# "Feet To The Floor Syndrome"



## RoyalBlood (Oct 21, 2018)

Hello everyone,

Looking for some input from those who are pumping and managing to offset morning FTTF BG spikes with increased basal rates. Even more so from those who don't eat breakfast.

When on MDI (Levemir/Novorapid), I was taking a 1.5u bolus upon waking to counter the spike I'd see every morning. This technique worked reasonably well and I'd typically be back in range 5-7mmol within 2 hours or so. This was even with skipping breakfast, a meal I have never particularly enjoyed nor wanted to have.

Since transitioning to a pump I was hoping that I could offset the morning spike with a preempted increased basal rate - however this has proved unsuccessful. Even with a ~200% basal rate starting two hours before waking and running for a duration of two hours. BG's start climbing shortly after getting out of bed and basically continue to do so until I eat. See below an example of basal rates and BG's - every workday morning follows a similar pattern: 

0000-0500: 0.75u/hr
0500-0700: 1.45u/hr  *wake up at 0645
0700-2400: 0.75u/hr

2230 BG - 7.6mmol
0500 BG - 7.1mmol
0650 BG - 7.3mmol   
1040 BG - 12.7mmol  *2.3u correction
1200 BG - 13.3mmol

From what I can tell, I have a couple of options.

1) Force down a small breakfast and bolus accordingly, with the possible addition of a small preemptive correction as when on MDI. Seems sensible but does involve breakfast. 

2) Continue skipping breakfast and increase 0500-0700 basal rate to a silly/questionably high rate. This idea I'm not overly keen on.

Any suggestions and advice from personal experience would be greatly appreciated. Thank you all in advance 

RB


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## Sally71 (Oct 21, 2018)

What's wrong with doing a massive basal increase for a couple of hours?  If it works, do it!  My daughter has the opposite problem, her BGs shoot up into the stratosphere as soon as she goes to bed, and it doesn't seem to have anything to do with when and what she last ate.  The only way I've managed to get round it is with a massive basal increase from 9pm to midnight, e.g. on school days she does from 1.65 u/hr 1900-2100 to 2.60 from 2100-midnight and then back down to 1.45 u/hr. We have to tweak it every so often, and of course we get hypos sometimes, but mostly it works.


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## SB2015 (Oct 21, 2018)

If the bolus on waking worked on MDI that could still be an option. I assume you want to do this on the pump so that you can head off the rise.  In order to get enough extra insulin to tackle the morning rise the basal rate would need to be high, so if that is how you want to deliver it then that would be a high basal rate for the hour before you get up.

I have a rise when I get up as you do.  I wake, test, bolus for anticipated rise as well as for breakfast (as long as BG is not too low).  I then shower etc and eat breakfast about 30 minutes later. This seems to keep me in target through the morning.  I adjust the breakfast delay according to my BG on waking.

I have a rise after exercise, possibly as my body needs some glucose to top up stores so my liver does a dump.  Counter intuitively I stop by having a small snack (with bolus) after the class.  I wonder whether this is something that could apply here. At least something for breakfast.


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## nonethewiser (Oct 21, 2018)

Easiest option is to bolus on waking just the same as you did on injections, saves messing about with basal rates and won't lead to a hypo on the days that you might oversleep.


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## RoyalBlood (Oct 21, 2018)

Sally71 said:


> What's wrong with doing a massive basal increase for a couple of hours?  If it works, do it!


I guess "nothing" is the answer to that 

I'll try both methods and see what I prefer/works best.


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## RoyalBlood (Oct 21, 2018)

SB2015 said:


> If the bolus on waking worked on MDI that could still be an option. I assume you want to do this on the pump so that you can head off the rise.  In order to get enough extra insulin to tackle the morning rise the basal rate would need to be high, so if that is how you want to deliver it then that would be a high basal rate for the hour before you get up.
> 
> I have a rise when I get up as you do.  I wake, test, bolus for anticipated rise as well as for breakfast (as long as BG is not too low).  I then shower etc and eat breakfast about 30 minutes later. This seems to keep me in target through the morning.  I adjust the breakfast delay according to my BG on waking.
> 
> I have a rise after exercise, possibly as my body needs some glucose to top up stores so my liver does a dump.  Counter intuitively I stop by having a small snack (with bolus) after the class.  I wonder whether this is something that could apply here. At least something for breakfast.


Yes, the bolus is to counter the feet to the floor rise. I'm in two minds whether to bolus or use a large basal rate. The latter puts me off for reasons like, sleeping in, possibly having lower that ideal BG before the large basal rate kicks in, etc. Wake, test, bolus is fool proof as you know your BG prior so can apply the correct amount of insulin. The only draw back is the 60-90 minute lag time before it reaches peak.


