Interesting info about and thoughts on the feet-on-floor phenomenon and dusk phenomenon


#1

So, I am noticing a more pronounced feet-on-floor phenomenon by now. Tresiba dosage increased to 15 units as well. Signs that the honeymoon phase is slowly fading away. It probably will still take at least a year until it is fully gone, but a progression is noticeable.

So I researched this phenomenon. It is driven by a hormone induced insulin resistance. When you get up, cortisol levels shoot up. One of the reasons for this is to give you more fuel. In non-diabetics, what happens is that BG levels start to creep up, which is immediately answered by heightened insulin secretion from the beta cells. This two-step mechanism facilitates the uptake of the extra fuel (the extra glucose).

But in T1s, the second step is broken. Therefore, the best way to handle this is to inject as early as possible, ideally before you get up. Why? Because this mimics closest the behavior in non-diabetics. And that’s because the early presence of insulin prevents a BG rise. If you don’t inject early, you let the BG rise and rise. This however is a situation that was never supposed to happen. The body is in an abnormal state. Furthermore, since this temporary hormone induced insulin resistance has to be countered by the insulin, you need more of it if you inject later. If you inject early, the BG is still at a normal level, and you only need enough insulin to keep it there, that is, to counteract cortisol and friends. If however you inject late, and the BG already creeped up, you need insulin to counteract these other hormones and additional insulin to bring the BG down.

This explains why those who inject early have the least amount of trouble, and why those who breakfast early also don’t experience these BG rises. Furthermore, if for example you ate something that digests slowly, and you were woken up by an elevated BG alert, and bolused for it, then this may explain why the next morning you might not have a BG rise - some remaining part of the bolus was still around when cortisol etc. kicked in after you stood up. It also explains potentially bizarre BG patterns when doing a corrective bolus - insulin is both fighting the hormonal resistance and driving the glucose into the cells at the same time, leading to complicated behavior.

Thoughts?


#2

I agree. It always takes more insulin to bring down a high glucose level than it does to prevent the glucose rise. There are only two control levers when it comes to dosing insulin: dose size and dose timing. Timing is a real art since our insulin sensitivity changes throughout the day. Something that works one time is not guaranteed to work the next.

Thinking these things through and deliberate experimenting can hone insulin dosing skills.


#3

Thanks for the research. Although I knew nothing of the research, that is what I am doing to counteract a high BG after breakfast. My basal is low all night but at 6AM I almost double it. Takes care of my breakfast and keeps me on target. Before a big increase in basal at 6A I would experience high BG all morning.


#4

Yep. I am learning this right now. Discovering all this is also a real mental help, since I was being stressed out and frustrated with these BG rises. Understanding them helps to stay cool. You no longer ask yourself “why is it rising yet again, I injected etc.” Instead, you think “damn, I should have injected earlier, that’s the hormonal insulin resistance acting up”. It helps to have some idea about what is going on.

Furthermore, I can use this to my advantage. I can plan for it when I do sports in the morning. I deliberately inject only a small bolus, to slow down the BG rise, and to prevent hypos (because, insulin + intense exercise = dangerous). And since the BG is rising, I don’t have to eat as many carbs prior to exercise. In essence, the liver is providing me with the carbs. If the exercise is moderate, I may not even need to eat carbs at all.


#5

You can try taking a small amount of NPH before you go to bed. It has a delayed onset, so if you time it correctly, it will come in right before your BG starts to rise in the morning.

When I am doing MDI, I take a little NPH before I go to sleep. When using the pump, I can just program the basal rates.


#6

Well, I try to avoid mixing basals. Also, NPH is useful for the dawn phenomenon, not the feet-on-floor phenomenon, unless you get out of bed every day at the exact same time.


#7

I think people with engineering, math, and science strengths tend to be more successful with controlling blood glucose in diabetes. I’m lucky to have this natural inclination. For people who don’t like math, this can be real drudgery. I look forward to the time when commercial automated insulin dosing systems render my skills obsolete.


#8

My thoughts as well. I am a software developer and generally interested in science and technology, and the calculations never bothered me. In fact, it puts my mind at ease if I can analyze BG related stuff. I never like to “wing it” or to just resort to saying “who know why the BG rises/falls”. And, I have been very successful with my BG management so far, constantly optimizing factors, analyzing and developing strategies for various situations like feet-on-floor increases etc.


#9

If you have an increase in basal it can help reduce the dawn phenomenon a little bit, and make it easier to manage.

