Ask a Diabetes Educator

“I have type 2 diabetes, diagnosed five years ago, and am 67 years old. I have worked very hard to manage this disease, but without the success I would like.”

This is how a reader to Diabetes Health started a letter to us. She had four questions, which we altered slightly to apply to our broader readership. We asked a member of the American Association of Diabetes Educators, Iris Sanchez, DNP, FNP, ADM, CDE, to share her answers to the reader’s questions. Sanchez is a family nurse practitioner and diabetes educator who practices in South Texas.

What causes my blood sugar readings to be high when I wake up in the morning?

Elevated morning glucose can be caused by the dawn phenomenon, the Somogyi phenomenon, the release of counter-regulatory hormones, or an excess consumption of carbohydrate the previous

The dawn phenomenon describes a state in which there is an overnight decline in insulin levels. The Somogyi effect describes a state in which there is a rebound to nocturnal hypoglycemia. Counter-regulatory hormones, including cortisol, growth hormone, glucagon, and epinephrine, can also cause morning hyperglycemia. The use of continuous glucose monitoring (CGM) can help determine if there are hypoglycemic episodes during the night or if there is a steady rise in glucose in response to decreasing insulin levels.

Why do my blood sugar levels go up after exercise?

Physical activity plays an important role in lowering blood glucose levels.  For several reasons, however, it is not uncommon to have higher blood glucose levels after physical activity. During lengthy vigorous physical activity, chemicals in the body, such as dopamine or adrenaline, cause a release of glucose for fuel. This can last for several hours, especially in those with type 1 diabetes. Dehydration or inadequate water intake can also lead to hyperglycemia. Be sure to evaluate the increase in glucose levels, how often the increase occurs, and the amount, type, and timing of food intake before initiating physical activity.

What solid or liquid foods would be a good substitute for glucose tablets or candy when I experience hypoglycemia?

Mild hypoglycemia, characterized by sweating, trembling, lightheadedness, and difficulty concentrating, can be treated with 10 to 15 grams of glucose. This can be found in simple carbohydrate sources, including eight or ten Lifesaver candies, two tablespoons of raisins, four to six ounces of nondiet soda or fruit juice, one piece of fruit, or one cup of lowfat or nonfat milk.  It is important to carry some form of glucose and to learn how many grams of glucose are contained in each serving of common food items.  To avoid overtreatment, it is also important to wait 15 to 20 minutes after initial treatment before treating again.

Travel is a struggle when it comes to making insulin adjustments for time zone changes and different altitudes. Any advice?

Pump users can continue their scheduled basal and bolus doses, but should change the time setting in their pump once the final destination is reached.  For non-pump users, a basal-bolus regimen with a
long- and short-acting insulin may provide a better regimen to adjust to time zone changes.

When traveling east across more than five time zones, a reduction in insulin dose is recommended to adjust for the shortened day.  When traveling west over five time zones, an increase in insulin dose is
recommended to adjust for the longer day.

Monitor your blood glucose more often, and carry a wristwatch corresponding to your departure time at your point of embarkation.  Incremental time adjustments during the first two days of arrival at the
destination are recommended.

Altitude changes can have an impact on insulin delivery with pumps.  Bubbles form when ascending, causing excess insulin delivery.  When descending, the bubbles dissolve, decreasing the delivery of
insulin.  It is recommended to disconnect the pump before takeoff, remove air bubbles before reconnecting once cruising altitude is reached, and place no more than 1.5 mL of insulin in the cartridge.

The preceding questions point out some of the problems encountered daily by people with diabetes. However, the information provided is not meant to substitute for individualized treatment. Ongoing
communication with a diabetes educator and healthcare provider is recommended.


2nd edition (2011) The Art & Science of Diabetes Self-Management Education Desk Reference.

Chandran, M & Edelman, SV, 2003, Have insulin, will fly: diabetes management during air travel and time zone adjustment strategies. Clinical Diabetes, 21(2), 82-85.

King BR, Goss PW, Paterson MA, Crock PA, Anderson DG. Changes in Altitude Cause Unintended Insulin Delivery From Insulin Pumps. Diabetes Care. 2011;34(9):1932-1933.

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