Compiled by: Barb Chafe (Parent of a teen pumper)

Medical Advice Disclaimer! Attention !

Disclaimer:

The following are tips and tricks we have learned ourselves, tried upon the advice of others, or have read about and thought they were a good idea. Many thanks to the Insulin Pumpers for all their help! Individuals are, well, INDIVIDUAL! What works for Erica might not work for you or your child. The key is to keep learning and determine what is the best for you or your pumper. Any changes you might be thinking of making should be discussed with your medical team first. They are key to your pumping success.

Morning Madness - Those Darn Phenomenons!

Mornings can be so frustrating! Hopefully you will find some information
below which will help you solve the riddle which is 'you'! Thank you to Hirsch
Meisels for his effort in putting this all together. Check out Hirsch's
website at: http://www.friendswithdiabetes.org

RISE and Shine!

Controlling Morning Blood Sugars

Some parts of this article are adapted from Pumping Insulin by John Walsh and
Ruth Roberts, and the Insulin Pumpers mailing list
http://www.insulin-pumpers.org

Are you experiencing fluctuating blood sugars during the morning hours? The
first blood sugar of the day is usually the most important one for controlling
the entire day's readings. "If I wake up high, my whole day is shot!" is a
typical complaint because an early morning high is often quite difficult to
bring down through the day.

Diabetes educators are constantly hearing the question, "How come I went to
sleep with an in-range BG number and I woke up with a much higher number? I
didn't eat anything in middle of the night; I didn't even dream about food!"

The answer is that diabetes does not always stick to the rules, or more
accurately, it sticks to its own set of rules. Once you learn these rules and
how to identify them, things will start to make sense and you will be better
able to deal with your morning blood sugars. In this article we will attempt to
show you some of these "non-rules", which will aid you in taking control of
your diabetes. There can be predictable reasons for your unpredictable and
"brittle" BGs! The secret is to learn how YOUR body reacts in different
circumstances.

As stated in our disclaimer, never make a change in diabetes regimen without
prior discussion with your health care provider. We are specifically
reiterating this warning here, as the following article discusses making
insulin changes. These tips have been collected from individual experiences,
and some may be rare exceptions to the rule; others, however, occur very
frequently (up to 70% of diabetics experience them). Remember, "If it isn't
broken, don't fix it". We have only provided this information with the hope
that if you are among those experiencing unpredictable blood sugars, this
additional knowledge may give you a clue of what's going on and how to overcome
it.

If you do think that one of the described phenomena apply to you, please do not
jump to conclusions before you check, double check and triple check your blood
sugars to verify this. Medtronic Minimed's Continuous Glucose Sensor, or the
Glucowatch from Cygnus are excellent tools for tracking blood sugar patterns,
as they test BGs automatically at constant intervals. Show your recorded logs
to your health care provider to discuss the necessary changes.

For instructions on testing your basal rates, refer to page 97 in the third
edition of "Pumping Insulin". Or, use the charts provided in the book "The
Medtronic MiniMed Insulin Pump Worksheets" on setting basals on the Insulin-Pumpers website, http://www.insulin-pumpers.org/howto/baslr.html

A final note about irregular morning blood sugars: Although it might seem that
reading about the various morning phenomena would make it harder to pinpoint
your exact problem, the opposite is true. During the day, it much harder to
isolate the exact source of BG fluctuations; you may wonder if a high blood
sugar is due to your basal or last bolus. But in the morning, you know that a
long time has past since your last meal or bolus. Morning trends are much
easier to identify if you know what to look for!

The Dawn Phenomenon

Some 50% to 70% of people with Type 1 diabetes find they need more insulin in
the early morning hours to offset a rise in blood sugar. This rise, called the
Dawn Phenomenon, is created by a normal increase in the production and release
of growth hormone, and to a lesser extent by cortisol and adrenaline, which
trigger the production and release of glucose from the liver. If this need is
not met by an increase in insulin delivery, the blood sugar rises as daylight
approaches and is high when the person awakens.

A typical adjustment for a person with a Dawn Phenomenon usually provides
slightly more basal insulin before and during the early morning hours.

People who have a strong Dawn Phenomenon find that it's difficult to control
the morning blood sugar with any injected insulin regimen. On a pump, however,
controlling the morning blood sugar becomes a simple insulin adjustment. The
basal rate can be adjusted precisely to prevent the blood sugar from rising
during the night. Easy programming allows each pumper to set basal rates to
meet individual needs at each hour. "I usually wake up in the morning with a
normal blood sugar!" is a joy shared by many new pumpers.

For some people, adjusting basal rates or long-acting insulin is not enough.
You can experiment with the following:

Same Basal, Larger Bolus: Instead of changing the basal rate, you may need
a higher insulin-to-carbohydrate ratio for breakfast. A Unit of Prevention
Is Worth a Pound of Correction! Another trick for controlling the Dawn
Phenomenon is to raise basal rates 0.1 to 0.2 u/hr at 1 a.m., as opposed to
making a larger insulin increase at 3 a.m. or 4 a.m.

