Screaming Dawn Phenom on Bernstein, too?

Food Nutrition
1

OK, I’m just starting to get some stats since converting to the Bernstein very low carb program, and they’re breaking my heart.

After two weeks of never going over 45 carbs in an entire day (15/15/15) and very often going no more than 35 in a day (5/15/15) I find that my (fasting) pre-breakfast readings are still 125 over target (225 or so) my pre-lunchtime readings are still 95 over target (195 or so) and my pre-dinner readings are only 45 or 50 over target (150 or so) – and I’ve had one really bad evening hypo already, after injecting Lantus before bed-time (I dropped to 52.)

So.

If I increase my Lantus enough to cover the morning and mid-day highs, I’ll crash and burn in the evenings and at night.

Now what? Do I inject more Novolog with breakfast/lunch and just accept that I’ll have eye and kidney damaging high BG between 3 and 8 a.m.? Do I set the alarm for 4 a.m. and give myself an injection? I have no idea what to do and my doctor isn’t much help.

Has anyone else found severe Dawn Phenom tracking them, even into the very low carb program?

2

Try taking Lantus in split doses.



Until you figure out your insulin:carb ratio & IISF, it’s hard to advise you. Sliding scale is too inaccurate. Low carb without accurate doses can only do so much. Since your premeal readings are high, you need to increase Novolog to handle the meal spikes & to correct highs.

3

Hi there! I have a huge “dawn spike myself” when not on my pump I have run into the same issues with my overnight profile. If you switch to Lantus am and it is indeed only the dawn issue, depending on the amount your Lantus may not hold you for the 24 hrs. I like he suggestion of splitting your Lantus dose. That worked for me, try 60% am 40 % pm. I have even had some folk switch to NPH I know it is old, but the peak is a better match for the dawn spike. Cheers
http://www.three2treat.com

4

Hi Billie – I only inject Lantus after dinner – about 37 IU before I go to bed at around 10 or 11 usually. My current understanding is that Lantus is supposed to give coverage for 22-23 hours, but maybe mine lasts longer and that’s why I go low at night? Perhaps it’s stacking at night? And then tapering in the wee hours back to one dose?

I’ll post back what I find out…if I ever do…

5

JeanV,

Hey there, I am not a MD so take this strictly as someone who has been diabetic for 32 years and doing Dr. B since 2006 (I run www.dsolve.com which has some info on dawn phenomenon control as well). I too have a very pronounced DP effect in the mornings–I have learned that each individual is quite unique and this is always just one of those deals that makes perfect control a challenge. Here are a few thoughts:

  1. Really understand your ratios using Dr. B’s methods–your ratios change throughout the day and especially in the mornings while DP is in effect
  2. For me, DP, which is associated which dumping glycogen in the mornings will go down after I have been low carbing and exercising for a while–I believe if you were to have your blood tested you would slowly see the glycogen stores in your blood start to decrease and this will subsequently help the DP to be less pronounced. There is a form of dieting called Cyclical Ketogenic Dieting (that I have tried) which is centered on the glycogen stores in your body so they are something that can be manipulated both higher (as in CKD) or lower (as in low carb with lots of exercise). Either way, my personal theory (haven’t been able to find any studies on it) is that this will have a subsequent impact on a diabetics DP effect.
  3. consider using milk thistle (silybin) and/or vinegar (even in capsule)–I have had a lot of success dampening my DP with these, but you have to carefully consider the impact on any insulin basal/bolus you take to ensure you lower those if you were taking more to control DP–this has worked for me and both are readily available supplements–you do need to be worried about purity, consistency, etc.
  4. Consider using NPH versus Lantus right before bed to control the DP as the curve for NPH may work better for you there–only do this once you have a good handle that your basal is correct and that your ratios (for both morning and the rest of the day) are fully understood

Those are just a few quick thoughts off the top of my head–here are a few DP resources I found on D-solve:
http://www.dsolve.com/news-aamp-info-othermenu-60/27-how-tos/94-bloodsugars
http://www.mendosa.com/blog/?p=232
http://www.google.com/search?q=controlling+dawn+phenomenon&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a

6

Hi Gerri – thanks again. I’m trying to make sense of this but as I’m very, very, VERY visual, it’s hard to comprehend or communicate what’s going on without us both looking at my beloved white board. ;0) I really am trying – and I really do appreciate your helpful advise more than you can probably realize. I wish you were my doctor! ;0)

Let’s say I split my Lantus dose and take 20 IU at 10 p.m. and 20 IU after I get up, say at 8 a.m. Won’t I end up with MORE Lantus in the evening (between 10 p.m. and midnight) when I don’t need it – and LESS Lantus in the morning (between 6 and 8 a.m.) when I do need it?

