My DD age 9 often has night time highs around 200-250 that are very flat but are very hard to bring down with insulin. Without treatment, they last from midnight to 4 AM and then sometimes come down on their own. We have tried insulin corrections and extra insulin (stacking) to little immediate effect. Eventually she comes down to a low that we need to treat (usually around 4 AM). We have two theories (1) hormones, and (2) fatty foods like pizza that create fatty acids that trigger the liver to release glucose. Has anyone else seen any information on this phenomenon? Our endo does not get it – she just thinks our insulin correction factor needs to be changed that time of day. But the phenomenon is sporadic. Our current procedure is to do one correction at the first sign of the rise, plus a temp basal 2-3 times normal for 2 hours. And turn off temp basal when she falls below 200.
Wow, complicated issue- perhaps a new endo who specializes in pediatric endo is the best thing. Sometimes, stress can be a factor- school just started. Has her activity level changed?
I’ve only been a Type 1 for about 12 years, and I’m a Type 1 onset. I have found my sugars rise at night too, and minor adjustments have helped. I’m on a pump.
Keep in mind- high is better than low. So for the time being, ask more questions, and get second medical opinions with medical professionals.
Also, talk to your daughter about school, the change of schedule, the hardship of going to a nurse and getting tested during the day.
I recently spoke with a surgical nurse who’s niece was recently diagnosed as a Type 1, she wasn’t eating lunch at school, because the line in the nurses office was too long with all of the other diabetic students, that she didn’t have time to eat.
Hang in there- sounds like you are keeping a close eye on things. Good luck!
I’m neither Type 1 nor pediatric, but I have such stubborn nighttime highs at times. I find they are usually associated with meals that were higher in carbs, but also contained more protein or fat (or both). For me, the other culprit is almost any kind of pasta. The highs I have from such meals are double-spikes - one fairly close to the meal and another that STARTS 4-6 hours later and can last 4-6 hours even with fairly aggressive action on my part. I have tried double-boluses and extended boluses, but have not gotten the right combination yet.
I may have to give up on some of those foods (have had problems even with smaller amounts) - dunno. NOT my preferred choice of action…
I can attest that “dawn phenomenon” is a stubborn customer from personal experience, but I’m an adult and the hormonal situation of a 9 year-old may be something else entirely. But I can also attest that…
Pizza. Is. Evil.
The hormonal theory is a good one. If valid then you’re doing the right things. Needing to correct a low after is more work but it gets the correction done. The only thing left is to begin the correction sooner. Sounds like your keeping that DD healthy. The other theory, the pizza one I don’t find that one ringing true. There’s another theory that may not ring true in your xylophone, sneaking food. Still I think those growth hormones raise blood sugar and what better time to grow than when relaxed and dreaming.
Thanks everyone for your comments. These highs are not like day time food highs, since they do not respond to insulin. For example, if we need to give glucose in the night, any resulting glucose high is soon gone with a nice normal curve response to insulin. But these highs are not curves but a very flat plateau. It is almost as if there is some homeostatic mechanism acting to maintain this level. Giving her high levels of insulin will create a range of peaks in the plateau, as the insulin starts to act and then fails. Even if we don’t give insulin, the high level does not get much worse, it seems to stay in the same general CGM level. Last night was another example, after a restaurant pasta meal. I agree pizza is problematic for us, and pasta is bad too, although with tomato sauce it seems to be better.
You may want to track what she’s eaten on those days you have to mega-treat the highs to have a better idea as to which of your theories is more likely. I’ve found that when I have a meal that’s higher in fat than usual, it changes my insulin resistance for hours on end. So a high-fat dinner (or even sometimes lunch) will affect me long beyond bedtime. I end up taking way more insulin than the usual I:C & correction factors would suggest. (For example, 1u usually brings me down about 100, but if I’ve had pizza, the correction is more like 1 u for 30-40.) Eventually things go back to normal & the same 1u will send me plummeting down. Good luck on your detective work. It can be frustrating!