An equal or even larger percentage of people with Type 2 diabetes find their
pre- breakfast reading is the hardest of the day to control. Even though their
problem also occurs at dawn, the source of the problem is different from the
Dawn Phenomenon. Most people with Type 2 have an excess of fat cells in the
abdomen, referred to as an apple shape. During the night, these fat cells
release fat, which is picked up by the portal vein going to the liver. This fat
makes the liver less sensitive to the insulin passing by.

Because of this insulin resistance, more insulin is needed to do the job of
stopping the liver in its production and release of glucose. If insulin
production fails to keep up with the rising need because of aging and weight
gain, the liver will make more and more unneeded glucose during the night. For
people with Type 2, an insulin pump is often the ideal way to deliver the
precise, small insulin doses needed to stop the liver from increasing glucose
production. Other ideas suggested in this article can also be adapted for Type
Twos.

The Wake Up Phenomenon

Others find that they experience a rise in blood sugars each time they wake up
in the morning (that has nothing to do with the time of day). The solution for
this one would be to administer a bolus every time one wakes up.

If this phenomenon appears even upon awakening from a short nap, try to program an extended (square wave) bolus before napping. Or, how about exchanging the
nap for a relaxing afternoon stroll? Again, the best we can do is to learn our
body's individual patterns, so that we can anticipate them and, hopefully,
prevent them.

The Break-Fast Phenomenon

A common occurrence is a steep incline in blood sugars following the first meal
of the day. This phenomenon persists at all meals eaten after a stretch of
fasting; this can mean an early breakfast, a midday brunch, or supper following
a Yom Kippur fast. Many people find that they cannot properly deal with the
sudden ingestion of carbohydrates if the regular insulin dose is administered.

One would have to experiment with higher insulin-to-carb ratios at the first
meal eaten every day. Or, if the high blood sugars appear only after a high
carb meal is eaten, then the amount of carbohydrates in your breakfast may need
to be reduced. (See our "Breakfast Smarts" article below for more breakfast
tips.)

The Motor Start Phenomenon

An interesting trend that some people experience has been informally dubbed the
"Motor Start Phenomenon". This is when blood sugars spike sharply following
breakfast, no matter how many or how few carbs are consumed. This phenomenon
tends to be inconsistent, surfacing and then disappearing in the same
individual. Its causes are unclear, but it may be stress and hormone related.
It differs from the dawn phenomenon in that it appears only after food is
eaten. Many people also find that it does not kick in when they sleep in longer
than usual, maybe because they are more relaxed on those days.

To test for the "Motor Start" Phenomenon: Go to sleep and wake up at your usual
time, but skip breakfast. Test consistently to get a fasting morning BG
profile. On another typical day, eat a protein-only breakfast and test BGs
constantly. On a third morning, eat a lower carb breakfast and record your
blood glucose readings. Finally, eat a high carbohydrate breakfast and log your
blood sugars. If you are experiencing the Motor Start phenomenon, you will
likely have high blood sugars on all mornings that you ate any food, except on
the day you fasted.

The best method we have found for dealing with this blood sugar rise is to
administer an extra fixed amount of insulin, usually about 1.5 to 2 units, upon
awakening or before eating breakfast. (It may be necessary to take this insulin
some time before eating to give the insulin a chance to begin working before
breakfast is eaten.) Just remember that as soon as your body's tendency
changes, this extra insulin must be eliminated. Otherwise, it can cause serious
low blood sugars.

The Rebound Phenomenon

Undetected low blood sugars in middle of the night followed by a re-bound can
cause stubborn highs and unpredictable blood sugars for the whole day,
especially in the morning. Checking once during the night at 2 am will not
always catch the low, since they can be fairly brief, (based on reports from
people who have used the CGMS). One option would be to do hourly checks spread
out over several nights. For example: the first night you check at 10, 1, and
4. Take a rest the next night, and then you check another night at 11, 2, and
5. And so on, until you covered every hour of the night. If this doesn't catch
it, talk to your doctor about using a CGMS or a GlucoWatch biographer.

The Caffeine Phenomenon

If you are accustomed to your daily cup of morning coffee (or a few daily cups
of coffee in the morning), then here's one more reason to break the habit:
Although caffeine has no carbs, some people have noticed that it causes their
blood sugars to rise. This may be due to the insulin resistance which caffeine
triggers in some people.

As with so many diabetes-related issues, every person is unique. Interestingly
enough, some people have noted that they have a "Reverse" Dawn Phenomenon,
meaning that their sugars go low at the time of morning when most people are
insulin-resistant. These individuals would actually need to decrease their
basal or long-acting insulin to compensate for this BG drop.

SWEET (AND SOUR) DREAMS: Did you know that your dreams could be a reflection of nocturnal blood sugars? If you are having bad dreams at night and waking up high in the morning, check it out! You may be experiencing nighttime lows and morning rebounds. Nightmares, or emotional and involved dreams, could sometimes be a symptom of low blood sugars. Or, it is possible that the chemicals involved in the dreaming process are actually causing the pattern of lows and highs. Set your alarm clock for 2 a.m. and find out what's happening with your BGs overnight!

