Type 1.5 Has anybody in Ireland noticed the medical profession is ignorant of the Dawn Phenomenon?

[Belzedar]

I’ve recently started to have my diabetic reviews with a teaching hospital in Ireland, the second of such two days ago. Dismayed by the doctor’s tendency to see me as a statistic rather than a guy with specific difficulties, she changed my meds to address problems she thought I SHOULD have (but honestly don’t) and dismissed anything I said that apparently contradicted her assumptions.

One of those was the Dawn Phenomenon. This, as I understand it, is the liver dump EVERYBODY experiences as they rouse themselves for the day but is problematic for diabetics because it isn’t accompanied by the insulin release to counteract it, resulting in high blood glucose levels for diabetics in the early morning. Now, from my reading, this seems to be a widely-recognised condition, with diabetes education sites saying half of the Type 2 diabetics are affected by it.

But it seemed that this diabetic clinic were quite unfamiliar with the term and not interested in it. In fact, though my glucose log shows higher levels in the morning than the previous bedtime (I do know fluctuations are normal and that as long as the difference between the bedtime levels and morning levels is at most 1.6, things are alright), she latched onto only the past two weeks where I told her I had started low-GI oatmeal with pecan nuts at bedtime to investigate the possibility of rebound from hypos during the night was my problem.


Conveniently dismissing the constant overnight readings for the past three months of my current log (and the evidence of the previous five years), that my levels rose overnight even though I habitually stopped eating at 6pm and that only changed when I introduced the porridge for supper two weeks ago, she blamed the whole thing on me for not taking bolus insulin with that porridge. Seriously, I ask you, is 3oz oats and an 1oz of pecans likely to make you hyperglycemic starting from a target glucose level (specifically from 6.2 at bedtime to 15.8 by the next morning)?


So, my question, do Irish diabetics know if the Dawn Phenomenon is a known thing in Ireland? Did I buy into some kind of bad science and should I just forget all about it? It does make it all futile because this is happening and it’s sabotaging my efforts. I’ve addressed the exercise, food, sleep and mental health issues and as far as I can see, it’s the medical dimension that really needs to step up.


One last thing. I have hereditary hemochromatosis which, though largely unmanifested, does impact insulin sensitivity and carb tolerance negatively, both things also adversely affected by circadian rhythms (meaning evening carbs cause a wallop of a sugar spike and insulin is largely ineffective in dealing with it. I have found that ten minutes’ challenging exercise with weights can bring my glucose levels down by over four points.). But what I know about that might be bad science - and I have little confidence in this doctor’s ability to hold up her end in a conversation about that.

 

[kitedoc]

Hi @Belzedar, I think that if you look on the home page and look under Dawn phenomenon, it says that not everybody experiences the Dawn Phenomenon or at least not all the time.
That is not meant as a criticism of what you have said and does not excuse your doctor not knowing about it.
Perhaps, if you are able to use a Libre device and obtain continuous BSL readings overnight on a few occasions you would have more luck in demonstrating to her what is happening.
If you do not have access to such a device you might have to look at doing finger prick readings over several nights say every 2 hours, as an alternative. For DP my understanding is that the BSL rise occurs starts somewhere around 4 to 6 am but that is an approximate.
Best Wishes on opening the eyes of those that have yet to see!!

 

[Member496333]

Every living human experiences the dawn phenomenon. It’s a result of the endocrine system releasing hormones that signal the liver to secrete glucose in order to help us wake from sleep and start the day. The measurable increases in blood glucose concentration in diabetics comes about because their insulin is largely ineffective at facilitating the uptake of that glucose into the cells, and because their insulin resistant liver doesn’t stop releasing it.

I should be surprised that a diabetes care professional doesn’t know this, but I’m not. In fact in my experience most diabetes professionals are simply reading from a pre-approved list of official advice and will dismiss anything you say as codswallop. After all, their knowledge of the disease is vastly superior

EDIT: my description is relating to type 2, but obviously the DP mechanism itself is common to all humans. I’m unsure how it interacts with other forms of diabetes.

 

[Belzedar]

@kitedoc Thanks for that. I’ve since decided not to waste my time on the wilfully blinkered. I was upset and discouraged that this doctor I’ve been on a waiting list for two years to see, and who has only seen me twice, had reduced me to her stereotype of T2 diabetics needing a kicking to motivate them. She ignored my records of five years showing me waking up hyperglycemic despite not eating anything after 6pm the previous day, going for the easy win of picking up on my eating oatmeal without insulin for the previous two weeks to see if that might quash any undetected hypos during the night. By the way, my records are VERY thorough. It's a spreadsheet of my own creation, not only recording my glucose levels, but the nutritional values of any meals and a log of what that meal was as well as a record of my bolus insulin for each meal. Those records also show that I average 1800 kCal daily, 85g net carbs and 30g fibre (avocados really come into their own there with 14g of fibre). All that was there in front of her. An enquiring mind would have used the data but she chose not to. As I said earlier, the whole session was demotivating, and indeed it’s taken me a few days to get my head back in the game and not surrender to the sense of futility and hopelessness she had triggered. After all, diabetes care relies on getting the food, the exercise, the sleep, the stress and the medicine right and the medical factor is the only one letting the side down in my case.

