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    How do you deal with the dawn effect?

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    ceej
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    How do you deal with the dawn effect?

    Post by ceej on Thu Mar 23 2017, 21:40

    I've been having some difficulty handling the dawn effect.
    As soon as I wake up my BS is great but very soon after waking (almost immediately) my sugar rises a bit. My normal routine follows that I walk the dog, after which my sugar rises further. I then go for a run and it rises even more!
    I don't really want to eat before doing these things so I've been taking some correctional insulin. Is this recommended?

    Even without exercise, which I realise can raise blood sugars itself, my BS rises. After eating breakfast, it keeps creeping up till lunchtime, whether I've exercised or not and whether I've taken some insulin or not! Any ideas about how I can handle this?

    Thanks.
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    chris c
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    Re: How do you deal with the dawn effect?

    Post by chris c on Thu Mar 23 2017, 22:51

    NOT a Type 1 but this also affects some Type 2s and I've read enough on forums to say the only answer is "suck it and see"!

    Some people use a nocturnal snack, maybe something like a biscuit and cheese, or a handful of nuts with a glass of red wine, basically with a few carbs and some fat to slow them down, so when your liver takes a peak in the early hours it sees some insulin and knows it doesn't need to dump a whole load of glucose. Harder for Type 1s though to judge if you need some late night insulin or if it will drive you hypo in your sleep.

    I "work" best with a small low carb moderate fat high protein breakfast as soon as I get up, but I stopped getting dawn effect when I went low enough carb to be in ketosis most of the time and could do an overnight fast for blood tests, drive to the doctor's and back and even do some shopping on the way without much happening. I do the breakfast anyway as I don't normally eat until any time between late afternoon and late evening, and as a slightly weird Type 2, similar to a MODY, I have a different insulin response, a bit like a good basal but little ability to produce boluses, so this works for me.

    One Type 1 I know used a couple of units of fast acting as soon as he got up and then went most of the day without food, but this would be a disaster for others. Whatever you try, keep some glucose tabs in easy reach in case it all goes horribly wrong!

    May be worth asking on Type 1 Grit or the Bernstein forum for more ideas from other Type 1s.

    ceej
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    Re: How do you deal with the dawn effect?

    Post by ceej on Fri Mar 24 2017, 07:40

    Thanks, Chris! There are a few ideas I can try there Smile
    Ithik it's also a combination, for me, of going for a fasted run but I simply don't feel like running after eating :/ Perhaps a small breakfast snack will work.
    I do take a couple of units before I take the dog out and another couple before I run but the blood sugars just keep going! More experimentation needed *sigh* Perhaps, like you, once I maintain low carb for long enough, it will become less of an issue.
    Cheers, again.
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    Derek
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    Re: How do you deal with the dawn effect?

    Post by Derek on Fri Mar 24 2017, 13:44

    Hi Ceej,
    Low carb brings ones fasting b.g down eventually, I am about 5.2 ish atm on waking, no meds, mine now is about the same after breakfast of three large fried eggs in olive oil, a few jumbo oats and flaked almonds.

    Actually the people who use a freestyle libre say there are liver dumps throughout the night when one is asleep!
    regards
    D.

    ceej
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    Re: How do you deal with the dawn effect?

    Post by ceej on Fri Mar 24 2017, 16:39

    Hi Derek,
    That's good to know about b.g. settling eventually. My waking is between 4.5 and 6 so I'm ecstatic about that! Very Happy Amazing that even after some oats your bloods are the same...mine would go through the roof :/ I'm finding that throughout the morning my b.g. can rise to up 15...and that's with having eaten breakfast (about 8g of carbs with insulin) and a few units of correction doses Sad
    Perhaps protein is doing something? It's incredible frustrating.

    Wow...maybe a bedtime snack would hep with the night time liver dumps?
    Thanks, Cassie

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    Derek
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    Re: How do you deal with the dawn effect?

