Does Dawn Phenomenon provide ANY measure of overall control?

[foxl]

An obvious question? Perhaps ... yet if it means your BGs are elevated for what? 2 hr of 24, how much does it affect A1c, and whether it does or not, how much does it matter?

Does increasing DP indicate diminishing control?

ETA: will search books and PubMed this week, but want to get YOUR opinions, first. Will summarize findings if possible!

[fgummett]

Great question Linda and one which I have long pondered myself... here's my 2 cents...

Fasting BG seems to be a focus for many (we even have an ongoing thread here for posting your latest). It may be a useful diagnostic criterion and I think many Doctors use it to gauge control, so perhaps that is why it has gained importance.

My diet is proportionally high in fat and protein with some carbs but almost absent of refined/concentrated carbs... as a result my BG is very stable through the day with barely a rise after meals BUT I do get a marked Dawn Phenomenon (DP) which -- when left untreated -- tends to keep me around 7.5mmol/l on waking but does resolve to below 7mmol/l within a hour or two, even if I don't eat breakfast immediately. So 80% of the day I am below 7mmol/l -- which I consider to be the high limit of normal.

So do I stress about DP? Not so much... but I have started back on some Metformin XR in hopes of reducing its effects.

I am no longer using the insulin pump as for me it is careful balance to minimise exogenous insulin while still maintaining good BG control... I know I can do still better and if the Metformin does not do the trick (still too early to tell) I may opt for a dose of Levemir at bedtime, or I could always restart the pump. I'm not boasting nor do I want to give the impression that everyone should immediately try to aim for the same standard as I have set myself... it has been several years of learning -- that never stops! -- to get to this place.

[Subby]

An obvious question? Perhaps ... yet if it means your BGs are elevated for what? 2 hr of 24, how much does it affect A1c, and whether it does or not, how much does it matter?

Does increasing DP indicate diminishing control?

DP doesn't seem very standard to me. I'd say the amount to which it matters, depends purely on what it is actually doing. So someone with a bit of a bump I would say it hard matters. Others have a struggle and obviously bad numbers, it would register as an issue to keep trying to deal with, for control, A1c, future health - one, all or a combination of those.

As for showing worsening control, my guess (just a guess) is that if DP is getting worse given the same approaches (diet, activity, meds, insulin, etc) it could suggest a degradation of important internal mechanics. Then again, the growth hormone hypothesis which appears to be a common/major one, suggests more of a spanner in the works rather than atrophy of central metabolic processes.

Let us know if there is anything compelling to suggest it is a useful and quantifiable indicator in your research. Can I ask what your thought is, and why you are looking this direction?

[sumi]

I would like an answer to this one too, Linda. My DP, although with lower numbers as time goes on, remains with me. If anything it seems more entrenched than ever. Sometimes neither exercise nor eating will budge it until about noon( I'm generally up about 6:00). However, my A1C is good, so in my case, having elevated levels for 1/4 of the day, doesn't seem to make too much difference. I would estimate that much of this time I am between 110 to 125.

[foxl]

Sumi, my A1c is good too! My August one was 5.5, then at the end of last month, 5.6. That is hardly a measurable change ... But I do have an increase in my morning numbers --and in the frequency of high mornings, recently.

My post-prandials seem to be the same as ever. It's just these dang mornings. So I am wondering if this is a subtle indication of change ... or not? It could be seasonal, it could be the test-strip change from One Touch, it could be because I am worrying more ... and it will recede. I just do not know.

[slewpnj]

I just had my 3 mo check up since dx. I took a log of my numbers which are fasting every morning and then a sampling of before and after some meals and before and after exercise. I was worried because the highest number of the day is the morning fasting. It's not obscene but still not where I would like to see it. Seems to fluctuate between 117 and 150 and doesn't seem to be any pattern.

I had new blood work but no new A1c yet. Doc said he wanted to wait until the next checkup (another 3 mos) which would have me on meds for 6 mos at that point (metformin 500mg 2x). My cholesterol, triglicerides and liver enzymes were so dramatically improved that the doc didn't change the metformin. He said it's not unusual to see higher fasting numbers with metformin, although he didn't use the term DP. He said that the stablilized numbers during the course of the day are more telling.

