Morning Levels Falling Mystery

[digihat]

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.

Thanks for your detailed reply 🙂

Ironically the last two nights ive been hovering around 12-13 and then a little higher with waking and yesterday hovering in 10 most of the day even with insulin rising back up again. Back under control day time wise thankfully.

With regards to evening meals most of the time I have a protein E.g Chicken, Fish with some veg carrot,peas swede etc a few time a week I have potatoes with evening meal as well. Try to limit a bit due high carbs and spiking but not cut it out. Sometimes have a chocolate bar as well afterwards around 20-25g at the most

In regards to taking extra bolus I'm not against doing that the annoying thing is just before i go sleep levels look steady and good then the meteoric rise kicks in. My general correction factor is around 3 we think at the moment. One thing I will mention is I don't sleep well and wake up alot in the night. Normally get back to sleep but wake up again. When I go to sleep the Novarapid is normally still active with about 1hr/1hr30 left at most based on 4hr active time

With regards to the morning from what I understand levels should stay steady without eating even if high and not gradually fall over an hour or two after waking correct me If I'm wrong then doing the intervention. Which in my head implies too much basal but at night appears not. Maybe I do just need to eat in the morning but levels shouldn't fall like that without some sort of intervention e.g bolus. Too much could be being released at once in the morning also has been floated as well.

Previously was taking 32 units a day for a few months which worked well for overnight and which kept rises contained mostly. Could be good old honeymoon period winding down as its been seven months since DKA/Diagnosis but I know this can vary or course had a cpeptide done recently hopefully give an rough idea of what production is left

Apologies for the very long reply all abit of a mystery trying to find the right solution which is also interesting at the same time.

Ill fetch some more recent graphs and show below

A good night on this graph but still the morning fall in red and then evening can see it trending off a little will put the following day below it this was a carb heavy meal in the evening a curry with rice


Following day did eat in the morning as levels were quite high at least for me normally with a correction mixed in

 

[digihat]

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.

During the week it is very hard to eat at 6pm not impossible but difficult on weekends tend to eat around 6-7pm for evening meals. Can try this on a weekend but not during the week, will be doing tonight will report back. Evening meals around normally around 8.-8.15pm we sit down as a family or at least try to when we can, bed is normally around 10.30-10.45 bolus is normally still active based on a 4 hour active cycle with 20 mins prebolus. A little wary of doing an extra shot and insulin stacking even if it is only a small amount confidence thing partly as well. Alot of the time when I look before going bed levels look steadyish rise from meal and then fall as you would expect

 

[Wendal]

During the week it is very hard to eat at 6pm not impossible but difficult on weekends tend to eat around 6-7pm for evening meals. Can try this on a weekend but not during the week, will be doing tonight will report back. Evening meals around normally around 8.-8.15pm we sit down as a family or at least try to when we can, bed is normally around 10.30-10.45 bolus is normally still active based on a 4 hour active cycle with 20 mins prebolus. A little wary of doing an extra shot and insulin stacking even if it is only a small amount confidence thing partly as well. Alot of the time when I look before going bed levels look steadyish rise from meal and then fall as you would expect

Thanks for response and appreciate it can be difficult as very important to try and stick to as normal a routine as possible and that involves the wider family.
Again understand you not wanting to do a correction even a small one hence the benefit of doing it 4-5 hours after your meal so eating at 6 and going to bed at 1030-1100 means you are not really insulin stacking as most of pre meal bolus will have worked its way through.
Also have to take into account what you eat in terms of blood glucose release timing so if you are eating at 6 then if you have a slow release food like a fatty carbs food like chips then you will notice it’s effects but if you are eating at 8.30 and go to bed at say 1030-1100 then you may not be aware of any rise and unable to take any corrective action.
Diabetes is a very individual thing and we have to try and find out works best for us and there are challenges which can compromise us all.
Personally I recognise that for me once I go to bed then it is very hard for me to control anything as the 3 modal actions are diet/ exercise and medication all of which I do not want to be messing around with once I get to bed hence I try and get Glycemic control as good as I possibly can.This means I will likely have a decent overnight graph as my basal ( which I take just before bedtime) I am pretty comfortable with and getting overnight control is the basis of how I move forward as I can fine tune things much easier at other times if required.

 

[digihat]

Thanks for response and appreciate it can be difficult as very important to try and stick to as normal a routine as possible and that involves the wider family.
Again understand you not wanting to do a correction even a small one hence the benefit of doing it 4-5 hours after your meal so eating at 6 and going to bed at 1030-1100 means you are not really insulin stacking as most of pre meal bolus will have worked its way through.
Also have to take into account what you eat in terms of blood glucose release timing so if you are eating at 6 then if you have a slow release food like a fatty carbs food like chips then you will notice it’s effects but if you are eating at 8.30 and go to bed at say 1030-1100 then you may not be aware of any rise and unable to take any corrective action.
Diabetes is a very individual thing and we have to try and find out works best for us and there are challenges which can compromise us all.
Personally I recognise that for me once I go to bed then it is very hard for me to control anything as the 3 modal actions are diet/ exercise and medication all of which I do not want to be messing around with once I get to bed hence I try and get Glycemic control as good as I possibly can.This means I will likely have a decent overnight graph as my basal ( which I take just before bedtime) I am pretty comfortable with and getting overnight control is the basis of how I move forward as I can fine tune things much easier at other times if required.

