Building Competency in Diabetes Education THE ESSENTIALS

3-10 | CHAPTER 3

to the end of the nocturnal period (0300-0600 AM), in the absence of carbohydrate intake in individuals with type 1 or type 2 diabetes (13). Most likely the mechanism of dawn phenomenon is nocturnal spike of growth hormone secretion and its subsequent physiologic effect on the liver (13). Using continuous glucose monitoring (CGM), Monnier et al. reported that dawn phenomenon induces high blood glucose levels not only before breakfast, but also after breakfast, contributing to higher insulin resistance post-breakfast (13). This is referred to as extended dawn phenomenon (13).

Glucocorticoids (12) Glucocorticoids (95% cortisol) stimulate hepatic gluconeogenesis and decrease glucose uptake and utilization. Glucocorticoids increase glycogen storage in the liver.

Endocannabinoid system and energy balance With the changing public policy in Canada and the legalization of marijuana for medical and/or recreational use in 2018, diabetes educators need to be aware of the endogenous cannabinoid system (ECS) and its potential impact on people with diabetes who utilize cannabis. The ability of the ECS to control appetite, food intake and energy balance has received significant attention recently. Understanding of this hormonal system dates back to the discovery of the therapeutic and psychotropic actions of Cannabis sativa 4,000 years ago (14). Marijuana refers to the dried hemp plant Cannabis sativa. It contains chemicals called cannabinoids which, if injected, smoked or eaten, interact with the receptors of the ECS (14). The endocannabinoid system is a lipid-signalling system that has important regulatory functions throughout the body. It consists of cannabinoid receptors, endogenous cannabinoids, and the enzymes that metabolise the endocannabinoids (14). Endocannabinoids have been linked to complex processes, such as pain, stress response, anxiety, appetite and motor learning (14). Fat cells (adipocytes) not only regulate the storage and release of fat, but also secrete a number of protein factors (resistin, leptin and adiponectin) that relate to insulin sensitivity (see Insulin Resistance, below). In the brain, the system relates to motor control, cognition, emotional responses and motivated behaviour. Outside the brain, it is a crucial moderator of the autonomic nervous system. Potential effects from animal models are outlined in Table 1.