My 12 year old T1D son does not show dawn phenomenon, but appears to be glucose sensitive in the morning. The symptom is that he used to have a sharp glucose peak to 250 or so shortly after breakfast, going down catastrophically into a low mid morning. I thought it might be worthwhile to share how we mostly resolved the issue.
His original breakfast was a 70 carb regular breakfast in the morning (cereals, 12 oz of milk, clementine). Our first step was to substitute a 45 carb breakfast that he liked as well or more, consisting of lower carb oatmeal with water, and a light Yoplait yogurt, for a total of about 45 carbs. This lowered his peak to approximately 200.
After that we played around as much as we could with basal and bolus insulin doses, as well as advancing his injection time to right after wake-up. None of it helped.
So we went back to diet as a solution. We experimented with a lot of different types of breakfast, going deep into the low- and no-carb range. We finally identified a low-carb breakfast that he really enjoys, and that works well for him:
1.5-2x portion of eggbeaters omlet with sauteed celery, peppers and mushrooms
2 turkey links
0.75-1 Yoplait light yogurt
Total - 15-25 carbs, about 400 calories.
This breakfast took his peak down to slightly over 150, lasting only about 30 minutes. By playing with some advance dosing (about 20 minutes), we are often able to stay below 150. For that, he needs to inject right after he wakes up and before his shower - so we are quite careful with it. But because he injects so little insulin, there is practically no BG drop in the shower. We also get him to take a quick 5 minute run with our dog right after breakfast.
After 2 weeks of 145-155 peak morning BGs, we are declaring it a success. We still have not been able to get rid of his late morning lows, but we are working on it.
Hi @WestOfPecos, the morning meal is a beast to tame. Our son eats oatmeal for breakfast pretty much every day (somewhere between 28g and 40 g of carbs depending on how hungry he is.) He is also very prone to having a low between 9:30 to 10:30 am, and because we use an artificial pancreas algorithm, using a conservative mealtime bolus and letting him spike to 250 didn’t seem to help, because the program would just pile on the insulin after he ate. That was pushing the low out by a half-hour, but it would still happen.
We’ve found that what was helpful was to visualize not the insulin on board, but the insulin activity. This would be how much of the insulin is active in any five minute window. The steep drop in my son’s BG in mid-morning roughly corresponded to the peak of insulin activity and was entirely predictable given his ISF and the amount of time it takes him to digest his food. Another thing I learned is that even if I deliver a big bolus up front, the insulin still takes about 90 minutes to 2 hours to ramp up. And because my kid’s insulin needs are so low at night, we were starting from a bigger insulin deficit. So that means you’re always going to have a big lag in when the insulin really starts working.
So what we’ve started doing is: a) letting him wake up a little higher BG (say, 150 instead of 120) b) prebolusing some small amount of insulin abut 30 minutes before he eats, enough to get him to his target or a little lower c) prebolusing for his meal by about five minutes for the oatmeal. If he’s been running high we will add some of the basal he needs over the next three hours into his bolus, and then tweak the settings so that he gets 0 basal for the next three hours.
He still has an anticipated late-morning low about 3 days out of five during the week. But I feel like we’re slowly but surely narrowing in on a breakfast routine that mostly keeps him below 160 and doesn’t crash him around 10am.
Congrats on paying attention to your son’s diet and how it affects his post-meal blood glucose. Is there a reason that you’re considering lower carb amounts while not seeming willing to up his fat intake? The Yoplait Light is a no fat yogurt but 6 ounces contains 16 grams of carbs. Have you considered a greek yogurt with a full 8-ounce serving size that only contains 9 grams of carbs but with 10 grams of fat? You can add back in a few carb sweeteners like berries to make it more palatable, if desired. Likewise with the eggbeaters. Why not use real eggs with heavy cream to make the omelette?
Fats satiate and help to keep the hunger pangs at bay until several hours later. They also slow down post-meal BG spikes. Trying to pull back on carbs without adding in fat tends to diminish dietary success in the long run.
I think the fats thing is very much a YMDV thing.
