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Basal testing with Dawn Phenomenon

Unicornz

Well-Known Member
Messages
107
Hi

I want to sort out my basal rates by doing fasting basal testing, but the problem is that I suffer from quite severe dawn phenomenon in the morning (sugars will rise from 6/7 to about 14/15, although I have set up my basal so that it will only rise 1 or 2mmol/l at the moment).

The rise in BG will start from the moment I wake up and I don't actually know whether it is stopped by me having my breakfast or whether there is some sort of cut off point.

My question really is, will it get in the way of me doing a fasting basal test in the morning? If I skip breakfast, I'm scared that my BG will just keep rising until I have some carbs to stop my liver from kicking out glucose. Does anyone else have this problem? Or does anyone know wether the liver will stop producing glucose after a while? This is the only thing that's holding me back from doing a basal test at the moment... it's so annoying!
 
Hi,

You are a complete mirror image of me in the morning!!!

i went from 5-9mmol upon waking, to 20+mmol in hours...

I now have my basal programmed to get rid of that completely, i can wake up at 6am and go until 10am if i wanted to with no breakfast and it's completely fine!!

I thought i'd never say that lol!

It took me a good few weeks to programme mine.. what i found was that my DP started before i actually woke up!! my basal is flat lined until 4am in the morning, then my basal rises slowly until 6am, sharply until 9am then slowly back down until 11am. then i have another flat line basal until tea time where it drops a little.

This is how i did it;

1. AM testing for 3 days.. every 2 hours.

2. pin pointed where my DP started.

3. programmed one hour at a time until my DP shifted hour by hour later until i would wake up.

4. Fasting tests. I had to abandon so many of these due to needing a correction, it is very very very frustrating, every time i need a correction i would raise the hours basal before by 0.10U

5. More fasting tests, eventually i didn't have to abandon as many as my DP was slowly getting under control, going up to 9mmol was my limit. After i started getting readings under 9mmol i stopped raising by 0.10U everytime i corrected. I switched to altering my basal based on two days testing.

6. For a while i did a two day fasting test every other week. The weeks inbetween i would test as often as the fasting tests but i has breakfast, this was to test if my basal was okay with food. I didn't want to set my basal too high to have breakfast early if eating stopped my DP resulting in hypo's. argh. Luckily for me this didnt happen. I always had the same two slices of toast with the same ratio and same extended bolus.

7. stopped alternating fasting tests and did the occasional 3am spot check and 5am spot check.

8. Jumped for joy when i woke up around 5-6 and managed to stay 5-6 until i decided i wanted breakfast.

The first time in two years that i decided i WANTED breakfast and not that diabetes NEEDED breakfast!!!


Soooo end result for me was that having breakfast at anytime was NOT a problem with DP. It doesnt matter what time i have breakfast. Not sure how this works for anyone else but my DP is purely sorted through basal and NOT eating breakfast. This may be because my DP starts before i wake up and not upon waking.

Just re-read this and i hope this makes sense to you a little?

Pheeew :)
 
I too suffer from a strong dawn phenomenon. I have fasted & fasted to get my basals right during the morning & have found that my needs jump drastically then fall away very quickly too.

It's easiest to explain in figures. I am pretty sensitive to insulin & only have a total basal requirement of 14.5u/24hrs.
ebony321 said:
It took me a good few weeks to programme mine.. what i found was that my DP started before i actually woke up!! my basal is flat lined until 4am in the morning, then my basal rises slowly until 6am, sharply until 9am then slowly back down until 11am. then i have another flat line basal until tea time where it drops a little.
Pheeew :)

Ebony & I are very similar. My BG also starts to rise at around 04:00, significantly after I get up, very fast when I leave the house, then my basal needs drop away again to late morning where they settle at roughly the same rate until late afternoon when they dip a bit more.

I get up during the week at 06:00. So knowing how long it take for the insulin to get to peak activity in me (2 to 3 hours as I have a fairly poor absorption rate), I make the adjustments 2 hours before I want them to be working.

