Type 1 & the Big "M" - Mornings
I have never considered myself a morning person. It has always felt tough to drag myself out of bed and I relish the weekends if a lack of commitments, allow me to have a lie in.
As a child, my parents struggled with knowing the best way to manage the often sharp rise to blood glucose levels in the morning. On the unsophisticated one injection a day routine with no home blood glucose monitoring, it was difficult to pinpoint a precise cause for my frequently high morning urine tests. The HCPs often talked about the somogyi effect (rebound high blood glucose levels following hypos in the early hours) or whether it was dawn phenomenon (the blood glucose rise resulting from the surge of hormones in the early hours to get you out of bed each day).
Once post menarche and into a more predictable routine, having left my student days behind, dawn phenomenon was an issue that I learnt to accommodate as part of my morning.
The first time I remember a change to this pattern was walking my daughter to school just over ten years ago. She was in the final year of junior school and as we approached the end of our twenty-minute walk, I remember feeling increasingly irritated with her, as she wasn’t walking in a straight line. I have learnt to recognise quietly, that internal feelings of irritation are often a warning sign that I am low. It quickly dawned on me that she was not the one with the problem. I had been doing a school walk of one sort or another for possibly the last twelve years without any problems and a very predictable blood glucose response. I had become complacent and only ever took front door keys and my phone – no bag, no hypo treatments – I had been following the same morning routine and eating the same breakfast and felt confident about how my blood glucose responded. In the twelve years of school walks I had never had a hypo. Until then! I told her what was happening. We stopped walking while I guiltily fished around in her packed lunch for something I could use to treat the low and tried to banish visions from my mind of what would happen if that wasn’t sufficient.
And that was the beginning of greater morning variability.
The most frequent pattern to contend with was still dawn phenomenon but increasingly, as the years went by, a further selection of morning responses joined the mix. So I now had to deal with either:
· Foot to the floor response (as above) – where my blood glucose would rise but it would not start at 3 or 4am but wait until I got out of bed. I might then experience a rise of 3.5mmol/l in the space of 10 minutes. Blood glucose levels might remain raised for up to an hour or could fall again of their own accord, without any intervention. No bolus insulin was given between the hours of 9am and 11am.
Delayed foot to the floor response – where my blood glucose would remain stable possibly for up to one or two hours after getting up, before blood glucose levels would start to rise.
Wake up and crash – where my blood glucose would remain stable as long as I stayed lying in bed but the minute my foot touched the floor, my blood glucose levels could often fall quite significantly. Blood glucose values could then bump along in the 3.8mmol/l to 4.0mmol/l range for much of the morning.
When these issues first started, I was on MDI and this made it impossibly difficult to manage background insulin doses to cope with this variability. My background dose was one injection of long acting insulin delivered at bedtime. Once injected, I couldn’t reduce or suspend the dose the following morning to help deal with whatever response my body decided to throw my way. As I approached my bedtime injection at the end of each day, I was left wondering what to inject, often feeling “paralysed” trying to determine a suitable dose without knowing what the following morning response would be.
After a two year battle, I managed to obtain insulin pump funding which, combined with a range of other methods, has helped in developing a system for dealing with the morning uncertainty.
So the factors that have helped?
a very brisk early morning dog walk before any food,
the ability to easily micro bolus insulin with a pump, regardless of where I am, and
delaying breakfast for two and a half to three hours after getting out of bed.
Early morning dog walk
I am awake mid-week by 6.30am and split my morning into roughly three 45 minute phases.
The first is spent convincing myself to get out of bed, shower, dress and transfer food for the day at work into my bag so that all is packed for work before heading out for my walk. This allows time to see whether my blood sugar is going to drop and whether any drop will be a continuing downwards trend or will stabilise but at a lower level than my fasting blood glucose test. This will determine whether I have any carbs before heading out for my walk.