For our son, a few scrambled eggs cooked with whipping cream for breakfast will spike him to 300, and high-fat breakfast meals require more than double the insulin of meals that have the equivalent number of carbs but lower fat.
If @WestofPecos son is spiking to just 150 for a half hour and eating that breakfast doesn’t make him feel deprived or micro-managed, I’d call that a major win!
I forget that lots of fat can make some kids’ BG skyrocket. My daughter’s BGs are more mature in their response to a moderately high fat load (minus pizza, Mexican food, and Chinese food for which there is no hope). I just wish puberty would end.
FWIW… I have found a very consistent connection between how late and how much I eat (in terms of carbs) the night before in terms of my DP issues the next morning, and my insulin sensitivity too.
If I snack late (10pm), and eat a fair amount of carbs (30g snack, let’s say), I will have elevated BG in the morning, and it will be very stubborn to get it back down, sometimes taking the entire morning, necessitating holding off lunch until 1 or 2pm. This despite having bolused properly for the snack and bringing my BG down to normal before going to sleep.
OTOH, if I simply have a light dinner, modest carbs (30-50g), at 6-7pm and then don’t eat again until the next day, I usually wake up with a good, normal BG, and can eat breakfast (again, 30g carb or so) and bolus for it without apparent increased insulin resistance.
My speculative theory is its all in the liver. The latter scenario more or less depletes glycogen stores overnight so in the morning the liver’s like a sugar sponge, very sensitive to insulin sucking up carbs and storing them away for the day. By contrast, the former scenario is basically soaking the liver in syrup before bed, and then expecting it to store up more in the morning when it’s trying to get rid of the excess – thereby ignoring insulin, and excreting glucose into the blood rather than removing it.
That’s my theory. Sounds good – probably is completely BS
@Dave26, I’m not sure if your pickled liver theory has been tested but it sounds rational to me :). I do think the liver is the under-appreciated player in a lot of T1D issues, actually. When I see my son’s BG spike 250 points in an hour in response to 10g of carbs, I am pretty sure not all of that comes from his body literally breaking down bonds in the incoming carbohydrates and turning it into ATP. Instead, I suspect his eating spurs liver dumping.
@Tia_G, I was fascinated by how you explained your thought process and results. Starting with a high BG was counterintuitive at first, but made total sense once I was able to follow your reasoning.
We still have mid morning lows about half the time during the week too. We are still injecting, so we don’t have access to pump programming capabilities - but my boy is now ready to take the step, which he had not been until a few weeks ago. We are experimenting to determine exactly how long bolus insulin remains active with him so as to do some bolus amount and timing adjustment, and see by how much we can improve the situation.
This is how we worked it through. Beyond lowering his peak, our requirements were to (1) find a breakfast plan that he really enjoyed, (2) make him feel quite full (= not hungry at all) and (3) keep the amount of calories roughly the same as before for his new “menu,” His original menu back in September (and before) was about 69g carbs, 19g protein and 8 g fat, for a total of about 425 cals. His new menu, for instance this morning, is 20g carbs, 46g protein, and 17 fat, for a total of 420 cals.
So the calories total is the same as before, the carbs went from 70-> 20, proteins 19-> 46, and fats 8->17, roughly double for the fats.
I would have no problem increasing the fats a bit further and decreasing the protein and/or the carb - I agree it could work better (as long as it is not too high in fat overall, because my son’s BG does blow up when that happens - no French fries for the boy, to his great regret, although we do make exceptions…). The main problem of the full Fage is that it adds 100 cals to the breakfast budget (and the boy does not like Greek or unflavored yogurt, to my unending disappointment).
Same issue for eggs vs eggbeaters: food budget problem. I wanted to make sure that his breakfast is satisfying to him in terms of quantity, so I am not sure about swapping for regular eggs, but fewer of them. And I am also nervous about his eating eggs every single day. In my generation we were supposed to eat margerine because it was better for you: I am not quite comfortable believing 100% of what modern science tells us because I am not sure if it will tell us the same thing 20 years from now (I am a scientist/engineer btw).
