Article by Hope Warsaw RD, CDE
Interviews with:
Arlene Monk RD, CDE – Diabetes Center, MN
Robert Clifton MD – cardiologist/professor U of Texas. 
From Diabetic Living, Fall 2011    www.diabeticlivingonline.com

Rearranged and additional notes added by Lisa Merrill MS, RD, CDE

Stumped by high fasting blood sugars?  (FBS)  Join the club.  “When I snack before bed, my fastings are lower than when I limit my nibbles”.  The true culprit is compromised hormone levels controls of blood glucose levels.

During the years (up to a decade) that Type II diabetes develops, the hormonal control of blood glucose breaks down.  These 4 hormones involved in glucose are:

1. INSULIN   Made in the beta cells of the pancreas, this helps the body use glucose from food by helping it move into the body’s cells.  People with Type II have slowly dwindling insulin production and reserves, and increasing insulin resistance.

2. AMYLIN   This is secreted from the beta cells and slows the release of the glucose into the blood stream after eating by slowing stomach emptying.  This increases the feeling of fullness.  People with Type I and II are amylin deficient.

3. INCRETINS  This is a group of hormones secreted from the intestines that include glucagon-like peptide1I   (GLP-1).
Increases insulin release after eating
Slows gastric emptying time
Promotes fullness
Delays release of glucose into the blood stream
Prevents pancreas from releasing glucagon which puts less glucose into the blood

4. GLUCAGON  Made in the alpha cells of the pancreas.   This breaks down glucose that is stored in the liver and muscles.  It releases this stored glucose to provide energy when glucose isn’t available. 

For Type II diabetics-  During the years Type II slowly develops, hormonal control of the blood glucose breaks down.  Eventually here is what happens during sleep:
Overnight the liver and muscles get the message from excess glucagon to ramp up the glucose supply (release it from liver and muscles).  Because the person is sleeping and not eating, there is not enough GLP-1, insulin, or amylin to deal with this excess glucose. 
This throws the feedback loop out of whack. 

Other Reasons-
DAWN PHENOMENON   This happens as part of the body’s normal circadian rhythm to wake you up and get you going.  Hormones such as growth hormone and cortisol are released to raise glucose.  Without diabetes the body simply responds to this early AM effect by putting out more of the hormones that keep the blood glucose in control.  That doesn’t happen with type I and II.

SOMOGYI EFFECT (Type I mostly)  This is a very high fasting sugar thought to be caused by the liver making a lot of excess glucose in response to hypoglycemia (low blood sugars) in the middle of the night.  There is a controversy as to whether it even exists with the rapid and long acting insulin available now.   If they are used right!

WHAT TO DO to prevent high fasting blood sugars- work with your team!!  Doctors, Registered Dietitians, Certified Diabetic Educators, Exercise Specialists, Nurses..etc

1. DIET- Balanced to contain ample protein, low starch veggies and regulated amounts of carbs and healthy fats.

2. MOVE- No matter what kind of aerobic activity you do, anytime of the day, you will be enhancing the body’s response to insulin….up to 10X the rate!

3. START-CHANGE or ADD medication. 
Metformin/Glucophage cuts down on glucose overproduction at night
Januvia and Onglyza keep more GLP-1 hormones circulating. 
The more potent injectable Byetta  (2 X a day) or Victoza (1 X a day) also increase the amount of circulating GLP-1

            Remember this- GLP-1  increases insulin production, slows emptying time in belly and fullness, and decreases the release of glucose.
Some people also experience weight loss with these. 

As Type II progresses after 10 years, people may need to add insulin (usually long acting Lantus or Levemir)

4. Overall the pounds shed from lifestyle changes can help hormonal disturbances, increase insulin sensitivity (it works better) and decrease blood sugar levels.

5. Nibble a small snack containing ~15 grams carb at night.  This shortens the time that the liver is in overdrive producing glucose.