Managing High Nighttime Blood Sugar with Normal Morning Levels

High blood sugar before bedtime and normal blood sugar upon waking?

Hello Dr.
Hsiao, my mother is seventy years old.
She takes insulin during the day and controls her diet for three meals, but her blood sugar levels are consistently over 300 before bedtime.
In the morning, her levels are often between 90 and 130.
What can be done to improve this? Thank you.

A-Xia, 70~79 year old female. Ask Date: 2015/03/26

Dr. Xiao Yongxun reply Internal Medicine

1.
There are many types of insulin, primarily including ultra-rapid acting, rapid acting, intermediate acting, and long acting.
The timing of their peak effect and duration of action varies.
Clinically, it is possible to mix rapid acting and intermediate acting insulins for injection, as well as other combinations, potentially including oral medications.
Additionally, the injection frequency may vary, ranging from once a day to multiple times a day, even exceeding four times.
Therefore, the composition and ratio of your mother's insulin injections, as well as the frequency and timing of injections, can all affect blood glucose test results.
2.
On the other hand, dietary content, proportions, total caloric intake, meal timing, and frequency can also influence blood glucose test results.
3.
The intensity, duration, and frequency of exercise can also impact blood glucose control.
4.
Of course, factors such as infections, sleep, stress, and drug interactions can also affect blood glucose levels.
5.
Your mother's fasting blood glucose in the morning is between 90 and 130 mg/dL, which is acceptable for a 70-year-old.
Generally, if there are no special restrictions, it is best to maintain the hemoglobin A1c (HbA1c) level around 7%.
6.
A bedtime blood glucose level above 300 mg/dL may be due to overeating at dinner, lack of exercise, consumption of foods with a high glycemic index, or the insulin not having fully taken effect.
7.
For diabetes management, blood glucose levels are generally recommended to be below 100 mg/dL before meals and around 140 mg/dL after meals, with an ideal HbA1c level below 6.5%.
However, stricter blood glucose control increases the risk of hypoglycemic coma.
Each episode of hypoglycemic coma is akin to a stroke; in severe cases, it can lead to hypoxic brain injury, resembling a vegetative state.
8.
Regarding your mother's situation, it is advisable for you and your mother to discuss the details with her attending physician before making any decisions.

Reply Date: 2015/03/26

More Info

Managing high nighttime blood sugar while maintaining normal morning levels can be a complex issue, especially for older adults with diabetes. Your mother's situation, where her bedtime blood sugar levels are significantly elevated (over 300 mg/dL) but her morning levels are relatively normal (90-130 mg/dL), suggests that there may be several factors at play. Here are some insights and recommendations based on her condition.

Understanding Blood Sugar Fluctuations
1. Dawn Phenomenon: This is a common occurrence in people with diabetes, where blood sugar levels rise in the early morning due to hormonal changes. Hormones such as cortisol, glucagon, and epinephrine increase insulin resistance and stimulate glucose production in the liver, leading to higher blood sugar levels. However, in your mother's case, her morning levels are not excessively high, which may indicate that her body is managing this phenomenon reasonably well.

2. Somogyi Effect: This phenomenon occurs when a person experiences low blood sugar during the night, prompting the body to release hormones that raise blood sugar levels. If your mother is experiencing low blood sugar at night (which may not be detected if she is not monitoring her levels during the night), it could lead to a rebound effect, causing high blood sugar levels in the morning.

3. Insulin Management: Since your mother is using insulin, it’s crucial to evaluate her insulin regimen. The timing, type, and dosage of insulin can significantly impact blood sugar levels. If her insulin dose is too low, it may not adequately control her nighttime blood sugar. Conversely, if it’s too high, it could lead to nighttime hypoglycemia followed by rebound hyperglycemia.

Recommendations for Improvement
1. Monitor Nighttime Blood Sugar: Encourage your mother to check her blood sugar levels before bed and possibly during the night (around 2-3 AM). This will help identify if she is experiencing low blood sugar during the night, which could explain the high morning readings.

2. Adjust Insulin Dosage: Consult with her healthcare provider to review her insulin regimen. It may be necessary to adjust her nighttime insulin dose or switch to a different type of insulin that provides better coverage during the night.

3. Dietary Considerations: Assess her evening meals. Consuming a balanced meal with adequate protein and healthy fats can help stabilize blood sugar levels overnight. Avoiding high-carbohydrate meals or snacks close to bedtime may also be beneficial.

4. Physical Activity: Encourage regular physical activity during the day. Exercise can improve insulin sensitivity and help regulate blood sugar levels. However, it’s essential to avoid vigorous exercise close to bedtime, as it can sometimes lead to elevated blood sugar levels.

5. Stress Management: Stress can significantly impact blood sugar levels. Encourage relaxation techniques such as deep breathing, meditation, or gentle yoga, especially in the evening.

6. Regular Follow-ups: Regular follow-ups with her healthcare provider are crucial. They can help monitor her overall diabetes management and make necessary adjustments to her treatment plan.

7. Consider Continuous Glucose Monitoring (CGM): If feasible, a CGM device can provide real-time blood sugar readings and trends, allowing for better management of her diabetes.

Conclusion
Managing diabetes, particularly in older adults, requires a comprehensive approach that includes monitoring, medication management, dietary adjustments, and lifestyle changes. By closely monitoring her blood sugar levels, adjusting her insulin regimen, and making necessary lifestyle changes, your mother can achieve better control over her nighttime blood sugar levels while maintaining normal morning levels. Always consult with her healthcare provider before making any significant changes to her diabetes management plan.

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