@rgcainmd, thanks a lot for the suggestion! We aren’t pumping yet, but I will save your solution for when we do (hopefully next quarter).
Yogurt/Eggbeaters: I gave a rather long response to @Terry4 above. We were trying to keep his calorie budget the same as his old breakfast menu, while at the same time giving him a breakfast that would make him really full/satisfied. The Yoplait yogurt fit in easily but the full Fage did not.
Funny you mention rage-bolusing: we just had an issue today… (full fat lunch from the school cafeteria that was not supposed to be full fat according to early menu, and that resulted in 3+ hours at 200 and some stacking).
I can certainly accept that a growing child’s metabolism is different than an adult’s. What I’m wondering is when you observed BGs blowing up that maybe that episode is not only when fat is high but when carbs are high, too. The MacDonald’s large french fries contain 24 grams of fat but also 66 grams of carbohydrates. For me, the combination of high fat and high carbs make post-meal control problematic.
I certainly accept that this could well be a YDMV characteristic. Fage yogurt with a few walnuts thrown on top + 1 teaspoon of maple syrup at 4.5 carbs might change the taste for your son. Or apple sauce with cinnamon sprinkled on top of the yogurt also changes the taste. That sour edge to the greek yogurt is an acquired taste, but I’ve grown to like it.
Your son is lucky to have such a capable advocate.
You are right @Terry4, what the heck, I’ll blow the food budget and try a full Fage. If it takes out the mid morning lows it will still even out in the end since you save the go-high snacks. I’ll have to be creative to make this palatable to the boy.
This is our first year, but we’ve already found out that the only way to progress is by experimenting. So we’ll try this one out. Thanks very much for your suggestions. Of course I will let you know how this pans out:-)
You are way too kind btw. The boy is lucky because his mom is an even-keeled angel of serenity and efficiency, not because of his idiotic dad.
So, something to consider on this front! It’s been really important to many of us that have lowered carbs in our diets as part of managing our blood sugar.
Protein and fats are more satiating than carbs. So when you reduce the amount of carbs in a meal, once you get over the whole “my portion size is physically smaller now,” most people end up fuller for longer.
You sound like you’ve made some pretty rational decisions about how you’ve changed your boy’s diet. But maybe consider that portion physical size isn’t the same as calorie density or total caloric content. And on the french-fries front, that might be another common phenomenon for many of us: it’s not the fat that is the culprit, but the combination of high-carb (in the form of starches and sugars from the potatoes) and high-fat (from the frying process). That combination, in particular, seems absolutely deadly to my BG.
Well @Terry4, your suggestion worked: thanks to you, @rgcainmd, @David49 and the others who gently pushed for the full fat alternative. He liked a full fat, low carb yogurt with splenda and bluberries. The outcome was to raise his breakfast calories just a bit, and lower his carbs enough to require no insulin for breakfast 2 days on a row, and no significant post-breakfast peak. That’s a victory. I’ll keep my fingers crossed that it keeps on going well.
I was also hoping it would decrease the morning lows. But it didn’t. So, clearly, those daytime lows are the product a too much basal insulin. The problem is - if we go any higher I think he will start going high at night. Painful choice.
@Eric2 (he is a godsend btw) suggested using NPH in the evening as a supplement to Lantus. This may be where we go if we don’t find a way to play with basal rates. Or more frequent daily snacks.
What is your basal regimen? It looks like you’re using multiple daily injections. What basal insulin do you use? I’ve recently experimented, for four months, with Tresiba. I found it a very forgiving basal insulin with respect to dose timing and a nice even ride. Many here have reported very good success with it.
If you’re using Lantus, you might want to consider a split dose, one a.m., one p.m. Although basal insulins claim 24-hour coverage, it’s likely not true for your situation.
I think a pump, with its incredible basal flexibility could be the answer for you. I would be sorely tempted to try Tresiba, first, just to keep things simpler.
Isn’t Tresiba only approved for patients 18 or older? I may be wrong about that, but that’s what the constant bombardment of TV advertising during the middle of Vikings has led me to believe!