Given the advertised (?reliable?) coverage of 24 hours “life” from each injection site: I’m visualizing these doses as being stacking during their full-coverage times, and each one causing the stacked totals to taper off in little dips two hours before each injection and then ramp back up at the time of the injection. Do you see what I mean?

Granted the dips and rises will have less amplitude with two injections, but unless I set the alarm and inject one of them at 3 a.m. (rather than in the evening) it seems that the dips and peaks will hit exactly when I don’t need them to hit. ???

I am working on collecting data to get my insulin:carb ratio and my IISF (thank you!!!) and I agree that the doctor’s sliding scale is way innacurate and cludgy.

I know I need to increase the Novolog (most in the morning, less at midday, least at night) but in the meantime, it seems like I have a big Lantus problem, too. I can only increase it so much without going frequently hypo between say 11 p.m. and 3 a.m. or whenever my darn Dawn Phenom rears its head. I’ve already had one severe hypo at midnight and another at about 1:30 a.m. I can’t track my blood sugar all night manually AND sleep.

What I WANT is CGM and I’m putting all this into charts and spreadsheets to try to convince the head of the diabetes program at my HMO to get off his duff and help me get CGM approved by the HMO. I don’t give a rip what 80 of their Type II patients need or don’t need. I’m not in the 80%. I’m me and I have genetics that are unique – Chippewa, Choctaw, French, German, Serbian, English, etc. tons of auto-immune disease in my family, a genetic complete lack of a diurnal cycle in everyone descended from my Great-Grandmother Emma (it’s called a free-running circadian rhythm), etc.

My HMO has this whole song and dance about “our studies show that CGM doesn’t make a measureable difference in type II outcomes over time” and I just want to SCREAM at them, “Then what is your FREAKING plan to help ME?”

(Insert sound of head pounding here.)

I told my doctor I’d be willing to pay cash for it, but would you believe our HMO doesn’t even have a soul on-staff who is qualified to train patients how to use it or monitor its use afterwards, so they won’t prescribe it? To me that sounds like malpractice but for some reason they’re getting away with it. I think their standards of “care” are bordering on criminal.

7

Thank you! I’ll study all this new information carefully over the weekend. I really appreciate your thoughtful response.

8

I’mT2 on minimal Metformin only, but I’m married[40years] to a T1, who splits his Lantus. Half in the morning and half at bedtime.Even though he’s not very accurate in his carb counting for his boluses, he keeps a fairly steady bg level throughout the day and hypos are rare. Perhaps this strategy would suit you/
Hana

9

Sorry, would be easier with your white board. Your reasoning in valid, but Lantus doesn’t stick around for 24 hours. Had an excellent endo explain this to me & wish I could recall the biochemical details, but basal taken before bed doesn’t last long. Maybe there’s something about this in Using Insulin as well. I took Lantus immediately before bed & as soon as I awoke with no stacking problems. I do the same with Levemir. You’ll have to play around with Lantus doses, what fun!, to see how much you need. It may be less than your current 40 units. It may not need to be equal halves either. You may find, for example, that 15 units in the morning works & 20 at night is what you need to tame dawn phenomenon. Not eating a dinner heavy in protein/fat helps also. Royal pain in the butt, but setting the alarm to test during the night is important. On a weekend:)

The way to test basal, is to skip meals & see how level BG remains. One day, skip breakfast, another day lunch & another day dinner. I hate not eating breakfast because this prolongs the dawn effect. Mine goes sky high if I don’t eat in the morning. Yep, we all hate doing basal testing.

A CGM is helpful, but remember they’re not terribly accurate. Good for seeing trends & you still need to test to assure the CGM data is correct. Some endos have CGM loaners. You’ve got a good case for one as T2 on insulin. Hypo unawareness is the main reason they’re prescribed.

10

I find the variable information on how long Lantus lasts in the body very distressing. On the one hand, the information on their website (which I assume must be FDA reviewed research done at the time the medicaiton was getting FDA approval?) is based on a test involving a fairly small pool of Type 1 diabetics. Everyone knows that the results that Type 1 diabetics with little or no insulin resistance get with insulin is very different than the results for Type 2 diabetics with moderate to severe insulin resistance!

So where is the study done with 300 to 500 Type 2 diabetics over a period of 18 months?