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## RoyalBlood (Oct 21, 2018)

nonethewiser said:


> Easiest option is to bolus on waking just the same as you did on injections, saves messing about with basal rates and won't lead to a hypo on the days that you might oversleep.


Exactly my thoughts.


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## Pigeon (Oct 21, 2018)

My basal rate varies from 0.375 to 0.925u/hr throughout the day. Not too silly if that's what you need! My highest rate is 5-7am to counter what you're seeing. I normally get up at 7, maybe 8 at weekends - don't have too many problems with lows if I sleep in  a bit.


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## Pumper_Sue (Oct 21, 2018)

It looks to me as if you need to do some proper basal testing and have more time slots. Once you have a complete picture you can make informed guesses! as to your basal needs

If you have sleep in days then set a separate basal to cover this.


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## everydayupsanddowns (Oct 22, 2018)

I’ve never been able to crack mine with basal alone. If it crank up the basal too much too early I find I am dropping dangerously close to hypo territory when I actually get up.

If I’m not having breakfast I find a small bolus on rising is still my best strategy (I also have a basal kick at that time of day but not a huge one).

For breakfasts I mostly just have a single slice of Burgen toast (except weekends) for which I have a slightly over enthusiastic bolus ratio and carb estimate which I leave cooking for 30 mins before eating. 

Good luck cracking yours.


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## Radders (Oct 22, 2018)

I find mine is unpredictable so I can’t really manage it through basal alone, although I do have two basal settings for weekdays and rest days with a boost for 2 hours before I wake. 
I notice that it is less of a problem when my total carb intake is moderate, presumably because there’s less in the tank: I don’t really know. I do a small bolus when I wake up as long as I’m not already under 5, and don’t eat for at least 45 minutes, taking the rest of the breakfast bolus about 15 minutes before eating. I then try and exercise for 20 minutes after breakfast and mostly it works. 
Good luck!


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## trophywench (Oct 22, 2018)

I am utterly amazed that your body needs exactly the same basal rate from morning until night - hence I also want you to do a couple of full 24 hour basal tests - obviously this takes a lot longer than 24 hours each, but the other thing I'd add is that basal increases to correct highs, or reductions to reduce lows, need to be started TWO hours before the rise, not ONE, to guarantee having enough insulin at the correct time.  So if you need a correction of 2u at 8am, you'd increase the basal by 1u at 6am and 1u at 7am, cos all of the 2u will be active by 8am.  However be conservative and only increase both by 0.5u to start off and test test test.


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## RoyalBlood (Oct 23, 2018)

Pumper_Sue said:


> It looks to me as if you need to do some proper basal testing and have more time slots. Once you have a complete picture you can make informed guesses! as to your basal needs
> 
> If you have sleep in days then set a separate basal to cover this.


Proper basal testing? That's what I have been doing Sue. 0.75u/hr works for me at all other times outwith the morning period, where I'm having the issue. It's always been an issue, both on MDI and with a pump. I never bothered detailing BG's for the other "time slots" (1200-1800; 1800-0000; 0000-0600) as I've done the testing and proved my rates sound for the respective periods.


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## RoyalBlood (Oct 23, 2018)

everydayupsanddowns said:


> I’ve never been able to crack mine with basal alone. If it crank up the basal too much too early I find I am dropping dangerously close to hypo territory when I actually get up.
> 
> If I’m not having breakfast I find a small bolus on rising is still my best strategy (I also have a basal kick at that time of day but not a huge one).
> 
> ...


Thanks Mike.

This morning was better actually - applied a 2u bolus as soon as I woke:

0610 - 5.9 *went back to sleep
0840 - 5.6 *got up and took 2u bolus
1040 - 7.2 *11g carbs and 1.1u bolus
1200 - 8.2
1330 - 6.8
1400 - 6.4 *target BG set to 6.5

I prefer this approach over the mad high basal rates as I know the remedial action (bolus) has been applied as close to the right time as possible. A work in progress but on the right tracks


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## RoyalBlood (Oct 23, 2018)

trophywench said:


> I am utterly amazed that your body needs exactly the same basal rate from morning until night - hence I also want you to do a couple of full 24 hour basal tests - obviously this takes a lot longer than 24 hours each, but the other thing I'd add is that basal increases to correct highs, or reductions to reduce lows, need to be started TWO hours before the rise, not ONE, to guarantee having enough insulin at the correct time.  So if you need a correction of 2u at 8am, you'd increase the basal by 1u at 6am and 1u at 7am, cos all of the 2u will be active by 8am.  However be conservative and only increase both by 0.5u to start off and test test test.


We're all different I guess Sue, nothing utterly amazing about that 

I'm sure there are very small differences in my basal requirements throughout different periods of the day - undoubtedly. I'm sure with further basal rate testing and experience on a pump (this is only week 3 by the way and I've been unwell since going live), these rates will change ever so slightly. But currently, 0.75u/hr is there or there abouts for me. But it's morning time I'm focusing on; the sole reason for this thread; which has always been problematic for me.

