During the years when type 2 diabetes slowly develops (which may be up to 10 years through developing metabolic syndrome and continuing on to prediabetes), hormonal control of blood glucose breaks down. To understand how your body responds, it's important to understand the essential hormones involved in blood glucose control.
Four hormones are involved in blood glucose control:
Insulin, made in the beta cells of the pancreas, helps the body use glucose from food by enabling glucose to move into the body's cells for energy. People with type 2 diabetes have slowly dwindling insulin reserves.
Amylin, secreted from the beta cells, slows the release of glucose into the bloodstream after eating by slowing stomach-emptying and increasing the feeling of fullness. People with type 1 and type 2 diabetes are amylin-deficient.
Incretins, hormones secreted from the intestines that include glucagon-like peptide 1 (GLP-1), enhance the body's release of insulin after eating. This in turn slows stomach-emptying, promotes fullness, delays the release of glucose into the bloodstream, and prevents the pancreas from releasing glucagon, putting less glucose into the blood.
Glucagon, made in the alpha cells of the pancreas, breaks down glucose stored in the liver and muscles and releases it to provide energy when glucose from food isn't available
For people in the early years of type 2 diabetes, the hormones that control blood sugar can particularly go awry. Here's what happens during sleep to a person with type 2 diabetes:
"Overnight, the liver and muscles get the message from excess glucagon to ramp up the glucose supply because the person is sleeping, not eating," says Marty Irons, R.Ph., CDE. "There is not enough GLP-1, insulin, or amylin hormones to stem the tide of excess glucose from the liver and muscles, essentially throwing this feedback loop out of whack."
High fasting blood sugar levels, particularly in the earlier years of type 2 diabetes, result from this hormonal imbalance. Evening meals and snacks may get the blame for morning highs, but hormones are the likely cause.
You can't completely reverse the hormonal imbalance of type 2 diabetes, but a combination of actions can solve the high fasting blood glucose problem. "With your health care provider's guidance, experiment to find what works for you," says Arlene Monk, R.D., CDE, a dietitian and diabetes educator at the International Diabetes Center at Park Nicollet in Minneapolis. The following tips offer some actions that may improve morning numbers.
As guidelines from the American Diabetes Association and American Association of Clinical Endocrinologists suggest, "Most people need to start a blood glucose-lowering drug at diagnosis to fight the insulin resistance and resulting hormonal imbalance," says Marty Irons, R.Ph., CDE. The most common starting medication, metformin, cuts down on glucose overproduction overnight. Beth DeLauder, 46, PWD type 2, takes metformin, as does Pete Hyatt, 59, PWD type 2. Both say it's been one factor among many lifestyle changes to help lower their fasting blood sugar levels.
Newer drugs are prescribed as starting or add-on medications when blood glucose goals aren't met. The oral dipeptidyl peptidase-4 (DPP-4) inhibitors sitagliptin (Januvia) and saxagliptin (Onglyza) keep more of the GLP-1 hormone circulating. The more potent injectable GLP-1 agonists exenatide (Byetta) (twice daily) and liraglutide (Victoza) (once daily) increase the amount of GLP-1 available. They're in the class of incretin mimetics, also called GLP-1 analogs. Some people also experience weight loss while using GLP-1 analogs
"As type 2 progresses, especially beyond 10 years, many people need to add insulin to control fasting and other blood glucose levels through the day," Irons says. "When starting insulin, most providers use long-acting Lantus or Levemir."
Weight loss, especially soon after diagnosis of type 2 diabetes, can help the hormonal disturbances, increase insulin sensitivity, and lower blood sugar levels. The best approach: "Make lifestyle changes, choose more healthy foods, trim the portions of less-healthy foods, and crank up your physical activity," says Arlene Monk, R.D., CDE.
You'll see blood glucose drop before the pounds do. "Losing weight pushed my A1C from 6.9 percent to 5.8 percent and my average fasting blood glucose from 140 to 100," says Beth DeLauder, PWD type 2. She's lost 35 pounds by minimizing processed foods and added sugars and sticking to her carb counts. Pete Hyatt, PWD type 2, who weighs about 220 pounds, has focused on not gaining weight -- a realistic goal. For people who have had type 2 diabetes for many years, losing weight alone is unlikely to correct fasting highs or other highs through the day -- medication, possibly in more than one category, is likely needed.
A small bedtime snack containing some carbohydrate, but no more than 20 grams, can help you wake up with better fasting blood glucose, says Arlene Monk, R.D., CDE. A bedtime snack shortens the time span that the liver is in overdrive producing glucose while you sleep.
Our Facebook fans suggested these carb-friendly options:
One serving of bite-size tortilla chips and fresh salsa
Hummus and edamame (soybeans)
Small piece of fruit
Sugar-free frozen pops
No matter what kind of aerobic activity you do or what time of day you do it, moving more enhances the body's response to insulin. "Being inactive is bad for us. Some is better than none; more is better than less," says Arlene Monk, R.D., CDE.
Easy ways to get more exercise:
Do 10 minutes of stretching after getting out of bed.
Park your car in the back of the parking lot to get in more walking
Take the stairs when, and if, you can.
Grab a friend to go on an early morning walk with you.
Sit on an exercise ball while on the computer or watching TV.
Before acting on a solution to lower your morning fasting blood sugar, consider the blood sugar numbers on your meter, your A1C results, your lifestyle, your schedule, the medications your health plan covers, and what you can afford. Use meter checks and regular A1C results to assess the solutions you try. Remember that your fasting blood sugar numbers tell you how you made it through the night. Checks midway through your sleep cycle cast light on what's happening overnight. Be ready to change your solutions if you don't hit your targets quickly and as your years with diabetes add up.
Hope Warshaw, R.D., CDE, coauthored Real-Life Guide to Diabetes (American Diabetes Association, 2009) and is a contributing editor to Diabetic Living.