For the last six months or so we’ve been struggling with my sons “Dawn effect”. Changed lantis in an attempt to get him down under 180 in the AM. HE regularly wakes up, 6-7AM 300+ even though a 3AM test shows him at 100-150.
This morning in the way to school we were talking about how he has to eat and that if he doesn’t his BG goes wonky. He then said that the only time he HAS to eat is when he’s hungry and that his BG only goes wonky when he’s hungry. He then stated that it also seems that his high numbers in the AM seem to correlate with him waking up hungry.
We’ll ask his doctor about this but do any of you diabetics see this and if so have you ever tried having a quick “Snack” in the middle of the night and does that have any effect? Just curious. Right now the doc wants us to keep upping his Lantis until we are under 180 80% of the time in the AM. However what we are seeing is kind of a bimodal distribution, wakes up some days at 100-120 and other days at 300-400. Not much in between. We are also seeing an increasing number of lows throughout the rest of the day which concerns me as far as increasing the Lantis further.
Not a diabetic, but my thought is monitoring his food intake and activity levels for a bit might give you some insight into why his levels vary so much in the morning. Maybe you already do this?
Not a diabetic, but my thought is monitoring his food intake and activity levels for a bit might give you some insight into why his levels vary so much in the morning. Maybe you already do this?
Yes, we keep track of all his carb intake for every meal and have to alter his insulin intake according to activity and intensity of activity. We found out the hard way that correcting after an intense workout ends up badly.
He has a pretty consistent schedule on both activity and eating so for the most part we are seeing these differences from day to day with the same schedule.
No, we test fairly regularly in the 2-3 AM range and rarely, in fact never, see high numbers.
Bedtime snack?
Yes, every night unless he’s really high for some reason. We even do snack when he is high and correct.
Activity 3 hours up until falling asleep?
Mon thru Fri he finishes swim @5:30 and then typically no high physical activity after that. Usually it’s come home, eat dinner, do home work, practice clarinet, kill a few dudes on COD, watch RV while having a snack and go to bed.
Add new stress?
Not really a new thing, something we’ve been struggling with for the last six months or so, but no new stresses I can think off.
My advice is to get on pump therapy. My daughter has been a type one for a little over 11 years and it has made life for her exponentially easier.
Back to your original question. We notice BS increase around 4 am. As described by her endo, it is the bodies attempt to prepare for the days energy needs and we see an increase in her numbers. With a pump this is easy, however with Lantus since it is just a single shot as a basal dose, it is tricky increasing the lantus to a level to accommodate that rise in BS and not keep him low during the rest of the day.
What’s his HbA1C? If it’s consistently under 7 mmol/L, maybe under 6 ( <126 ) for type one and his age ) I wouldn’t worry to much about daily variation ( except the lows, of course ), check with your Endo.
Lantus shouldn’t be causing lows. A miscalculation of the fast acting insulin can cause lows.
Diabetes is very much a YMMV condition, what works for one might not work for someone else.
I am not an Endocrinologist and I am type 2 ( since 1998 ) not type 1.
Ask your Endo or Diabetes Nurse if avoiding the bedtime snack could help with the dawn effect.
I am not a diabetic, and not and endocrinologist, but am a physician. A quick literature search told me that it has been known since the 1980’s that the dawn effect is caused by growth hormone surges during sleep, which increases insulin resistance. How old is your son? Is he done growing? Is he having a growth spurt? It is possible that these will improve as growth is finished. I would definitely ask your endocrinologist on how to treat it. An insulin pump may be his best option.
Physiologically, it makes sense that he is hungry when his sugars are high, because that means that his tissues are starving (because they cannot get the sugar without the insulin.)
Sounds like you guys are doing a terrific job. Best of wishes.
What’s his HbA1C? If it’s consistently under 7 mmol/L, maybe under 6 ( <126 ) for type one and his age ) I wouldn’t worry to much about daily variation ( except the lows, of course ), check with your Endo.
He’s a little high the last couple checks which is why we are trying to get it down, just under 7.5. I think a big reason for this is the 5-9AM numbers as if he’s shooting up around 5-6 and it takes a while to get him down after breakfast he has several hours of high numbers each day.
Lantus shouldn’t be causing lows.
Too much of it would I believe.** ******While it may be a slower acting insulin it can drive your overall base rate down. This is especially prevalent with excercise which causes the insulin, of both types, to be more effective. I talked to a type one that did RAGBRAI and he said by the end of the journey he was using less then half of his Lantis then he was when he started.
**Diabetes is very much a YMMV condition, what works for one might not work for someone else. **
Absolutely which is why I’m throwing this out there to see if anyone else had ideas or had seen the same thing.
Ask your Endo or Diabetes Nurse if avoiding the bedtime snack could help with the dawn effect.
Again we have a great endo and a great staff we deal with regularly, I’m just looking for “More minds” as sometimes people have done things that the docs, particularly those that aren’t diabetic, might not have thought of.
A quick literature search told me that it has been known since the 1980’s that the dawn effect is caused by growth hormone surges during sleep, which increases insulin resistance. How old is your son? Is he done growing? Is he having a growth spurt?