[xMenace]

My DP is very steady with usually only minor fluctuations. It is much easier for an IDD to determine this. Those that make some of their own insulin would have a very difficult time isolating actions.

[usaken]

I have had Tp2 for about 15 years. The dawn effect has always been a problem for me. Day and night BG's have generally been OK around 120-135. The past few years the wakeup BG have been unacceptable, around 210 average. I was taking Glucophang, Gliburide and Actos. About a month ago the Dr switched me to NPH insulin and dropped the Actos. I started with 5u and am now am up to 40u with very little noticable change with wakeup BG (a little lower, maybe -10) The big change is that the daytime BG have sprung up to 160-0180. I dont know what is happening but I would describe it as a train wreck! Ken

[sumi]

Linda, I do remember at the beginning of summer some people saying that their levels were better and I wondered if this might be to extra vitamin D. If, for whatever reason, they go down in summer, they must go back up in winter (sorta like daylight saving time).
Ken, your description of a trainwreck sounds right. I hope someone will have some ideas for you.

[jcaboose]

DP remains a problem/concern for me. I've been testing 2-4 times a day, and for the last several weeks my overall average has been within a couple points on either side of 125. During the day I'm usually between 90-110, but my first reading of the day is usually somewhere between 140-190. Ticks me off, and I'd certainly like to see it much lower, but I'm trying not to get too hung up on it. Don't know whether I'm rationalizing or not, but it seems to me that a few hours of "bad" numbers shouldn't outweigh 4-5 times as many hours of good or at least reasonable numbers.

[foxl]

Don't know whether I'm rationalizing or not, but it seems to me that a few hours of "bad" numbers shouldn't outweigh 4-5 times as many hours of good or at least reasonable numbers.

Yep. that is my thinking, too.

Now of course the other question is, WHERE was my DP that summer when I felt SO LOUSY, but my FBG at the MD's office was "normal???" No fair, I tell ya!

[foxl]

The loss of postprandial glycemic control precedes... [Diabetes Care. 2007] - PubMed result

Well here is an article that discusses DP in the framework of deteriorating control. However they are looking at rather HIGHER A1c's ... and WAY higher carb intake, than seem relevant to me or most of us!

It does have a nice graph of 24-hr BGs though.

Small wonder MD's blow us off if that is what people are studying!

[MCS]

Had the DP thing going for a while myself, may still be there, its wait and see for me right now.

From what I can determine, DP is a lack of communication between your stomach, liver and pancreas. Everyones body is geared to ellevating thier glucose levels upon waking. Its people with impaired communication that have a DP problem.
Mine would start at 7:00 am, wake up in the 80-90's and soon go to 140 with in 30 minutes and stay elevated till lunch. If I could manage to trigger an insulin release, BG numbers would be good all day.

Is this a sign of less control, not sure. Is it reversible, maybe.
From what I have found the hormone responsible for this communication is called GLP-1, a gut hormone that is released when the gut senses, lipids, glucose and protiens. If you have low GLP-1 or the trigger mechanism is faulty you get no communication and have a better chance of having a DP problem. This is just my take on things.

[Rekarb]

I am almost always 20 pts higher in the mornings than at bedtime. That number, however, below the magical 140 mark so I'm not concerned.
I've never saw my DP as more than my liver screwing with me. If I don't eat for awhile during the day bgs go up, I assume because my body is getting me ready to go out and chase a rabbit for food. Everything for me involves the 1 hour spike and it involves staying out of the glucose toxic area above 140. I believe that everytime I go up there some of my beta cells lose sensitivity to glucose levels. The more I'm up there - the more sensitivity I lose and the worse my control becomes. The converse, I believe, is also true.

DP and those stretches between eating where my bgs rise don't figure into this scenario. I had come to consider morning readings and DP a waste of time but seeing this other posts makes me question that.

Mike

[kmac]

That really is a good question. Intuitively I think that when my DP starts to come back it is a signal to be extra vigilant in my control. When I do that my morning numbers will go back down. But maybe they would have done so anyway??????? Who knows. DP is something that plagues me and every time I think I have it figured out it raises its ugly head again.

It is obviously a complicated mechanism and for you, with 1.5 it must be even more so.

Kathi