During sleep, you are without food (fasting) for hours. It makes your blood glucose drop, and proportionally your insulin level is also reduced. At the same time, glucagon level rises, which instructs the liver and muscles to ramp up glucose supply.
Fasting can elevate cortisol levels, which in turn raises blood sugar. So, for someone with blood sugar regulation issues such as diabetes, fasting may make their blood glucose worse.
What is the Somogyi effect?
The Somogyi phenomenon is due to your body’s reaction to midnight hypoglycemia. Since the patient is sleeping, they don’t feel the hypoglycemic symptoms such as tiredness, shakiness, tremors, or confusion. This low blood sugar is undesirable. Thus your body reacts to this with an overshoot of counterregulatory hormones such as glucagon, epinephrine, growth hormone, and cortisol. It makes the liver dump hepatic glucose, which raises morning blood glucose levels even up to the 300s. Additionally, counter-regulatory hormones may cause insulin resistance for about 12 to 48 hours.
Fasting blood sugar level is elevated in reaction to the preceding low. Thus Somogyi effect is also called as rebound hyperglycemia.
The patient has succumbed to increasing the insulin dose still more; this leads to further hypoglycemic episodes. A vicious circle leads to an increase, and increased insulin doses occur with extremely unstable and brittle diabetes.
High dose insulin / Missed meals --> Hypoglycemia at midnight --> Body adjusts by releasing cortisol, glucagon, etc. --> Hyperglycemia in the morning --> Treatment is by insulin dose modification.
What causes the Somogyi phenomenon? Causes of the Somogyi phenomenon may include wrong insulin treatment (dose or timing) or missed meals/snacks.
What are the symptoms of Somogyi rebound? At night, if you wake up a few times sweaty with a rapid heart rate indicates adrenaline shoot-up and rebound hyperglycemia. But, unfortunately, evidence shows type 1 diabetes do not wake during hypoglycemia episodes.
When & who discovered the Somogyi effect?
In 1938, in a group of unstable diabetics study, Dr. Michael Somogyi and Kirstein noted excess of treatment with insulin could be a cause of extreme hyperglycemia and improper control. This phenomenon of rebound hyperglycemia; hypoglycemia followed by hyperglycemia is known as the Somogyi phenomenon.
Prevalence of Somogyi Phenomenon
Prevalence of Somogyi phenomenon is about 12.6%, but often goes undetected! Somogyi effect is less common as compared to Dawn phenomenon.
About 10% of insulin-treated diabetics, fall into the brittle or unstable diabetics. The Somogyi phenomenon is rare; occurs in diabetes type 1 and is less common in type 2. It is more commonly associated with type 1 diabetes because it is associated with little endogenous insulin production and reliance on insulin.
Diagnosis of Somogyi phenomenon
How do you detect the Somogyi effect? The best method to detect Somogyi is continuous blood glucose monitoring. However, it is not yet widely used. Alternatively, you can detect it by testing your blood glucose more often, say 8 to 10 times with your blood glucose meter specifically more often during pre-dawn.
If you are experiencing high fasting blood sugar levels even after increasing your nighttime insulin dose, then it might be a Somogyi phenomenon. If you are experiencing hyperglycemia that does not respond to your treatment as expected, then it is most probably due to the Somogyi effect. To confirm diagnosis check your blood sugar at 2 or 3 a.m., if it is low, then it confirms the diagnosis of the Somogyi Effect.
I am not sure, if the morning hyperglycemia is due to Dawn or Somogyi effect, what to do? The simple lazy way is to a slight decrease in the insulin dose at night. If there is an increase in blood glucose level in the next day morning, then it is a Dawn phenomenon. If the glucose level is normal or decreased in the next day morning, then it is a Somogyi phenomenon.
Treatment & Management
How do you treat the Somogyi effect? Somogyi phenomenon recommends a gradual reduction in the insulin dose to achieve stable blood sugars, decreased urinary glucose excretion, and effective diabetic control. If the Somogyi phenomenon is wrongly detected, a reduction in insulin dose will only aggravate the hyperglycemia.
The best treatment option is to prevent the hypoglycemia from happening. For this, you need to reduce evening or bedtime insulin dosage.
Additionally,
- You can take bedtime snacks high in protein, moderate in fat, and low in carbohydrates to avoid midnight hypoglycemia. For example a piece of toast with peanut butter, or some cottage cheese, or yogurt, or some nuts and a small piece of cheese.
- Always manage your glucose level slightly higher before going to bed.
- Take a blood glucose test between 2 to 3 a.m. and check how effective your treatment is and consult your doctor, if you need any changes such as type and dosage of insulin, or oral medication.
- Substituting your regular insulin with an immediate-acting insulin analog, such as Humulin lispro, may help you. Still, it is not firmly established.
A liver dump can happen if you take insulin (or other insulin-stimulating medications) without an adequate amount of carbs and may end up with low blood sugar levels. So it is important for you to balance medication with the proper quantity of carbs, this usually requires testing to arrive right quantity for you.
Similar to medication, an excess amount of exercise not balanced with an adequate quantity of carbs ends up with liver dumps. Carbohydrates are not enemies for people with diabetes. Instead, you should learn when and how to take them for beneficial results.
It looks complicated at the beginning, but over time, you start learning to balance it correctly. You just need some testing with patience and interest to learn.
For many diabetic insulins are not working to their optimal level; it is because of injecting insulin in the skin area affected by lipo hypertrophy. The most used insulin injecting area may develop fat build-up. Therefore, you must rotate your insulin-injecting site often.
The best solution for this high fasting glucose level is to take your dinner before sunset (i.e. before 7 p.m.). Take real nutritious food preferably low in carbohydrates. Additionally, go for a lazy walk (not brisk walking), this helps to faster regulation of blood glucose after dinner and helps to avoid midnight drop in glucose, which in turn helps stop the dumping of glucose by the liver. This, help normalize fasting blood glucose level.
Somogyi controversy!
SOMOGYI's concepts were not universally accepted. Because studies using continuous glucose monitoring show that low glucose does not precede high glucose in the morning or at night. Reference: Nocturnal hypoglycemia in type 1 diabetic patients: what can we learn about continuous glucose monitoring? Diabetes & Metabolism, 2007: 33: 360-365.
The Somogyi phenomenon has been documented in great detail; as the exacerbation of diabetes by excess insulin action. Still, there is controversy about its existence. Asymptomatic hypoglycemia is one reason the Somogyi phenomenon has not been widely accepted. Somogyi effect is controversial and difficult to prove its presence or absence.