Thanks for your detailed reply 🙂

I've had my evening meal so will see where we end up!

Yeah agreed if I ate earlier wouldn't be as much of a concern regarding the insulin and stacking as it would be worn of by then.

In terms of foods I do try to limit any high glycemic foods I have during the week and especially in an evening mostly limiting potatoes among a few things but not removing entirely I do try to keep my overall carbs down as well dont like doing bigger doses more chance of error etc although not really had that yet thankfully. I don't have the best knowledge of the difference breakdown rates with Protein Fats etc need to learn more in that area.

Yeah fully agree its different for us all and very individual.

My day time control is not too bad generally just night time is my main nemesis had it under control for a few months but I'm still honeymooning or might be tailing off got diagnosed DKA about 7 months ago but this can vary as well.

Exercise is on going challenge getting that right but slowly getting there with how to adjust insulin etc do gym and like doing long walks

 

[SimonP]

With regards to evening meals most of the time I have a protein E.g Chicken, Fish with some veg carrot,peas swede etc a few time a week I have potatoes with evening meal as well. Try to limit a bit due high carbs and spiking but not cut it out. Sometimes have a chocolate bar as well afterwards around 20-25g at the most

With very few carbs you may need to add some extra bolus to cover the protein, though I can't recall the recommendation off the top of my head (something along the lines of treating it like carbs using 25% of the quantity.)

Hard to know if this would cause what you see though, my feeling is probably not as it's quite flat overnight. You never know though, don't completely rule it out.

In regards to taking extra bolus I'm not against doing that the annoying thing is just before i go sleep levels look steady and good then the meteoric rise kicks in. My general correction factor is around 3 we think at the moment. One thing I will mention is I don't sleep well and wake up alot in the night. Normally get back to sleep but wake up again. When I go to sleep the Novarapid is normally still active with about 1hr/1hr30 left at most based on 4hr active time

On the positive side if you're waking up anyway you can always check your BG value 😉 Though this is easier if you've got it on your watch (XDrip+/Juggluco/etc.)

Re stacking I know it's advised against, but I think this is simply to avoid people accidentally taking too much insulin, I stack all day every day on purpose, but I'm happy to do this as I can see an estimate (seems pretty good) of how much IoB I have in my system using XDrip+ (I enter my insulin and carbs in the app too, so I can see what it predicts my BG will be based on carb absorption and insulin breakdown.)

With regards to the morning from what I understand levels should stay steady without eating even if high and not gradually fall over an hour or two after waking correct me If I'm wrong then doing the intervention. Which in my head implies too much basal but at night appears not. Maybe I do just need to eat in the morning but levels shouldn't fall like that without some sort of intervention e.g bolus. Too much could be being released at once in the morning also has been floated as well.

Yes, actually normally people's levels rise in the morning due to hormones (growth hormone and cortisol) encouraging conversion of glycogen in the liver to glucose, so your drop in the morning could be even more pronounced in fact were it not for this (so be careful if you drink alcohol the evening before, or do lots of exercise as both of these also reduce the liver's ability to produce glucose, though for different reasons.)

The difficultly of taking a single basal injection a day is that different people have different basal requirements across the day (and different insulin sensitivity). Usually getting overnight to be stable and in range is the done thing as you're asleep so can't correct with bolus, but it may be that this won't work for you (unless you can eat something in the morning) and therefore a correction bolus to drive you down may be the answer (though see my comment/caveat later re being in the honeymoon period).

But everything I've said is based on supposition, I may be completely wrong. I would certainly look to experiment/(safely) perturb the "system" and see what effects you get to try to narrow down what is going on.

Previously was taking 32 units a day for a few months which worked well for overnight and which kept rises contained mostly. Could be good old honeymoon period winding down as its been seven months since DKA/Diagnosis but I know this can vary or course had a cpeptide done recently hopefully give an rough idea of what production is left

Such a long time ago for me, I don't remember, sorry, but the fact you're in the honeymoon period further muddies the waters, your daytime lows may be down to your pancreas doing its thing - I don't know what is typical (or if typical is even a thing) for endogenous insulin production (times/triggers) during the honeymoon period, hopefully someone will pipe up.

As a comment, basal insulin requirements do change for some people on a seasonal and temperature basis (and monthly for some if one is female), as well as based on activity levels (and altitude too interestingly).

Apologies for the very long reply all abit of a mystery trying to find the right solution which is also interesting at the same time.

No need to apologise to me, I'm terrible for writing essays here, but I think it's much better to lay out all the information, so keep doing it! 🙂

 

[everydayupsanddowns]

Apologies for the very long reply all abit of a mystery trying to find the right solution which is also interesting at the same time.

Good to hear about your ongoing experimentations @digihat

Those graphs overall look mostly really solid. Gentle undulations on the whole, and a high proportion of Time In Range by the looks of things.

Any additional polishing and finessing from this point on is probably going to evolve into the lifelong cycle of tweak, retweak, retweak that seems to be required as life changes, and the seasons roll around.

Well done!