Morning Hi

Dear all,

I tried my best about controlling my morning hi Bg. I will wake up at 116, pump in insulin 30 min before food sometimes 45 min. but still goes hi after food. I increased the carb ratio, still hi. I increased the basal after i eat, still hi. I dono what to do. Any tips … Is it only me or its hapining to some of you !

This is a really common problem, and there are several reasons this could be happening. Most likely the problem is that your basal rate is too low overnight, leading to highs in the morning.

The best way to figure out what is going on is to check your BG overnight. Its a real pain, but it does work:
(1) You need to check your BG just before going to bed. If your BG is normal fine before bed, you’re already off to a great start.

(2) Next, you need wake yourself up in the middle of the night. If you sleep for 8 hours, wake yourself 3-4 hours before you get up and check your BG. If your BG is high then, it is likely a basal issue.

If you’re really low in the middle of the night, you may be experiencing a type of rebound effect called the Somogyi Effect. When your BG goes really low, your body responds by increasing the production of glucose and other hormones leading to high BG in the morning. In this case, you may need to decrease your overnight basal.

(3) If your BG is normal in the middle of the night, and before you go to bed, but you still wake up high (before meals) you may also be experiencing what is called Dawn Phenomenon. Basically, when you sleep your body produces stress hormones that cause your BG to rise usually right before you wake up in the morning.

(4) If you discover that your BG is high when you wake up in the middle of the night, you may need to increase your overnight basal rates. You’ll need several overnight readings to be sure, but this is the usual case (in my experience). If your BG is normal when you wake in the middle of the night, you may need to program the pump to increase your basal just a short while before your wake to help cover your morning meals and high sugars. There are other solutions, such as exercising late in the evening, etc. but if you continue to have issues, I would discuss those with your health care practitioner.

So, here’s a quick summary:
(1) Normal BG at bedtime, low in the middle of the night --> need lower overnight basal
(2) Normal BG at bedtime, high in the middle of the night --> higher overnight basal
(3) Normal BG at bedtime, normal in the middle of the night --> early morning basal increase

You’ll notice the key is to first be normal before bedtime. If you do decide to modify your basal rate, you’ll still need to wake up in the middle of the night to see how its working. And GO SLOW! Don’t make massive changes in your basal, especially overnight, you may end up going way too low!

Good luck, and I hope that this helps! Remember the key with pumping and basal/bolus ratios is to try and stay at 50% basal, 50% bolus. If you’re bolusing too much, it is likely a basal issue.

If you do the overnight basal rate testing as Tim suggests, when you test before bed, try to make sure that any bolus in your system is out.

Also it might help to know when you are going high in the morning? It seems like you wake up normal… so is this 1-2 hours after eating? If so does it go back down to range before your next meal? And what kind of food are you eating? Some peope do well just by eating a low/no carb breakfast…

Excellent points, Xanthasun. You’re right, 116 isn’t terrible for a morning fasting BG, but it’s really relative to the BG value before going to bed. For example, if you’re going to bed at 116 and waking at 116, then your overnight basal is probably close to correct already. If your night time BG is 140 and you wake at 116, that’s a whole different story. Either way, one would expect that the fasting BG (when you wake up) would be one of the lowest of the day (in theory) since this is the longest you would typically go without any carbs. An “ideal” fasting BG in the AM would probably be between 80-100.

For me, when I’m behaving myself with good control, I’ll go to bed around 110 and wake up in the 80s or 90s. My post breakfast BG at two hours would usually be below 120. I use to always be high in the morning and it took about a week of waking up at different times during the night and slowly increasing my overnight basal to finally get it where it needed to be.

Even if your morning glucose isn’t that high, I’m still going to guess that this is a basal issue. Typically, if you have to bolus more for a given time of day/meal it means that your basal is too low before the meal.

All of the questions Xanthasun asked above are great, and I’d be curious about those as well. I’m of the school of thought that you shouldn’t have to necessarily eat something low-carb to keep your BG controlled, though. If your pump settings are where they should be, a normal healthy breakfast should be fine and not make your BG spike.

Thanks alot dear Tim that was really helpfull … Could you please tell me more about the 50/50 basal bolus issue. I am totally not aware of it … Thanks again …

Basically, that means that 50% of your daily insulin should be from basal, and that 50% should be from bolus. On the minimed pumps these percentages can be found under UTILITIES --> DAILY TOTALS. It will give you the total daily insulin (in Units) and then show you the break down of basal and bolus. If your bolus is > 50%, you most likely need to increase your basal.

On other pumps, I’m sure there are similar ways to determine this numbers. Good luck!

I would hesitate following some of the number recommended, although they are well meaning, the specifics of adjusting your basal is dependent on several factors.

If you are on the pump the basal can be adjusted hourly on most pumps. On the MDI, the PM long acting will impact the daytime BG balance and the AM long acting will impact the nighttime BG if you are splitting your long acting basal.

The 50/50 for basal vs bolus is the starting point and often is not what the ratio is for B vs B. Mine is 45/55 or 40/60, depending on what kind of shape I am in.

The starting point for getting on track, may be to not eat for a day and see what the real basal only BGs are. From there you can make the appropriate basal adjustments. If you are using a pump you can get away with breaking the fasting into smaller time periods as long as you don’t let background bolus impact the BGs (from 4 to 6 hours after bolus).

If you are on MDI, you may need to let thing ride for 36-48 hours to see the real BGs because of the long acting activity lasting 24 hours and with a 12 split dosage, the basal dosage last 36 hours.

It seems like a strain, but the outcome for me has been the best control possible.

If are looking for a book get “Think like a pancreas…” It should be required reading for all Diabetics. It is the real deal about how it all works and what you need to do to manage D with insulin.

Be patient. It takes time to get it right. Make sure you are only dealing with one variable at a time. Basal first, bolus / Carb second, then you can have some fun with the food experiments.

See if your MD or CDE can give you a CGM for a few days, most have one available for helping D in your situation.

Dear Tim,

Thanks for accepting my friend request … I did what you recomended me to do, my basal/bolos rate is 68 % basal to /32 % bolos. I know for sure i have a problem, my avarage is quiet hi . Can you please tell me how to adjust it in this ratio. By the way i have same pump of yours and i am using novorapid insulin.



Stephen makes some good points below, and I didn’t intend to imply that you should be at EXACTLY 50%/50, but it should be pretty close. Given the numbers you present, I would suggest that maybe your basal is too high and bolus is too low. This is just a very superficial interpretation of your numbers. Like others have mentioned, in reality it can be much more complicated. My guess would be with these ratios that your post-meal BG is probably going to be consistently high. My recommendation would be that you meet with your Endo or CDE or whoever it is that you see concerning your diabetes and sit down and readjust your numbers to where they need to be. Once again, good luck, I hope that everything gets sorted out!