Nowhere that I can find.

So the doctor that originally prescribed Lantus to me – and the CDE in his office who taught me how to use it – told me:

  1. It lasts 24 hours at a very even rate of delivery (maybe starting to taper off at 22 to 23 hours);
  2. Once we titred the dose I should NOT worry about hypos (they gave me zero preparation for hypos);
  3. NOTHING about how my dawn phenom and regular day-to-evening drop in insulin resistance would result in very high mornings and near-hypos to hypos in the evening, a daily drop of about 100 mg/dl from 6 am to 10 pm on (basal, not counting blips for meals/Novolog).

I’ve been poking around and found one reference last night to Lantus only lasting 11 hours in some bodies and to Lantus stacking up dangrously in others due to it staying active for up to 30 hours.

This is all very, very frustrating as an insulin dependent Type 2. I feel like my body is actively fighting with the lovely, idealized version of Lantus that I was taught about by my CDE, but no one in the medical profession (not bloggers and other diabetics, but “real” medical professionals) is doing anything about this but throwing up their hands and blaming me for being fat and Type 2.

When I tried to discuss this with my doctor all she did was remark, “It’s too bad your insurance doesn’t cover gastric bypass surgery.”

Well, it doesn’t – so what are we going to do about this???

Crickets…

So I guess I’m on my own in reading, researching, trial-and-error and hoping I don’t go blind or go into a coma while I’m trying to figure it out.

Yeah. I’m frustrated and scared, but I’m not giving up!!!

Right now I’m working on a very regimented, carefully weighed/measured low-carb menu that I can follow like a little robot for say a week or two and do lots of measuring and testing to see if I can get some valid numbers for my insuln:carb ratio and IISF, knowing full well that what works one day might not work the next day due to hormones, stress, illness, exercise and the phases of the freaking moon.

11

Very frustrating indeed. There should be insulin studies done on T2s, though I’d wager they wouldn’t yield the info needed. As a hormone, insulin doesn’t act in easily predictable patterns for anyone. Would be helpfiul to at least have general info on what to expect. There are T2 members on Lantus who may be able to help. Some are also on rapid acting.

Lantus isn’t level & it sure didn’t last 24 hours for me. Lantus pharm reps have done an excellent job promoting its many virtues. IMHO, Levemir is far superior. I argued my way into getting Levemir because my doc refused to believe my Lantus experience. I won because Ipleaded to try it for one month as an experiment. Told him I’d admit I was wrong & he was right & wash his car if the experiment didn’t work. Think it was the car washing offer that did it:)

Crazy, but diabetes is a learn as you go disease. Don’t look for black & white answers or it will drive you nuts. Truth is doctors & many CDEs go by their textbook, which doesn’t exist in the real diabetes world.

When I was discharged from the hospital (DKA), I knew nothing. The gave me a handful of scripts. I didn’t even know how to give myself an injection. I had to flag down a nurse to show me the day I went home. I was given confusing & conflicting hand-outs & that was it. I spent days crying in frustration because I had no clue what to do. No one even told me what basal or bolus was for! I was told to take 35 units of Lantus & given a warning about dying in my sleep. 35 units was an absurd amount for my weight & amazing I didn’t die overnight. I take less than a third of that now. My point is that you are not alone in your frustration or your struggles.

12

I totaly understand JeanV what you are going through. My situation is similar. If you are interested feel free to read on.

This is my third week going low carb. I received my DR. Bernstein books last week and am trying to read them as fast as possible. As I read each chapter I am learning what and how much and how often to eat. I actually think I wasn’t eating enough before I found his guides. Anyway the first week doing low carb I was running nearly 300 in the am. I wake up at 5:00am Monday-Friday. Before and after meals I would be in the 200’s-300’s. My second week I was running in the 200’s range Am-PM with an “Occasional” super high 100’s [almost 200]. in the morning. This week, my third week I am in the 100’s range. I did have two low sugars on Monday night one was 54 and the other 42 and over corrected so I woke up with a BG of 279. As I read more of the book that afternoon, I found to correct lows I eat a pack of Smarties instead of a small meal.So on Tuesday when my BG was at 113 at 11pm I started to freak out I would get way low in the middle of the night so I ate a pack of smarties, when I woke up my BG was 155.
Thursday and today Friday, my BG is running in the 90’s range to about 143. I am so excited! I haven’t been doing this good since first diagnosed in 1994! I know I have more work to do to get to the 80 range DR. B wants us at but I think I can do it.

Any idea how to maintain a BG of the 90 range without having a low sugar at night?