We’ve discussed this and for the most part think this is likily and part of the issue. He’s 10 and on top of the growth issue he will/is heading into puberty that will throw EVERYTHING out of wack.
An insulin pump may be his best option.
Up until now the endo was hesitant to put him on the pump because we’ve been able to have low A1C’s and keep good control with injections. We’ve been hesitant about the pump for a number of reasons…first of all the fact that he’s a 10 YO boy and odds are pretty good that anything around him will get smashed and destroyed
We did a trial with a continuous monitor and he did not like the injection site being there all the time and did not react well to the tape and cover they put over it.
That being said it will probably be out best option but we were kind of hoping to hold out for a more complete pump system that included monitor and automatic insulin adjustment. Did the Ron Santo JDRF walk last week and one of the medical device manufacturers there said they are still 5-7 years away from that though.
My advice is to get on pump therapy. My daughter has been a type one for a little over 11 years and it has made life for her exponentially easier.
We may end up there eventually but are hesitant for a few reasons. We are trying to leave that choice up to him and he’s been on the fence about it for a while now. Some times he wants to other times he doesn’t. His doc/Endo actually wanted us to stay with the injections because we had had good numbers and was following the “Leave well enough alone” policy. That may change if we can’t get the AM numbers down.
What pump does your daughter have? Do you have a CGM?
She is on her second Medtronic pump. We also have a CGM but honestly we do not use it very often. It is great for looking at trends and to fine tune your basal settings but you are still required to take an actual BG reading several times a day. We also notice that it really lags behind by our 30 minutes from what is truly going on.
How old is your son? We had weird patterns when puberty hit. The hormonal changes greatly effects her numbers. We did not notice the dawn effect until that time.
The best thing we taught our daughter was to test her BG many times a day. She averages 7-9 times a day and contently has A1C levels in the lover 7’s.
I was against the pump at first, because her treatment was working, however it was strict as in terms of what she ate, ect. After about a month of her therapy I quickly changed my impression of it. Not only did her A1C levels from about a point, she had much more freedom to eat what she wanted, when she wanted it.
Question- Have you researched the use of metformin in Type 1 diabetes?
Reason I ask is that perhaps your son would see benefit from the control it places on the liver during the night. There are some interesting articles out there that you may want to peruse. Of course his Endo is the stopgap for all ideas, but it might be worth the discussion.
As a type 1 myself I find evening exercise a big help coating dawn phenomenon… This sounds weird, but is he a good swimmer and not need much glucose to keep going?maybe he is taking in too much during the swimming and overshooting somewhat?
Dawn phenom sucks, but it also maybe an age thing- as mentioned I believe growth hormone has a bit to do with it. Other than that I 2nd the pump thing. I’m on mdi but am tempted with the pump so I don’t have to feed the lows during exercise all the time. I share that frustration of having to supplement every freakin 10 mins! Makes leaning out a bit harder
Up until now the endo was hesitant to put him on the pump because we’ve been able to have low A1C’s and keep good control with injections. We’ve been hesitant about the pump for a number of reasons…first of all the fact that he’s a 10 YO boy and odds are pretty good that anything around him will get smashed and destroyed
We did a trial with a continuous monitor and he did not like the injection site being there all the time and did not react well to the tape and cover they put over it.
That being said it will probably be out best option but we were kind of hoping to hold out for a more complete pump system that included monitor and automatic insulin adjustment. Did the Ron Santo JDRF walk last week and one of the medical device manufacturers there said they are still 5-7 years away from that though.
~Matt
My son is also T1D ( a few years now) and is now growing so fast that he has osgood schlatter syndrome in his left knee (14 y/o)
HbA1c’s is the low 6’s (since the start as we have always kept a very tight rein on his BGL’s) and has never considered a pump due to his physical activity. And by physical I mean the pounding he puts his body through (various forms of football, track, etc).
As for the morning BGL’s my suggestion would be to recheck his levels a little later in the AM before he wakes. I think you may find he could be going hypo after the 2-3 AM check and the level is a rebound after the hypo.
Our Endo warned us about this due to my sons very good HbA1C levels (thinking he was constantly bordering on going hypo) http://www.diabetes.co.uk/blood-glucose/somogyi-phenomenon.html
Something to think about at least.
Hope you get it sorted. If youre as anal as we are about his levels, I know how frustrating it can be!
As for the morning BGL’s my suggestion would be to recheck his levels a little later in the AM before he wakes. I think you may find he could be going hypo after the 2-3 AM check and the level is a rebound after the hypo.
At this point we’ve narrowed it down to two possibilities. Going hypo and the “Rubber band” effect as you suggested and or response from growth hormone.
What we are going to try is having him take a small snack at 2-3 AM. Since he’s going to bed at 9 or so by 5AM he has gone eight hours without food. Mon thru Fri he’s doing 90 minute swim as well which ends @5:30. So for right now we will try that and see if it has an effect. If it is a growth hormone issue the only real correction is insulin at that time of day, which is pretty scary considering he’s not taking in any carbs. The potential for dangerous lows is pretty significant.