If my morning response has been either dawn phenomenon or a foot to the floor response that leads to a blood glucose that appears to stabilise below 8.5mmol/l, this exercise generally works to halt any further rise and will often return blood glucose levels to a more normal fasting range. I rarely correct an out of range reading at this level before starting the exercise as when tried, this has almost always resulted in a low at some point on the walk, even when the correction is quartered.
If my blood glucose is higher than this, I will often give a very small correction dose of 0.2-0.5u. This is between a fifth to a half of the normal correction dose I require to get my blood glucose back to a reading in the 5 mmol/ls when beginning to creep up above 9 mmol/l, but combined with the impending exercise, is all I often need.
I then have a very brisk 45 minute dog walk with Herbie, keeping an eye on my CGM trace that is sent to a pebble watch.
There are rare occasions where the walk will not be sufficient, either with or without a pre starting micro correction, to stabilise or reduce an out of range starting reading. In these situations I will usually micro bolus a correction dose of insulin once I am fifteen minutes from the end of my dog walk, which should be sufficient to halt any continuing rise, especially with the increased sensitivity to insulin that should kick in with exercise.
My final 45 minutes allows time to bath Herbie (if muddy paws) and change before we both head out of the door to work. This also allows time to see any further blood glucose response, especially where I have micro-bolused either during or near the end of the walk. If this has resulted in a minimal impact on blood glucose levels, I am likely to need a higher bolus dose for breakfast. If I feel the blood glucose drop has been greater than expected, I can compensate for this by reducing my breakfast dose of insulin once at work.
Delayed timing of breakfast
Maybe this is stating the obvious but the key problem with eating any meal is determining the appropriate insulin to carb ratio. It is recognised that you will need more insulin to deal with carbs at times of the day when you are more insensitive to insulin but what happens when this sensitivity changes from day to day? Eating breakfast as soon as you get up doesn’t give sufficient time to identify the likely response for that day.
I recognise that I am now at a stage of life that allows me to do this. Both children are in their twenties and completely self-sufficient. I work very close to home so do not have to factor a long commute to work into my morning routine. My job also allows sufficient flexibility in managing my diary to eat breakfast at my desk in the morning. So the two to three hour wait has helped in a number of ways. I am more likely to know the type of insulin:carb ratio I will need for breakfast. If I have a blood glucose that has managed to creep into the 9-10mmol/l range (or on a few occasions higher) before breakfast, I can bolus and leave the hour often required to start to see blood glucose levels reduce, before eating, which reduces the length of time that I am likely to be out of range for the remainder of the morning. To eat on top of an already higher than desirable blood glucose reading, will just keep me out of range for longer.
I don’t miss not eating first thing. I am not sure whether changing calorie needs as I’ve got older have stopped me feeling hungry on waking or whether I was never really hungry at 7am but had lived most of my life dictated to, regarding when and how much to eat, to ensure that I had food to match the insulin in my system. It can be easy for old habits to become engrained but pump usage has given me greater flexibility in choosing when to eat.
So, this may sound very regimented but having managed this way for a number of years, the process and decisions start to become just another part of my routine. I sometimes find myself responding to morning events without having consciously gone through all the thought processes identified above. However, what is also interesting is that there have been a few days recently where I have taken my eye off the ball (or more importantly the CGM) and have been surprised by a very rapid post walk/pre-breakfast spike.
And there are even some days where I get a beautiful CGM trace and no additional tweaks or decisions are required outside my pre-programmed basal and bolus settings. I am hopeful that in time, when fully menopausal for long enough, this may become more of the norm but once again, only time will tell.
I am writing a series of blogs about my experiences of managing type 1 as I approach the menopause. I hope this will help others to understand the range of changes that may affect them. However, I am very aware that my experiences may well be very different to yours…. So please use this for ideas, discussion with HCPs and not as gospel. Please talk to your team before experimenting with techniques that have worked for me. Please experiment slowly and safely, to see how you react when trying to find techniques that may work for you. It has taken me nearly five years of self-funded CGM use and trial and error, to come up with my tool kit. Even then, it never works all of the time!