Before bed & during the early hours of the night I have only 0.4 or 0.5u/hr. This rises from 02:00 (affecting 04:00 onwards) to 0.6, 0.7 then at 04:00 jumps to 1.0. This increase is therefore working as I'm getting up and ready for work. From 07:00 to 08:00 (when I'm leaving the house & travelling on the train therefore my activity level & alertness state increase) my BG used to rise significantly, so at 05:00 my basal jumps again to 1.4. As I settle into my day, the need drops away & I drop back at 06:00 (covering 08:00-09:00) to 1.2. then 1.0, 0.9, 0.7, 0.6, 0.5 right down to 0.3 late in the afternoon.

My range therefore is from 0.3 to 1.4. I'm not sure how this compares to you, but what I'm trying to say is whatever your basic requirements (my most common basal is 0.4 or 0.5) with a strong DP, expect to need a significant amount more to counteract it.

Unfortunately, plugging away at fasting for a few hours at a time then increasing your basal (remembering to increase the rate 1, 2 or 3 hours before you want it to act depending on your absorption rate) to see how you react is the only sure way of getting it right.

I hate fasting and after having a blip in my Hba1c recently have had to start from scratch again, so I know what a pain it is. However, keep careful records (I'm a bit obsessive with this and make spreadsheets of my fasts so that I can easily compare the difference that each change makes) and hopefully you'll see the impact that each 0.1 change makes.

I have a fairly old pump which has a minimum increment of 0.1, but you probably have one with smaller incremental possibilities.

I now know that each 0.1 increase/decrease seems to reduce/increase my BG by about 1%. I found that I was having roughly the right amount of insulin over the morning, but not enough to counteract the DP & too much later on so it looked like I was spot on if I tested before breakfast & before lunch, but testing every hour during a fast showed me rising from 5.0 to 11.5 over 2 or 3 hours then dropping back again to 5.0 7 or 8 hours later.

I also test every hour when fasting, more than the DSNs recommend, but more helpful for me even if my fingers do end up like pin cushions.

I also wouldn't be too concerned about your BG rising during fasting to low double figures, a day or two of slightly high BGs is not going to affect your long term health. If you go from 5 to 12 between 6am & 10am, stop there, make a slight adjustment & try again. I fasted this Tuesday, all day, missing both breakfast & lunch. It showed me that I still have a little way to go to get it right, but I'm nearly there, I started with a BG of 6.6, dropped by 1.5% during the first hour, (so I've probably over-increased the basal around 04:00), then settled around 5.3-5.8 through the morning. I was elated that I'd finally got it right, until I suddenly went hypo at 15:00!! So back to tweaking again and dropping 0.1 in a couple of places and time to fast again next week.

Don't forget, you're not alone if you hate fasting, get grumpy with people & are generally unpleasant to be around when you're doing it! Drink lots of water & black coffee/tea it helps reduce the hunger pangs.

I also have much less DP at weekends when I sleep in until at least 08:00, so I have to have a completely different morning basal profile for days off.

Also, if you exercise irregularly (less than once every other day), don't try to fast for 2 days after exercise as your liver will be replenishing its glycogen supplies for up to 48 hours, you'll be needing slightly less insulin overall during that time and the results will be skewed because of that.

Good luck.
 
Hi guys,

Sorry I've not been on in ages. Thanks for your replies it's very helpful. I still haven't come up with the guts to try a fasting test; there are just too many things to take into account in the morning, like most of the times I walk to work and sometimes I get lifts. But I can't predict that I will get a lift until I've already started walking because it depends on whether someone from work drives past me or not.

If I walk all the way my BG ususally stay fairly stable until I get to work, when I get a lift they rise. I could give myself a small bolus if I get a lift, but seeing as insulin doesn't start to work until about half an hour or so it won't make much of a difference because it only takes 10 minutes to drive to work.

How do I set my basal up for that?

Another thing that's holding me back is that I'm somehow convinced that my DP will last until I have my breakfast. I'm scared that if I fast, my BG will just steadily keep rising until I eat something, in which case it would be silly to adapt your basal rates to it because if you do start having breakfast then and DP stops you will end up hypoing all the time after breakfast because your basal is set up to counteract a rising BG.