I would strongly suggest a CGM, does she wear one? She may be going low and then having a rebound effect, liver dump. I’ve had these too, and seriously could not get them down. I typically use only .5 units for correction which can drop me 50+ points. In the middle of the night, when these highs happen to me, they simply won’t come down, it takes a ton of insulin. Or, she’s just not getting enough insulin during that time. I’ve never heard of ‘fatty acids’ or foods that trigger the liver to release glucose’ where did you get that theory from? And yes, you’ll need to change your ISF. It’s not always the same time frame for me either. It’s the reason why I’m restarting on a pump. Change and experiment with her dinner, meals without these high fats and see if it makes a difference?
i’m not sure it’s the fat from the pizza. my endo told me ‘fat’ is about the only thing most people don’t have to bolus for. many type 2’s eat low carb - high fat diets for that reason, doesn’t effect BG’s.
This may be a stupid question, but have you done the basal testing? A light meal at 6 pm and no food after that. You mention CGM levels in one of your posts. If you are using CGM it makes the basal testing a whole lot easier. If you are not, you may be able to get a loan from your clinic. You can do basal tests using fingersticks but overnight they are a monumental PITA.
Basal insulin requirements can vary hugely depending on the time of day. It may be that your daughter requires a lot more basal overnight. Once you get into a “not enough basal” situation my experience is that this triggers insulin insensitivity and it can take a lot of insulin and several hours to correct the situation.
Run the basal tests for a couple of nights. If you can identify from the CGM trace the time at which BG starts to rise, you want to increase the basal rate around 2 hours before the start of the rise. It is trial and error, but you may find that you need to program in a surprisingly large rate increase.
Good luck.
Joel
I enjoy this discussion. Tell us more about your daughter with diabetes.
The low rebound idea is a good one. We certainly have seen highs that rebound from a low and they are resistant to insulin too. She does use a Dexcom G4 CGM which is how we can follow this effect.
We do use a CGM. Because the effect is sporadic, that is, not every night, we do not program a basal rate to cover it. But I agree on these nights it is probably a basal rate problem, since she has not eaten recently, but the question still remains – where is the glucose coming from and why? We fix the high with a bolus and a temp basal rate increase, but it is very resistant.
Here is my anthropomorphic theory (I may have read it or synthesized if from my reading, I don’t remember which). If there is an abundance of fatty acids in the blood stream, the liver doesn’t know where it came from – either food or from storage due to lack of glucose. It assumes from storage, so the liver responds by releasing glucose. The essential fact is that free fatty acids lead to increase of glucose. Read this about the pizza effect:
Here is a quote from the article:
“Research has shown that dietary fat and free fatty acids (FFAs) impair insulin sensitivity and increase glucose production.”
One word: HORMONES
My daughter is 13 years old and we are riding the same roller coaster. Temp basals have helped somewhat. I’ve pretty much accepted the fact that we’re going to have to ride this coaster and just hang on for dear life. “This ride WILL come to an end” has become my mantra…
I heard at TCOYD yesterday that the common pre-dawn phenomenon is caused by growth hormone and goes away with longevity of disease slash age.
[quote=“justanordinarygyrl, post:2, topic:47643”]
et second medical opinions with medical professionals.Also, talk to your daughter about school, the change of schedule, the hardship of going to a nurse and getting tested during the day. I recently spoke with a surgical nurse who’s niece was recently diagnosed
I’m confused:~D
I have a 12 year old with the same problem. Did you find any other resolution? We just keep looking at upping basal rates from 12-3 but our problem seems sporadic too. It is frustrating to make corrections at high 200s, low 300s with no change for hours.
I have this same issue. My endo ended up switching me from lantus, to levemir, hoping that my body was just starting to reject the lantus and it needed a change. However, levemir seems to be doing the same thing. My blood sugars shoot up as soon as I fall asleep. By 3-4am, I’m in the high 400s! And it takes FOREVER for my blood sugar to come back down.