13

Your experience with initial diagnosis and so-called instruction made me cry.

Multiply your and my experience by thousands and thousands of diabetics each year and it makes me want to start a HUGE class-action lawsuit against the entire medical industry for turning out, licensing and paying these lazy, ignorant idgets year after year after year.

How DARE they? You know? How dare they?

I can’t imagine how they sleep at night, as lazy, incurious and downright dangerous as they are. Then they turn around and whine about the cost of malpractice insurance? Really?!?

14

How dare they are is right! Far, far more egregious cases than mine. Read things here that keep me up at night.

15

Hi Yolanda, you’re doing GREAT!

I have the same problem you’re having – higher in the morning, lows at night. So no, I don’t know yet how to balance everything, but I keep trying. Do you inject fast-acting with meals as well as daily Lantus like I do? Geri has some good ideas about the need to adjust the fast-acting through the day (if you’re like me, for the same number of carbs in a meal – say 15 gm – you might need a little bit more fast-acting insulin in the morning or at lunch and less fast-acting at night.)

I just got the book Using Insulin so I hope it will help me understand better.

Hang in there – your progress is VERY impressive.

16

Thanks, Trev. I’m thinking about setting an alarm and checking my blood sugar at 3 or 3:30 a.m. on a few nights (say early Sunday morning for three weekends) and see what’s going on around then. If I injected my Lantus at 3:00 a.m. – to rise and level off at its top plateau level at 4 a.m. – I wonder if it would knock back the Dawn Phenom?

17

HI Jean~
You have so many scientific and well thought out answers here already, I just was going to add my tidbit of personal experience I had a terrible time with DP and no need to reduce weight. I am on Dr. B’s diet, for two years now. I am a Type 1.5 with a slow onset diabetes Guess now I should just say Type 1. I take 14 units of Levemir before bed with 1000mg metformin, upon waking I take 1000mg more of metformin then if I eat more than 6 carbs I use Novolog to help. I don’t know how you feel about this oral med metformin, but it does work for me along with my long acting Levemir. I have the problem with my liver dumping all the extra glucose all morning from the time I step out of bed until 10am ish. This has really controlled it for me with all three working in the past six months. It seems to be a changing game as the D progresses for me. I know we are all different and I hope you have great success and find the best solution for you now. Chin up and good luck!

18

Thanks for your reply, Dawn, but Metformin and I don’t get along. I tried it for two years – and I spent most of that two years in the ladies room. Sigh.

It’s too bad, because I know it helps a lot of other type II’s with their control. I just couldn’t take it anymore.

I’d like to try Levemir but my HMO won’t cover it. They have all these draconian rules based on the 80/20 thing – if 80% can get by on the cheaper drug, they won’t cover the 20% who need something different. I’m thinking about suing them into the next century…they shouldn’t be legally allowed to practice medicine without a license, and being a bean counter is NOT the same thing as being a doctor, even if you’re a bean counter for an HMO.

19

Hi Jean, thank you for your comment. On Friday I started taking some fast acting 1-2 units before lunch and if I was still above 140 a couple hours later another 1-2 units. I am still not in the 90’s range all day but have seen some BG’s of 96. I still am in the 100’s range but working on it. Friday night about 10pm my BG was 106 and this time I didn’t take anything to raise my BG INCASE I got low at night. I woke up at 4:15 am and checked my suagr and it was 186 so I ate a couple slices of turkey breast because that’s what DR. B says to do, eat protein in the morning to avoid your BG raising due to Dawn Phenomenon and I didn’t want it to get higher because I wanted to go back to sleep. When I was up by 8am my BG was at 196. Anyway to day is Saturday and I just felt hungry all day so ate more protein than normal so I am still in the 100’s but they are the higher 100’s range. Tomorrow is Sunday and it is a new day and I will try again. Another member of TU Diabetes commented to me that DR. B has webinars that you can view on Youtube and people send in questions and he answers them. I think I will look for some of these tomorrow regarding Dawn Phenomenon. Maybe we are still new to this diet and it will just take some more time for our bodies to work this out. I am PROUD of you Jean for sticking with it!

20

Yolanda,



Eating mostly protein for breakfast to curb dawn phenonmenon is different than eating protein in the middle of the night. Curious why you’d eat with 186 BG.



Dr. B has monthly 1-hour web casts. You can register at www.diabetesincontrol.com & submit questions there. There are interiews with Dr. B on Youtube & taped talks at conferences, but his webcasts aren’t there.