This patient received an inappropriately large dose of insulin NPH in the evening, which resulted in a nocturnal hypoglycemic state. This is followed by a rebound hyperglycemia the following morning, called the Somogyi effect. The remedy is to lower the dose of night time insulin. There is a natural increase in blood sugar that occurs due to increased cortisol secretion in the morning (Dawn phenomenon). This is mild and transient and is not an indication to modify the insulin dose. Illness and other stressful events will cause an increase in cortisol, which will elevate blood sugar levels, requiring increased dosages of insulin to maintain glycemic control. However, this elevation is constant for the duration of the illness and does not only occur in the mornings. Volume contraction is not an appropriate explanation for this patient’s morning hyperglycemia.