Morning Levels Falling Mystery

[digihat]

Good Morning Everyone 🙂

Just wondered if anyone might have any thoughts on the below I'm a bit baffled Im catching up with my DSN in a few weeks so was going to bring it up then as well

I currently take 22 units of Toujeo in the morning was previously 32 units but had to reduce it quite drastically recently to stabilise bloods abit due to meds i was on. I'm off these the meds now and starting to gradually increase the basal again once every 7 days under consultant advice.

One thing I have noticed is regardless of being on 32/22 units a day that my levels start to fall quite abit after a little while first thing in the morning I dont often eat breakfast as I don't get hungry. In the past I put this down too much basal based on a basal test. However I get quite abit of overnight rise which is why the Toujeo was at 32 previously. This makes me think it's not related to the basal as I see the same behaviour while being on a lot less. I know overnight can be down to food as well but i have noticed my highs being higher than before probably down to not enough basal

Ive attached this morning's graph to show what I mean

Hope the above makes sense

 

[everydayupsanddowns]

When do you eat your evening meal @digihat ?

 

[digihat]

@everydayupsanddowns usually around 8pm last night didn't have anything particularly high glycemic index wise. What I end doing alot at the moment is I have to raise levels after an hour or two normally just before bed alarm is at 5mmol currently lost alot of my hypo awareness based on advice from consultant. Then it keeps rising while sleeping not surprised due to lower my basal quite abit recently but then morning if I don't eat goes off a cliff pretty quick. Maybe that is simply the issue

Ive attached yesterday graph to show late evening where it shows when i took a mini can

 

[everydayupsanddowns]

Ah that’s interesting. Looks like the initial high levels overnight are probably connected to what happens late evening?

I wonder what it might look like if you shifted your evening meal nearer to 6pm?

Do you prebolus at all for your evening meal? Your meal bolus from 8pm would be still active until 2-3am, so your drop overnight is at least partly rapid insulin I think.

Timing your meal bolus to match the food digestion might help take the edge off the rise? Start with injecting 5-10mins before starting to eat, then cautiously add 5mins wait-time until your meal rise levels out a little maybe?

 

[digihat]

Ah that’s interesting. Looks like the initial high levels overnight are probably connected to what happens late evening?

I wonder what it might look like if you shifted your evening meal nearer to 6pm?

Do you prebolus at all for your evening meal? Your meal bolus from 8pm would be still active until 2-3am, so your drop overnight is at least partly rapid insulin I think.

Timing your meal bolus to match the food digestion might help take the edge off the rise? Start with injecting 5-10mins before starting to eat, then cautiously add 5mins wait-time until your meal rise levels out a little maybe?

Yeah when I was previously doing 32 units which kept it suppressed for the most part but still likes to rise. I can eat earlier if I want we just try to always eat as a family where we can 8pm tends to be when it falls.

I pre bolus about 20 minutes normally which i have found works pretty well me so far but im finding my levels aren't responding as much to food such as potato normally get a good spike quickly recently barely moved

I wake up around 5/6 am I then take the toujeo first thing. Levels stay steady for about an hour then drop quite fast this as an example morning not done exercise or eaten anything either just to clarify

Might just be a quirk of my diabetes and my body

 

[digihat]

I took a mini can and then some slow release carb not long after posting its steadied out maybe I just need to eat breakfast

 

[Inka]

Perhaps the Toujeo is releasing too quickly @digihat ? There have been (worse) issues with Lantus occasionally causing hypos due to this. If you can’t sort it, then you could try a different basal.

On a note, I find eating closer to 6pm makes the evening and night blood sugars easier to control, so do try that too.

 

[digihat]

Perhaps the Toujeo is releasing too quickly @digihat ? There have been (worse) issues with Lantus occasionally causing hypos due to this. If you can’t sort it, then you could try a different basal.

On a note, I find eating closer to 6pm makes the evening and night blood sugars easier to control, so do try that too.

That's an interesting point @Inka haven't really thought about that before

I ate abit earlier last night rise still happened although looking back through recent graphs my rises are alot more delayed for the same meal joys of trying to figure it out

I think i need to change timing or basal as you suggest been working on the basal for months thought I had it at 32 just been right for awhile but that feels too much now. Need to change something as I need to do a few interventions most days at the moment dont find it staying steady alarm is at 5 to rebuild hypo awareness for the moment but we will get there eventually

 

[digihat]

Just bumping this thread up with an update after I saw my DSN the other week. We've tried changing up the timing to evening instead of morning still same series of patterns followed. They offered to switch my to tresiba which we agreed we would do if the switch timing didn't work which looks to be what the outcome will be. The annoying thing is the Toujeo works fine the rest of the day. Currently taking Toujeo 38 units having to knock it up more for overnight almost there I think. From what i can tell there doesn't seem to be too much difference between Toujeo and Tresiba?