Now as @JimLahey says, everybody experiences the dawn phenemenon. It’s a normal way of rousing for the day. It’s just problematic for some people, particularly diabetics with inadequate insulin. There are even some in the medical field who are of the opinion that it’s of no clinical interest since the high glucose levels sort themselves out in a couple of hours anyway.

 

[kitedoc]

Hi @Belzedar, As they say: You can lead a horse to water but ..., or you can present a mind with carefully procured information but one cannot make them think unless they are open to it. And the mind is like a parachute. It only works when it is open.
Again from my diabetes experience not as professional knowledge or opinion:
The relevance of the Dawn phenomenon (DP) is whether it causes an unacceptable rise in BSL and that there is no other cause proven for this rise in BSL. Hence the check of BSLs overnight and, as you have shown, the absence of carb intake to otherwise explain the BSLs early morning.
As this site's Home page under Glucose, far left hand side, various possible remedies are suggested and there are threads about DP and how people manage it (type Dawn Phenomenon into the question box upper right of the Forum page).
Being on insulin can help as there might be some changes which might help and sometimes the only remedy besides use of an insulin pump is that some diabetics have had to resort to waking about 4 am or earlier to give themselves a dose of short-acting insulin to prevent the BSL rise.
It is a shame you do not have the understanding and wisdom of the doctor who should know about DP..
Perhaps your GP and yourself can work out a way. Best Wishes.

 

[Belzedar]

Thanks @kitedoc These posts have been very thought-provoking and quite helpful. In fact, I hit on a new line of enquiry that really resonates with me. The Dawn Phenomenon is universal. It’s the presence of cortisol and Human Growth Hormone readying the body for action. The liver plays its part by using neoglucogenisis to dump glucose into the blood for transport round the body. Everything is doing its job.

Now, the pancreas is doing its job by releasing pulses of basal insulin every couple of minutes to keep the liver from overshooting. BUT if the liver is insulin resistant, it’s incapable of responding to that and carries on regardless - dumping glucose into the blood. This, I've read, happens whether the liver responds to low sugar levels after several hours of fasting during sleep (the Somagyi effect) end even in the “fed” state (because of the hepatic insulin resistance). I had recently discovered the effectiveness of taking a shot of Novorapid at about 3am to anticipate the glucose spike from 4am and it was this that my Doctor and I parted ways. She forbade me to ever taking insulin without food - without pausing for a second to consider that I wasn’t susceptabile to hypos, having had less than twenty recorded hypo readings in the past seven years (yup, that’s about two or three low readings a year) and for my part MORE more carbs just to satisy her requirement wasn’t likely to bring my glucose levels

 

[Daibell]

Every living human experiences the dawn phenomenon. It’s a result of the endocrine system releasing hormones that signal the liver to secrete glucose in order to help us wake from sleep and start the day. The measurable increases in blood glucose concentration in diabetics comes about because their insulin is largely ineffective at facilitating the uptake of that glucose into the cells, and because their insulin resistant liver doesn’t stop releasing it.

I should be surprised that a diabetes care professional doesn’t know this, but I’m not. In fact in my experience most diabetes professionals are simply reading from a pre-approved list of official advice and will dismiss anything you say as codswallop. After all, their knowledge of the disease is vastly superior

EDIT: my description is relating to type 2, but obviously the DP mechanism itself is common to all humans. I’m unsure how it interacts with other forms of diabetes.

Yes, sadly my experience of diabetes GPs is the same. They can be good general GPs but when it comes to diabetes they tend to have known less than me as the training appears to be very poor (like never heard of Late onset T1 i.e. LADA). That sounds arrogant but sadly true in my experience. My DN is much better she knows her limits but does a good job with what she does know and listens and questions. So be prepared to use your own knowledge bank when needed.

 

[Bluetit1802]

A few years ago my surgery stopped all fasting glucose tests completely, even on non-diabetics at routine MOT tests. They only do an HbA1c.

I was told the reason for this was because of the unreliability due to raised levels caused by glucose dumps from the liver in some people, exacerbated by stress at getting to the surgery and anxiety about the forthcoming tests. So at least my surgery understands this!

 

[Member496333]

A few years ago my surgery stopped all fasting glucose tests completely, even on non-diabetics at routine MOT tests. They only do an HbA1c.

I was told the reason for this was because of the unreliability due to raised levels caused by glucose dumps from the liver in some people, exacerbated by stress at getting to the surgery and anxiety about the forthcoming tests. So at least my surgery understands this!