    Post by Derek on Fri Mar 24 2017, 17:12

    @ceej wrote:Hi Derek,
    That's good to know about b.g. settling eventually. My waking is between 4.5 and 6 so I'm ecstatic about that! Very Happy Amazing that even after some oats your bloods are the same...mine would go through the roof :/ I'm finding that throughout the morning my b.g. can rise to up 15...and that's with having eaten breakfast (about 8g of carbs with insulin) and a few units of correction doses Sad
    Perhaps protein is doing something? It's incredible frustrating.

    Wow...maybe a bedtime snack would hep with the night time liver dumps?
    Thanks, Cassie

    Hi Cassie, Have lost nearly 4stone on low carb high good fats. Only have two desert spoons of oats and have two table spoons of olive oil to fry eggs lightly and soak up oats and almonds.
    Now 6'5" and a skinny 13 stone and trying to put some weight on.
    I tend to eat full fat yoghurt berries and a square or two of dark chocolate between 2000-/2100 but we go to bed early in the country!Smile D.

    ceej
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    Re: How do you deal with the dawn effect?

    Post by ceej on Fri Mar 24 2017, 17:59

    Wow - well done! So you find that combining carbs with fats releases the sugar more slowly?
    I might try your snack idea...I don't eat after my dinner (about 5.30-7pm) until 8am the next morning. Thinking about it, that's probably why my liver goes into overdrive in the morning!
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    Derek
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    Re: How do you deal with the dawn effect?

    Post by Derek on Fri Mar 24 2017, 21:32

    @ceej wrote:Wow - well done! So you find that combining carbs with fats releases the sugar more slowly?
    I might try your snack idea...I don't eat after my dinner (about 5.30-7pm) until 8am the next morning. Thinking about it, that's probably why my liver goes into overdrive in the morning!
    I do it so my meds (non diabetic) are separated by 12 hours. But it may help my b.g. as well. D.
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    yoly
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    Re: How do you deal with the dawn effect?

    Post by yoly on Sat Mar 25 2017, 20:56

    The dawn phenomenon should really not be a problem if it’s not high enough to cause problem over 130(7.0). The reason it is correlated with a lot of bad effects and complications in studies is because people with high morning glucose eating high carb diet will have postprandial levels well above the damaging levels. But if you if your are controlling your post meal numbers with LCHF there should be no need to have a big concern for above normal number in the morning. You just need to eat something to stop the liver dump when you wake up or use some insulin if you are insulin dependent.

    ceej
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    Re: How do you deal with the dawn effect?

    Post by ceej on Sat Mar 25 2017, 21:39

    Thanks, yoly.
    My concern is that, despite taking some insulin in the morning- waking bg of about 4-5,it still rises much higher than 7 over the course of the morning...more like 12 by lunchtime!

    Example 1 :
    7am - wake 4.9
    7.30 am - 20 min dog walk
    8.30 - 9.8 - 2 units and 20 minute run
    9am - 12
    9.30 - 9 and breakfast of 11g net carbs and 2 units
    12 - 5.5

    Example 2 (after seeing exercise affects bg)
    6 am - wake up 4.9
    6.20am - 6.1
    6.30m - 1 unit of insulin and a 20 minute dog walk
    7.00 am - 2 units and a 20 minute run
    7.30 am - 8.5, and took a unit to correct
    8 am - 7.5. Breakfast 11g net carbs and 2 units


    I feel like I'm taking way too many injections causing insulin to overlap but if I was to take that much straight away when waking, I would hypo.. :/ Aaaargggh!
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    chris c
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    Re: How do you deal with the dawn effect?

    Post by chris c on Sat Mar 25 2017, 23:27

    What do you use for basal and when? Just curious, one well controlled Type 1 I knew split his basal asymmetrically (I think he was one who returned to Beef Lente) and had no qualms about using anything from 0 to a dozen shots of bolus (the latter usually when he was ill and he got massive IR and a corresponding loss of his usual control, or when he was forced by circumstances to eat crap)

    ceej
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    Re: How do you deal with the dawn effect?

    Post by ceej on Sat Mar 25 2017, 23:35

    I use Lantus and inject at 10pm...5 units. I guess, if it's working I shouldn't be worried about taking multiple shots of bolus...out of my comfort zone, it seems.
    I really appreciate the input and suggestions...thanks! Smile
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    chris c
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    Re: How do you deal with the dawn effect?