I hope this all makes sense somehow... I don't really know what to do!
 
I don't think your DP would be affected by when you have breakfast. You need to separate the two sides if the treatment (basals & boluses). If you're getting up at the same time each day for work, you DP will probably commence at & continue for about the same amount of time.
So (ignoring your walk/lift difficulty for now) if your basal is set right to deal with your DP, you shouldn't be going hypo after eating unless you're having too much bolus for the meal. If you're used to having a larger bolus which includes extra to deal with the rise expected each morning, you need to offset the bills with the basal. Does that make sense?

You really do need to fast to get it sorted & unfortunately, there's no point in taking time off to do it ad your 'day off' insulin needs are probably different to your 'work day' insulin needs. As I said before, don't be too concerned about going high for a few hours, it won't do you any harm. Fast until you can't bear the BG reading any more, then eat, bolus & correct the high. Make basal adjustments in small increments & do it again. It's no fun, but it's the only way I'm afraid.

As far as your walk/lift issue is concerned, I'd have my basal set for walking & drop a little bolus if & when I got picked up. Yes, it may not have any effect for at least half an hour, but it'll stop you being both high later on and hypo (if your basal is set for getting a lift & you end up walking).

The other option is to pop a dextrose or two during your walk. The basic requirement for walking is 22 grammes of carb per hour. If you prefer to set your basal for getting a lift, eating 1 dextrose tablet every 10 mins should keep you BG up. (assuming you walk at an average pace & ate average weight etc. - WWW.diabetesnet.com has a good section on exercise & calculating carb requirements and/or insulin reduction).

Persevere, the DSNs are always full of the positives of pump treatment & gloss over the massive problems some of us have getting the baseline numbers right & making it fit with our busy lives. I've had my pump 2 years this week & still think I'm not quite there when it comes to getting it right, but I keep chipping away & each month is a bit better. (I hope you get yourself sorted quicker than me!) However, sometimes we have to accept that there's no perfect solution & either a correction bolus or a little extra carb is always going to be necessary on occasion. Some of us have more "occasions" than others!

Chin up.
 
Thanks so much Cheryl that all makes perfect sense! I feel a lot more confident about trying the basal test now :) I think I will follow your advice and set it for a walk for now and do a small bolus when I do get a lift. Hopefully in a few months I will have been able to buy a car and then I can change the basal to fit a non-walking morning instead!

I have noticed that I've been waking up a bit higher than I'd like the past week or two as well so I will start by having another look at my overnight basal and once that's sorted I will try and crack the mornings!

I will keep you updated on my progress, and thanks so much again for your support and info it's really been a huge help! My last HbA1C was 6.9% and my next one is in four months and I'd really love to be able to get to 6.5 or lower by then so this is really important!
 
It might've made more sense had I read it through properly & corrected all the predictive text errors! I hope you were able to substitute the nonsense words with a good guess at what I really meant. Sorry.

Aiming for below 6.5%? You've got very high standards. Good luck.
 
Cheryl said:
It might've made more sense had I read it through properly & corrected all the predictive text errors! I hope you were able to substitute the nonsense words with a good guess at what I really meant. Sorry.

Aiming for below 6.5%? You've got very high standards. Good luck.

Well I might need glasses in that case since I didn't spot a single mistake :lol:

We're planning on having a baby within the next few years. So yes, not too soon yet but I just want to get myself all ready for it by having the best control I can possibly get!

Well then, I finally pulled myself together and did a morning fasting test this morning, and I was astounded with the results to be fair. I thought it was going to be a complete mess and would go up really high and stay there for ages, but it didn't at all!

07:00 - 5.4
08:00 - 8.4 (DP still kicking in there)
09:00 - 7.0 (this is after having walked to work for 45 minutes uphill at a fast pace)
10:00 - 5.6
11:00 - 6.5
12:00 - 5.7

So it seems I do need a bit more insulin for the first hour after waking up, and I think as a result of that my readings later on in the morning might go too low so I'm expecting I will need to turn it down a bit more after that to keep that level. All in all, really not a bad result.