Not sure I agree entirely with that logic. A metabolically healthy person shouldnt really exhibit big spikes. If they do then they’re insulin resistant. Whilst I understand the sentiment, one can make an argument that it allows more people with insulin resistance to slip through the net and “score” a HbA1c sufficiently averaged to avoid a diagnosis.

Happy to disagree though of course

 

[Bluetit1802]

Not sure I agree entirely with that logic. A metabolically healthy person shouldnt really exhibit big spikes. If they do then they’re insulin resistant. Whilst I understand the sentiment, one can make an argument that it allows more people with insulin resistance to slip through the net and “score” a HbA1c sufficiently averaged to avoid a diagnosis.

Happy to disagree though of course

You are probably right, and most likely logistics come into play. If everyone were told to fast before any tests involving glucose, as used to be the case, and because all fasting tests are done earlyish in the morning, there could be a long, long waiting time for these tests. Non-fasting HbA1cs can be done at any time of the day, with much less of a waiting time.

 

[kitedoc]

Thanks @kitedoc These posts have been very thought-provoking and quite helpful. In fact, I hit on a new line of enquiry that really resonates with me. The Dawn Phenomenon is universal. It’s the presence of cortisol and Human Growth Hormone readying the body for action. The liver plays its part by using neoglucogenisis to dump glucose into the blood for transport round the body. Everything is doing its job.

Now, the pancreas is doing its job by releasing pulses of basal insulin every couple of minutes to keep the liver from overshooting. BUT if the liver is insulin resistant, it’s incapable of responding to that and carries on regardless - dumping glucose into the blood. This, I've read, happens whether the liver responds to low sugar levels after several hours of fasting during sleep (the Somagyi effect) end even in the “fed” state (because of the hepatic insulin resistance). I had recently discovered the effectiveness of taking a shot of Novorapid at about 3am to anticipate the glucose spike from 4am and it was this that my Doctor and I parted ways. She forbade me to ever taking insulin without food - without pausing for a second to consider that I wasn’t susceptabile to hypos, having had less than twenty recorded hypo readings in the past seven years (yup, that’s about two or three low readings a year) and for my part MORE more carbs just to satisy her requirement wasn’t likely to bring my glucose levels

Hi @Belzedar. Somogyi effect and DP are separate things. You would have to prove that there were low BSLs occurring with a related rebound BSL rise. People get DP for different reasons than Somogyi. Please get this straight otherwise you will be confused.
Yes, some doctors are very hidebound and what you did with having a 3 am boost of insulin and watching your BSL carefully was what many do. Pity your GP does not read more and only rely on what was learnt at medical school years

Not sure I agree entirely with that logic. A metabolically healthy person shouldnt really exhibit big spikes. If they do then they’re insulin resistant. Whilst I understand the sentiment, one can make an argument that it allows more people with insulin resistance to slip through the net and “score” a HbA1c sufficiently averaged to avoid a diagnosis.

Happy to disagree though of course

A diabetic can suffer big BSL spikes for a number of reasons e.g. eating many carbs at a meal. In that case the BSL spike from this is NOT due to insulin resistance.

 

[Member496333]

I said a metabolically healthy person, in the context of blood checks to determine whether or not that is so

 

[kitedoc]

I said a metabolically healthy person, in the context of blood checks to determine whether or not that is so

What is so?

 

[Member496333]

What is so?

The discussion at the time of my post was regarding blood tests to determine whether or not a person has any metabolic issues. Not whether or not diabetics exhibit dawn phenomenon and why.

 

[kitedoc]

The discussion at the time of my post was regarding blood tests to determine whether or not a person has any metabolic issues. Not whether or not diabetics exhibit dawn phenomenon and why.

Please define "metabolic issues".

 

[Member496333]

In this context - insulin resistance, insulin deficiency, diabetes. Not sure where you’re going with this but it seems you may need to go back to bed and get out the other side. I’m not looking for an argument.

Have a great day

 

[kitedoc]

In this context - insulin resistance, insulin deficiency, diabetes. Not sure where you’re going with this but it seems you may need to go back to bed and get out the other side. I’m not looking for an argument.

Have a great day

Ok, but I am in the Southern hemisphere so bedtime is a tad different. Insulin resistance is not actually that easy to measure that is whyI was trying to understand you.

 

[Member496333]

For the purposes of the discussion at hand, if a person exhibits markedly elevated blood glucose concentration in the morning, they are likely either insulin resistant, insulin deficient, or both. My only point was that choosing to ignore this metric in favour solely of HbA1c will likely mask the spikes and make the average appear more acceptable, thus delaying a potential diagnosis. In my view, fasting glucose should be the first test followed by HbA1c to confirm or disconfirm metabolic abnormalities. Others are free to disagree.

Hope I’ve made myself clearer