels as much as possible within your target range goals – not too high, not too low.

As we know, things don’t always go according to plan and a stressful day at the office or an unexpected illness can send your blood sugar in the wrong direction. Days like this will happen from time to time. Here are some tips to cope1:

  • Don’t beat yourself up – managing your diabetes doesn’t mean being perfect.
  • Analyse your day and think about what was different and learn from it.
  • Discuss possible solutions. This can be with your doctor, your diabetes educator or even a face-to-face or online diabetes support group. Try joining some of the online diabetes communities out there, such as the Accu-Chek Facebook page which has over 148 000 members. You can join the conversation at AccuChekSubSahara.

Understanding the steps to diabetes self-management

We explore ways to help you learn and implement self-management practices.


The diagnosis of diabetes

If you or a loved one have just been diagnosed with diabetes, you may be feeling an overwhelming amount of mixed emotions. Diabetes is a complex and serious condition, and living with it every day can be challenging1. Part of that challenge is due to the fact that the management of diabetes will largely rest in your hands. This can be daunting. Be kind to yourself and remember that small positive steps every day will make a difference in the long run.

Getting started with self-management

Ideally, on diagnosis, you should have access to a team of healthcare professionals. This may include the treating doctor, a diabetes educator or coach, and possibly a dietitian.

However, in many cases you might only have access to a doctor and your time spent with him or her in consultation will be limited.

In the beginning, you may feel overloaded with information about what to eat, how much to exercise, when to take your medicine, how to test as well as confusing terminology, such as HbA1c, hyperglycaemia, hypoglycaemia, glycaemic control etc.

To help make sense of it all, diabetes educators have developed some key areas to focus on1:

  1. Healthy eating

Having diabetes does not mean you must give up your favourite foods. Over time and through experience, you’ll learn how the foods you eat affect your blood sugar. You should eat regular meals and make food choices that will help control your diabetes better1.

Work with a dietitian or diabetes educator to develop a healthy, balanced eating plan that suits your lifestyle. Remember that it is okay to treat yourself once in a while. You can also visit the Accu-Chek website and download the Accu-Chek portion plate which will give you some practical tips on healthy eating.

  1. Being active

Guidelines for the management of Type 2 diabetes refer to studies that have proven that regular physical activity significantly improves blood sugar control, reduces cardiovascular risk factors, and may reduce chronic medication dosages2. Regular physical activity may also improve symptoms of depression and improve health-related quality of life2. Try to include a combination of cardio and resistance training into your weekly exercise routine.

  1. Self-monitoring of blood glucose (SMBG)

The International Diabetes Federation (IDF) recommends SMBG as an effective means for patients with diabetes to understand more about their condition and the influence of events – such as exercise, stress, food and medication – on blood sugar levels3.

However, for SMBG to be effective, it’s recommended that you practice structured testing using a tool, such as the Accu-Chek 360 3-Day Profile Tool3 which can be found on www.accu-chek.co.za

Structured testing is testing at the right times, in the right situations, and frequently enough to generate useful information3. Always agree with your doctor or diabetes educator what your individual structured SMBG testing plan is.

Another aspect you should discuss with your doctor will be your target range for your blood sugar levels. In the beginning, understanding this range and what is considered out of range may be confusing, so you may want to make use of a meter such as the Accu-Chek Instant Meter which offers a support tool called the target range indicator (TRI)4.

A study done on the TRI showed that 94% of study participants were able to easily interpret their blood sugar values through the use of the target range indicator4. Furthermore, 94% felt that the support tool will help them discuss their blood sugar values with their doctor4.

  1. Taking medication

You may need to take medication to help keep your blood sugar (glucose) level steady. Diabetes can increase your risk for other health conditions, such as heart or kidney related problems, so you may need to take medicine to help with those too1.

  1. Problem solving

When you have diabetes, you learn to plan ahead to be sure you maintain blood sugar levels as much as possible within your target range goals – not too high, not too low.

As we know, things don’t always go according to plan and a stressful day at the office or an unexpected illness can send your blood sugar in the wrong direction. Days like this will happen from time to time. Here are some tips to cope1:

  • Don’t beat yourself up – managing your diabetes doesn’t mean being perfect.
  • Analyse your day and think about what was different and learn from it.
  • Discuss possible solutions. This can be with your doctor, your diabetes educator or even a face-to-face or online diabetes support group. Try joining some of the online diabetes communities out there, such as the Accu-Chek Facebook page which has over 148 000 members. You can join the conversation at AccuChekSubSahara.