I'm still a little bit anxious because I find it hard to believe that every day will be exactly like this, and also because I haven't been waking up with perfect 5s lately, more like 8s and 9s and 10s. I also think that my bolus ratio for the morning might not be 100% right so nights and bolus are the next two things on my list to crack!

I will get there eventually :roll:
 
Hey, those results are almost spot on. Looking at the first & last, you're getting exactly the right amount of basal insulin. Next step then is to shift the delivery of it forward a little to try & flatten out that curve.

I don't know your basal rates, but (assuming you're on a smallish amount, e.g.15-20 basal units per 24 hrs) this is what I would do:

Stating with the 08:00 reading, the basal delivery hour which will affect that result will be either 05:00-06:00 or 06:00-07:00. Only you can judge which is most likely to be the right one to change. I would increase this hour (5-6 or 6-7) by 0.2u. (for me I'd change 05:00-06:00 as I know that the insulin takes quite a while to get going, if you absorb insulin more quickly, change 06:00-07:00).

I would then reduce each of the next 2 hours by 0.1 units. So you're getting the same amount of basal insulin, but just a little earlier in the day.

I would also increase the next hour by 0.1 & decrease the hour after that by 0.1 to try & flatten out that wave from 10:00 to 12:00.

It's logical really, you're increasing by 3% in one hour then dropping by 3% over the next 2 hours, so take a little off the 2 hour falling period & put it into the earlier one hour rising hour period.

It's never going to be an exact science and no two days will be exactly the same.

Bear in mind, I'm basing my actual numbers on my pump & how much I know 0.1u affects me. You're the best judge of whether to make your changes in smaller or larger increments.

Unfortunately, it's then time for another fast to test the changes.

It's a great result though. Now you can take the next step of perhaps slowly increasing your insulin to carb ratio at breakfast time to deal with those late morning highs. Many people need a higher insulin to carb ratio at breakfast time, as my consultant reminded me just yesterday! (until I pointed out to her that my highs are afternoon/evening, so I seem to be the opposite!)

Keep at it. You'll crack it eventually (I keep telling myself that and after 2 years am finally making some progress!)
 
Thanks again so much for all the advice and support. I really am not kidding when I say that I probably wouldn't have bothered taking the step to doing the actual fasting test if it weren't for you!

I'm on 21 units of background insulin over 24 hours. Pattern looks as follows:

00:00 - 0.9 u/h
03:00 - 0.8 u/h
05:00 - 1.35 u/h
09:00 - 0.75 u/h
14:00 - 0.6 u/h
18:00 - 0.9 u/h
22:00 - 0.75 u/h

I could either up my 05:00 to 1.4u/h or try and add in a new line for 06:00 that gives me 1.4u/h, seeing as I'm waking up on good numbers it will only make me go low if I make the change too early.

And then I'm completely confused as to when to start reducing a bit of my later insulin to keep me stable... :lol:
 
Your pump is newer & more flexible than mine so it makes it harder for me to suggest something. However, I'd probably increase a bit more than 0.05 for the hour where you're rising fast. My rates step up & back down like this:
00:00 0.5
02:00 0.6
03:00 0.7
04:00 0.9
05:00 1.4
06:00 1.2
07:00 1.0
08:00 0.9
09:00 0.7
10:00 0.6
It's a nice clean curve up h back down again with a definite spike to deal with my DP which seems to be at it's worst between 07:00 & 08:00 which is when I am leaving home & travelling to work.

You may need to consider a more frequently changing basal rate during those morning hours, similar to my curve, rather than keeping it in blocks of 3 or 4 hours. For the rest of the day my basal is 0.4 or 0.5 (I'm trying to upgrade to a pump which might allow me to stay flat at 0.45 rather than changing every hour up & back down again, but that's a different, long, boring story).

I'm a bit reluctant to suggest figures as I would hate to suggest something which made you keel over in the street on your way to work, plus my experience is only of me, but think about a 'stepping up each hour then back down again' from 05:00-09:00 having the same amount overall, just in a more flexible way.
:shock: it's sooo confusing, I know.
 
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