This mornings graph

 

[SimonP]

I think I'd be tempted to take more bolus to cover your evening meal and/or split the dose to cover into the night, and then you'd probably be able to reduce basal to (hopefully) avoid the morning low. Have you tried a fasting test in the evening, not much fun, but you could also look at reducing your total carb intake for the test rather than eliminating it completely to see if it's an issue with insufficient bolus.

 

[digihat]

I think I'd be tempted to take more bolus to cover your evening meal and/or split the dose to cover into the night, and then you'd probably be able to reduce basal to (hopefully) avoid the morning low. Have you tried a fasting test in the evening, not much fun, but you could also look at reducing your total carb intake for the test rather than eliminating it completely to see if it's an issue with insufficient bolus.

Yeah thats an interesting to suggestion will make a note of it to try it out. I try to keep my carbs down generally within reason of course. This is the graph from last night pretty steady had potato with the evening meal as well. Ive been making observations of patterns this morning was awake at 5 yet levels have stayed steady. The only difference is I have come into the office today about an hour travel which includes walk bus etc. The morning falls I have seen happen when I was taking a lot less basal in the low 20's so it might be some quirk of my body I need to fine tune! Thanks for the suggestions

 

[helli]

I try to keep my carbs down generally within reason of course.

Why?
Managing Type 1 diabetes is about managing insulin not diet.
There is nothing wrong with eating carbs (and more than one potato) if you are able to match the insulin.
Some people with Type 1 chose to follow a low carb diet because it reduces their bolus dose. However, in the absence of enough carbs, out body will break down protein so you then have to start counting protein and dosing insulin for it.
When I tried this, I found I needed a different insulin to protein ratio for different types of protein. Oh, and the protein conversion happens later than the carbs so I needed to always split my dose. This seemed unnecessarily complicated for me and quickly reverted back to a normal level of carbs.
Carbs are not evil despite some of what you read from type 2 keto zealots.

 

[digihat]

Why?
Managing Type 1 diabetes is about managing insulin not diet.
There is nothing wrong with eating carbs (and more than one potato) if you are able to match the insulin.
Some people with Type 1 chose to follow a low carb diet because it reduces their bolus dose. However, in the absence of enough carbs, out body will break down protein so you then have to start counting protein and dosing insulin for it.
When I tried this, I found I needed a different insulin to protein ratio for different types of protein. Oh, and the protein conversion happens later than the carbs so I needed to always split my dose. This seemed unnecessarily complicated for me and quickly reverted back to a normal level of carbs.
Carbs are not evil despite some of what you read from type 2 keto zealots.

Its just the approach I decided to take as I try to keep my bolus down really i generally have about 120grams ish a day or carbs sometimes more. I dont have an arbitrary target I aim for per say. I generally dont avoid foods barring celiac disease side of things which i have. I may reduce the amount of times a week i have certain foods but I still have them. I used to over eat quite abit as well when I got to my heaviest of 108 KgG before the rapid weight loss kicked from the diabetes where as I'm holding steady at about 79Kg now.

I think its partly a fear factor as well due to larger bolus more room for error when ive had some larger bolus its back fired a few times with battling to keep levels up afterwards

Only about 7 months in so far still learning. Im doing a 4 day course in the summer which should help.

 

[SimonP]

Just to clarify my point, it was that to do an evening basal check one would normally skip supper, but you can also get some useful information by just eating fewer carbs than usual.

I do and I don't limit carbs, Tidepool's log tells me I eat an average of 260g CHO per day, though I do try to limit single-sitting (i.e. main meal - supper for me) carbs to <100g (and ideally <70g of carbs) for exactly the same reason as you say @digihat, namely smaller bolus so any mistakes on bolus effectiveness/carb counting result in smaller perturbations. I always split dose, which is useful as you can then monitor what's happening over e.g. the evening and end up with smaller correction requirements if something was miscounted/etc.

But that is all rather off topic.

What would be useful to see a day's worth of BG data along with when/how much insulin/carbs you took. Combining data sources makes it much much easier to spot trends. XDrip+ is very useful in this regard (with carbs on board decay curves and IoB decay curves), though there are doubtless other methods, perhaps also including the standard Libreview(?) app in its latest incarnation.

 

[digihat]

Just to clarify my point, it was that to do an evening basal check one would normally skip supper, but you can also get some useful information by just eating fewer carbs than usual.

I do and I don't limit carbs, Tidepool's log tells me I eat an average of 260g CHO per day, though I do try to limit single-sitting (i.e. main meal - supper for me) carbs to <100g (and ideally <70g of carbs) for exactly the same reason as you say @digihat, namely smaller bolus so any mistakes on bolus effectiveness/carb counting result in smaller perturbations. I always split dose, which is useful as you can then monitor what's happening over e.g. the evening and end up with smaller correction requirements if something was miscounted/etc.

But that is all rather off topic.

What would be useful to see a day's worth of BG data along with when/how much insulin/carbs you took. Combining data sources makes it much much easier to spot trends. XDrip+ is very useful in this regard (with carbs on board decay curves and IoB decay curves), though there are doubtless other methods, perhaps also including the standard Libreview(?) app in its latest incarnation.