Can you kindly elaborate on what you mean by "increase the basal by 1u at 6am and 1u at 7am, cos all of the 2u will be active by 8am."

Thanks.


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## Pumper_Sue (Oct 23, 2018)

Would you be good enough to post your basal rates and results please? Hopefully we can help you a bit more.
If you did basal testing whilst unwell then suspect it was a complete waste of time though as it's surprising how much difference it makes.

What TW is telling you is that when a basal slot needs changing do it 2 hours before the change is needed.

My basal is set at 0.067 @ 6am and jumps up to 1.45@8.30am that's because I need it. If you need to increase your basal you need to end of story. 

I can't remember where I read it but think it says that if you have to correct more than 2units per day then your basal is not correct. Obviously if within 2 hours of a meal then look at your carb ratio as long as your basal is correct as you do not want to medal in other depts. until your basal is ok.


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## RoyalBlood (Oct 23, 2018)

Pumper_Sue said:


> Would you be good enough to post your basal rates and results please? Hopefully we can help you a bit more.
> If you did basal testing whilst unwell then suspect it was a complete waste of time though as it's surprising how much difference it makes.
> 
> What TW is telling you is that when a basal slot needs changing do it 2 hours before the change is needed.
> ...


Sure thing, I'll need to dig out my log sheet where I wrote my results down against my rates. But as you said, being unwell it's nowhere near accurate and isn't all that useful. I couldn't have asked for worse timing to be unwell and start pumping...


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## Radders (Oct 23, 2018)

RoyalBlood said:


> Thanks Mike.
> 
> This morning was better actually - applied a 2u bolus as soon as I woke:
> 
> ...


Those look like a dream set of results RB.


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## Pumper_Sue (Oct 23, 2018)

RoyalBlood said:


> Sure thing, I'll need to dig out my log sheet where I wrote my results down against my rates. But as you said, being unwell it's nowhere near accurate and isn't all that useful. I couldn't have asked for worse timing to be unwell and start pumping...



My suggestion would be to redo your basal testing and don't be afraid to increase your basal as and when needed as basal testing when unwell is a waste of time.


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## Elaine B-S (Oct 24, 2018)

Crikey, people with Type 1 have a lot to consider, respect to you all!


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## RoyalBlood (Oct 28, 2018)

Hello guys, a little follow up with some good news 

Cold has cleared up and things have calmed down massively BG wise. Morning BG issue has been conquered, so I'm very happy. This basal profile works perfectly for when at work; I work away from home.

0000 - 0500: 0.70u/hr
0500 - 0730: 1.65u/hr
0730 - 1030: 1.20u/hr
1030 - 2400: 0.55u/hr

Morning basal results 25/10:

0600 - 5.7
0655 - 6.8
0805 - 6.2
0915 - 6.7
1150 - 5.6

Morning basal results 26/10:

0600 - 4.7
0800 - 6.1
1000 - 6.5
1200 - 5.9

Very chuffed!


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## Pumper_Sue (Oct 28, 2018)

Pleased all is well with you now.


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## Radders (Oct 28, 2018)

RoyalBlood said:


> Hello guys, a little follow up with some good news
> 
> Cold has cleared up and things have calmed down massively BG wise. Morning BG issue has been conquered, so I'm very happy. This basal profile works perfectly for when at work; I work away from home.
> 
> ...


Looks good! So pleased you have managed to sort it. Would you consider adjusting upwards slightly between 4 and 5 am to prevent the small increase you’re still getting between 6 and 7?


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## Eddy Edson (Oct 28, 2018)

Elaine B-S said:


> Crikey, people with Type 1 have a lot to consider, respect to you all!


Absolutely!


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## RoyalBlood (Oct 28, 2018)

Radders said:


> Looks good! So pleased you have managed to sort it. Would you consider adjusting upwards slightly between 4 and 5 am to prevent the small increase you’re still getting between 6 and 7?


Yeah that's certainly an option! Tonight I may try 1.8u/hr 0500 - 0730 (10% increase)? With that I may also change 0730 - 1030 from 1.2u/hr to 1.1u/hr (10% reduction) as I do seem to be marginally lower at 1200ish vs the rest of mid morning?


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## Radders (Oct 29, 2018)

RoyalBlood said:


> Yeah that's certainly an option! Tonight I may try 1.8u/hr 0500 - 0730 (10% increase)? With that I may also change 0730 - 1030 from 1.2u/hr to 1.1u/hr (10% reduction) as I do seem to be marginally lower at 1200ish vs the rest of mid morning?


I wouldn’t change the 5-7 rate myself, I’d just change from 4-5.


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