You don’t have to get up at the same time every day, because you can take it at a different time when you go to bed, depending on when you plan on waking up. As long as you know when you will be waking up, you can just plan to dose at a certain time at night.


#10

Unfortunately I don’t know when I wake up. It fluctuates. Sometimes I sleep more, sometimes less.


#11

What’s NPH?


#12

It is a very old insulin. It was basically the first “basal” insulin. The idea was discovered in 1936, but it was first sold around 1950.

They add protamine zinc crystals to the insulin to delay its onset. It has a very unique curve, unlike any of the current basals. This makes it useful for increasing a basal amount at a specific time of day. I used to take it in the morning for my dinner needs. Then years later I used it at night for higher morning basal needs.

Unlike current basals which are relatively flat throughout, NPH has a peak many hours after injection.

I still use it on occasion because it is unlike any other in terms of its action.

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#13

Yeah, for a pronounced dawn phenomenon, it can be useful. The really big problem with NPH comes when you use it as the only basal. Then, you need to inject it twice daily, and you have to deal with the peak of the second injection somehow. The classic solution is to cover it with meals, which means having to eat the same thing at the same time of day.


#14

Okay thanks, wasn’t familiar with acronym.


#15

@Eddie2’s description of NPH is excellent. If memory serves me, NPH decodes as Neutral Protamine Hagedorn.


#16

I find if I give a unit of Novolog early between 5 and 6 am, it makes my whole morning go much smoother. I am usually able to give another 3 units of Novolog when getting up a couple of hours later and I am set for the day. Yesterday my glucose was down to 90 within two hrs after eating my oatmeal and fruit bowl. This doesn’t always work, but it usually does.


#17

Very useful post @athx9891, thanks. DP is certainly a familiar problem to most of us but you certainly add some useful facts to the picture. Like many, I never really got a handle on DP until I started using a pump, which allows me to anticipate the a.m. rise with an elevated basal rate starting around 3 a.m. Like, a lot elevated. I was surprised how much it took to get ahead of the rise when I first started pumping. On MDI, my endo put me on Metformin to help deal with it, and it wasn’t nothing, but having a programmable basal rate was the real answer for me. It’s also something that seems to have gotten worse over the years.

One question you touch on slightly is something that has confused me in similar discussions: some people say that having a carb-ish breakfast is actually a help in reining in DP. I gather the idea is that giving your body some extrinsic carbs tells your liver it doesn’t need to kick out all that glucose because you’ve got it covered.

I’ve always been a coffee-only breakfaster since even before I was dx’d, and I take it with no sugar, just cream and Splenda, but I actually have to bolus for it as I would for two slices of bread. This assertion has made me wonder if I wouldn’t be better off having a couple pieces of toast with my morning coffee, and seeing if the same bolus would still work, though I’ve never tried to test it intentionally. It’s kinda hard to change routine and anyway I try to keep to low-carb for other reasons. But I’m curious what anyone else thinks about it. The whole idea seems counter-intuitive to me, but then T1? Intuitive? Ha ha ha ha ha!


#18

My answer was going to be “just be glad you don’t need to know,” but @Terry4’s response is much more informative, and @Eddie2’s suggestion that helping with DP is actually a useful application reminds me that however much I loathed being on that stuff for 20 years, to the point that the very thought of it still makes me shudder a little, it does have its uses.


#19

Or as I called it, the Eat Now Or DIE regimen.


#20

One question you touch on slightly is something that has confused me in similar discussions: some people say that having a carb-ish breakfast is actually a help in reining in DP. I gather the idea is that giving your body some extrinsic carbs tells your liver it doesn’t need to kick out all that glucose because you’ve got it covered.

I do not know about effects on the DP, since it is a different phenomenon. But, for the feet-on-floor phenomenon, I don’t think it works that way. Rather, people are used to eat breakfast every day right after waking up, and without realizing it, cover the bolus for countering that phenomenon by adjusting the I:C ratio. In other words, the I:C ratio is too low. I mean, too much insulin is injected for the carbs, but they don’t notice, because the extra insulin covers the phenomenon. But actually, the correct calculation is to add the bolus for the phenomenon separately. So, like: total_insulin = feet_on_floor_bolus + IC_ratio * breakfast_carbs. I’m experimenting with it, and in my case, feet_on_floor_bolus seems to be something between 1,5 and 2.

By the way, what is the directionality of the I:C ratio? Is it worded in the mathematically correct way? I mean, what does “higher” mean? Is 1:6 considered higher or lower than 1:12 ? I always get confused by this, because mathematically, 1:6 is higher, and also higher because it means more insulin, but the carb number is lower.