I use libre view mainly I spend a lot of time looking over data and patterns when trying to figure things like this out which I like doing must admit. I do want to something abit more customised which I know can be done from what I've read. I can grab some recent graphs if that would be helpful?

 

[SimonP]

If you can show a day's worth of BG data annotated with insulin and (rough) quantity and times of carbs that makes life much easier for both yourself and others on the forum to give some opinion (and of course it is only that! 🙂)

 

[digihat]

If you can show a day's worth of BG data annotated with insulin and (rough) quantity and times of carbs that makes life much easier for both yourself and others on the forum to give some opinion (and of course it is only that! 🙂)

Grabbed a couple of graphs from over the last few weeks. I would have included last few days however they weren't normal due a bad low of 2.6 so have omitted them 🙂

Both graphs show the general trend of morning collapsing levels and overnight levels rising. This is why Ive been raising my basal but yet feeling I am taking too much as in the morning my levels go off a cliff. I generally don't eat in the morning as I'm rarely hungry. Most mornings I nedd to raise my levels treatment

Ive added a bonus graph at the bottom from when I was taking 22 units showing the morning fall 🙂



Long Acting 36 Units Toujeo
Lunch 58g Carbs 5 units of NovaRapid 20 min prebolus
Tea 42g Carbs 4 units of NovaRapid 20 mins prebolus 20 mins prebolus



Long Acting 38 Units Toujeo
Lunch 50 Grams Carbs 4.5 Units Novarapid 20 mins pre bolus
Tea 55 Grams carbs 4.5 Novarapid Pre bolus 20 mins
1 blood glucose raise in morning with mini can

Here is a graph from when I was on 22 units for a period of time similar pattern in morning

 

[SimonP]

Your numbers look good, nice and flat (aside from the overnight high you're trying to fix), mine aren't generally that flat! 🙂

What are you eating for your evening meal? Also are you eating anything else (even without carbs) during the evening (even protein and fat will be partially converted to glucose in the absence of carbs)?

It looks like the rise starts as your supper-time bolus is wearing off. It could be that your supper is taking longer to absorb or your insulin sensitivity is different at this time of day. I'd be tempted to take a unit of Novorapid at bedtime and see what that does to the overnight levels (may need more than one unit.) and at the same time reduce basal.

Obviously there are concerns about taking bolus insulin before going to bed, so something to discuss with your healthcare team, but if it were me and I could see I didn't have any bolus on board, I would happily experiment with a dose of bolus that wouldn't make me go hypo to see what effect it has. I regularly take 1 or 2U of Novorapid before bed if my blood sugar is trending up.

The alternative is to eat something in the morning, which I realise you don't want to do, but even something small without any bolus cover would bump you up enough to avoid the low - e.g. an apple or small bowl of cereal, etc.

 

[Wendal]

Your numbers look good, nice and flat (aside from the overnight high you're trying to fix), mine aren't generally that flat! 🙂

What are you eating for your evening meal? Also are you eating anything else (even without carbs) during the evening (even protein and fat will be partially converted to glucose in the absence of carbs)?

It looks like the rise starts as your supper-time bolus is wearing off. It could be that your supper is taking longer to absorb or your insulin sensitivity is different at this time of day. I'd be tempted to take a unit of Novorapid at bedtime and see what that does to the overnight levels (may need more than one unit.) and at the same time reduce basal.

Obviously there are concerns about taking bolus insulin before going to bed, so something to discuss with your healthcare team, but if it were me and I could see I didn't have any bolus on board, I would happily experiment with a dose of bolus that wouldn't make me go hypo to see what effect it has. I regularly take 1 or 2U of Novorapid before bed if my blood sugar is trending up.

The alternative is to eat something in the morning, which I realise you don't want to do, but even something small without any bolus cover would bump you up enough to avoid the low - e.g. an apple or small bowl of cereal, etc.

Evening May be worth trying Inkas idea of eating at 6pm and then you have the option of better assessing your overnight requirements as the pre evening meal bolus should have more or less finished.
You then have the option of doing a small correction as Simon and must admit is my normal routine if I am running high just before bed depending on last reading.I find the smaller correction based on the latest info is the best way to optimise a reasonably stable level overnight.

 

[helli]

Evening May be worth trying Inkas idea of eating at 6pm and then you have the option of better assessing your overnight requirements as the pre evening meal bolus should have more or less finished.
You then have the option of doing a small correction as Simon and must admit is my normal routine if I am running high just before bed depending on last reading.I find the smaller correction based on the latest info is the best way to optimise a reasonably stable level overnight.

Doesn’t that depend on what time you go to bed?
And what time you finish work.
For example, I finish work around 6pm, then go to the gym and then make tea. I couldn’t eat before 6 pm but, as I go to bed at around midnight, my evening bolus has more or less finished when I go to sleep.