    Post by chris c on Sat Mar 25 2017, 23:40

    Doesn't work so well with Lantus but can be done with Levemir quite successfully. Since your waking BG is so spot on though I'd be disinclined to change what is obviously working and try hitting the subsequent rise with bolus in different quantities and timings (with glucose tabs in easy reach)

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    Re: How do you deal with the dawn effect?

    Post by ceej on Sat Mar 25 2017, 23:44

    I might talk to my doctor about changing if I can't sort it. I'm assuming it's better for me to preempt the rise by taking insulin before rather than reacting once it's already gone up? Silly question? :/ And should I be concerned about doses overlapping?
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    chris c
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    Re: How do you deal with the dawn effect?

    Post by chris c on Sat Mar 25 2017, 23:58

    Theoretically yes, "insulin stacking" is regarded as a big no-no. But that comes I think from the DAFNE advice to NOT test your postprandials, only wait until before your next meal. With modern fast acting stuff there's much less overlap compared to R - which some low carbers have reverted to as it seems to work better with high fat and corresponding slower glucose rise and drop.

    I had a thought, have you seen

    http://www.rbch.nhs.uk/bdec2/

    they have/had an online course which many Type 1s regarded as world class and far superior to some of the face to face DAFNE courses.

    Yes timing your bolus before eating and before exercise can have major effects. Remember though that I have no experience of this, I'm just relaying what I have read. Some of the Type 1s I've "known" have A1cs better than a lot of Type 2s and even better than some "nondiabetics" but getting there takes quite a lot of tweaking, and not a few mistakes. You seem to be mostly doing well!
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    yoly
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    Re: How do you deal with the dawn effect?

    Post by yoly on Sun Mar 26 2017, 14:25

    Of all the insulin's Lantus insulin glargine is the most likely to produce anti insulin antibodies that make it less effective in some people. In most people the basal don’t last 24hrs either, so some find it more effective to split the dosage. If you don’t mind the many injections the best control can be achieved with small dosages of rapid insulin injected as needed along the day. The only real need for basal will be at night only if it goes too high to damaging levels. The best is to have a continuous monitor if not possible, test as many times as you can. Just be sure not to over do the insulin better to have a short high that too low blood glucose because the over correction with insulin.

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    Re: How do you deal with the dawn effect?

    Post by ceej on Sun Mar 26 2017, 14:30

    Hi yoly,
    I didn't know that about Lantus. I don't mind how many injections I take, I'm so used to it. Yes, I'm noticing evening bg that indicate the basal is waning. I test a lot anyway so looks like I' on the right track...and thanks, I'll be careful not to over-do the qa Smile
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    chris c
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    Re: How do you deal with the dawn effect?

    Post by chris c on Sun Mar 26 2017, 23:05

    Lantus can be weird. Theoretically it lasts 24 hours but in practice it may last anywhere between 18 - 30 hours. Also it seems to be most likely to remove hypo awareness. It works well for a lot of people but not for the rest. I knew someone who (AFAICR) used to shoot the Lantus in the morning, then because it was wearing off, would use some NPH at night to overlap its tail. Also some people find it takes maybe a few days for changes in basal to fully take effect.

    Levemir or Beef_L both seem to be more predictable in more people, but though Levemir is also marketed as once per day it is less likely to last 24 hours, but correspondingly easier to split, especially into asymmetric doses, as the results show immediately. Most GPs and a lot of endos won't even admit that Beef-L is still on the market though. To be honest I don't know if it still is (Wockhardt) or if there are any other newer basals, I haven't been keeping up. I do know that hardly anyone keeps good control on NPH or mix (Insulaturd and Mixturd were popular descriptions) though I knew someone once who shot it three times a day with some success (his insurance wouldn't permit anything more expensive).

    Again largely for financial reasons (coming shortly to an NHS near you) I knew someone who as Yoly suggests used R several times a day, he called it "Pseudo-pumping" which I've also heard being done with fast acting but requires a lot of calculation.

    Your best bet for this kind of info would be a Type 1 site. NOT anywhere official where they preach carb up and shoot up and lousy control.

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