BREAKFAST SMARTS: Some of the following tips might work only for those on
insulin pump therapy, some will work for those on multiple daily injections and
flexible insulin therapy, and others might work even for those on the
conventional regimen.

Cereal is a universally favored breakfast food. There is no preparation
involved, it is quick to serve and consume, many nutrients are added, and of
course, many of us enjoy it!

Cereal measurements should always be done by weight of the dry cereal. Most
cereal changes volume dramatically as the box is moved around and the cereal
settles. The investment in a good quality kitchen or food scale is definitely a
must.

Which cereal should one select for a healthy breakfast, and how can we avoid
the high BG peaks caused by these rapid acting cereals (high glycemic index)?

When it comes to choosing a cereal, it would seem probable that the
sugarcoated variety would produce worse BG results. Interestingly enough, this
may not necessarily be the case because the sugars used are complex and require
time for the body to process before they can be converted into glucose. The
opposite is true of the "plain" cereals, which include products like Cheerios,
Corn Flakes, Cream of Wheat, etc. Highly refined grains are converted to
glucose very rapidly, much faster than the sweeteners used in the "sugary"
stuff; therefore they are extremely high on the glycemic index. The solution
might actually be to let the kids eat junk food!

You might also try squirting a little honey on a "plainer" breakfast cereal.

The above two tips were shared by Michael Robinton, executive director of
Insulin Pumpers.

CAUTION: They may not work for everyone! Some people do find that they react best to the plainer cereals.

Don't forget to count the milk; it has a lot of carbs. Milk contains 12 grams
of carbohydrate per 8-ounce cup (1.5 grams per oz.).

Adding almonds to the breakfast cereal might also prove beneficial. Fat slows
down digestion and lowers a food's glycemic index (GI). Adding a protein to
your breakfast menu would have a similar affect, especially if you eat the
proteins first.

Try eating a high-fiber cereal such as Fiber One to lower the glycemic index
of your breakfast. At the June 2002 ADA conference, research was announced
showing that the glycemic load of breakfast affects the midday meal metabolic
responses in individuals with Type 2 Diabetes. In other words, through changing
just your breakfast habits, you may see an improvement in both post breakfast
AND lunch blood sugars. Your entire day will be brighter!

Some say that cereals made from finely ground whole wheat flour would have a
glycemic index similar to that of its white counterpart, but oats would have
lower GI values.

Many diabetics substitute bread with rice cakes, thinking that the rice cake
will have a better affect on their blood sugars.

Here are the facts: Rice cake has a higher Glycemic index (110) than bread
(101). Mixed grain bread with a GI of 69, or Sourdough bread which also has a
lower GI, would be much better choices. Rice cakes are also hardly lower in
carbs, as one cake has at least 9 grams of carb, while one small slice of bread
contains about 13 grams. If you come across a brand of rice cakes whose label
states that it has just 5 grams of carbohydrates per cake, you have stumbled on
an unfortunate mistake (unless it's a thinner slice than usual)!

Although the newer, rapid acting insulin (Humalog and Novolog) allow the
freedom of injecting or bolusing right before the meal, if one anticipates a
blood sugar rise after breakfast then it might pay to administer the insulin a
little earlier. This gives the insulin a chance to start working before the
food kicks in. The recommendations are to administer the insulin between 5 and
15 minutes prior to eating, but some people have seen greater benefits by
taking the insulin even earlier, as much as 15 20 minutes before eating
breakfast. Just make sure you don't take it too early, to avoid hypoglycemia.

It has also been reported that the use of Novolog, as opposed to Humalog,
eliminated the post-breakfast BG spike. This benefit was observed in children
as well as adults. [At the time of this writing, Novolog is the only
rapid-acting insulin approved for use in insulin pumps in the US.]

Keep in mind that some people might require a higher insulin-to-carb ratio for
breakfast, due to some of the phenomena mentioned in the article above. For
example, one's insulin-to-carb ratio might be 1:12 for breakfast, while it is
1:20 for lunch.

Alternatively, you might find that increasing the insulin dose specifically
for cereal will do the trick of keeping BGs in range. You may require a
different amount of insulin for a breakfast consisting of toast, for example,
than for a breakfast consisting of cereal with the same carb content.

ON THE GLYCEMIC INDEX... There has been much media opposition to the Glycemic
index. It is interesting to note, however, that all opinions do in fact
support the glycemic index, without realizing it. For example, EVERYONE agrees
that one has to eat glucose tablets or another FAST ACTING carbohydrate to
treat a low blood sugar. Why not eat a piece of chocolate to bring up the low
blood sugar? Because, when we need an immediate response in blood glucose, we need a high GI food!

[On the same topic: it is important to note that when milk is suggested for
treatment of hypoglycemia, it refers only to low fat milk which is higher on
the GI than regular milk. The fat in the regular milk slows the absorption of
the carbs (lower GI), which makes it less recommended for treating a low.]