Posted by on Tuesday, 25 October 2016

Night-time nonsense. Perfection isn't possible.

The darkest hour, just before dawn, yesterday
I stumbled across this little bit of research again today. And while I know I had clocked it in the past, and was aware of it - this time it came as a huge relief.

I have not been feeling altogether cheery about my diabetes of late. Off and on for something getting on for a year I have been feeling more than usually grumpy and disheartened about it. I have written (mercifully few) ranty grumblings about it every so often. Partly driven by a couple of clinic appointments where I somehow managed to spend the weeks before and afterwards twisting and distorting either real or imaginary conversations into spirals of judgement, impossible requirements and self-destructive behaviours. Quite reasonable and well handled suggestions suddenly becoming a cloud of frustration and rage in my head, and a lead weight in my heart.

Many people would describe this as 'diabetes burnout', but that always sounds a bit too dramatic and significant. Mine is perhaps more of a 'diabetes weariness', with occasional outbursts of 'OH FOR GOODNESS SAKE WHAT ON EARTH IS THE POINT'.

Diabetes is such a mind game. Confidence and self-belief count for a lot for me. I do better when I feel things are going better, and I am much more likely to go off the rails or make (deliberate/knowing) poor choices when my levels are all over the place anyway.

You may recall that one of the changes I had been trying to make related to my remaining overnight hypoglycaemia. Nothing like as bad as it would once regularly have been (I have not had any severe hypos either in the day or overnight for years) but time spent hypo overnight is still something I really want to reduce further. Well after the best part of a year, and having tried a whole bunch of different approaches (some disastrous, others not so bad) I'm not sure I'm very much further forward. Without continuous monitoring it's hard to be 100% sure, but it seems I will still dip below 4.0mmol/L at some point on something like 3 nights in a month. I am now running most of the other nights significantly higher and that has resulted in an increase to my A1c by something like 0.5%-1%. On the plus side though, my number of BG checks below 4.0mmol/L last month was slightly lower than normal (whatever normal pretends to be).

So some things are a bit worse. And other things are a bit better. Well that all sounds familiarly 'life with T1D' to most of you I'm sure.

But here is the thing - if you, like me, struggle with variability in levels overnight. There is a LOT we can do to reduce it. There are strategies that we can put in place to really help. But it will never be perfect.

And we have to find a way to make peace with that.

During the day, you can do your best to reduce variability - to make good food choices, to dose carefully, to make adjustments around activity and exercise. And all the time you can watch and check and see how you are getting on. Check. React. Adjust. Move on.

What this piece of research, published in Diabetes Journals in May this year, demonstrates though - is that overnight insulin requirements are likely to be even more variable than those during the day. Think about that for a minute. In almost 2,000 days and nights that were measured and compared there was more variability in insulin need overnight than during the day. More variation with NONE of the variations in food, activity and all the rest.

That doesn't mean that it is not worth trying, of course. We still need to do the best we can to make up for our errant pancreases letting us down on the whole insulin-production front. Keep checking, reviewing and adjusting. Throwing in the occasional overnight basal test every now and then ("Hooray!", said no one ever). But it is worth bearing in mind, if you are struggling this week, that you are not on a level playing field. What works well most nights might let you down tomorrow, and that is not your fault.

Perfection is not possible. All we can do is our best.



  1. Thanks Mike - as ever this is very interesting & apt.

  2. Excellent blog Mike, sorry to hear about your Weariness and hope the writing of this blog is a catalyst to see a reduced Weariness.
    Amy uses CheckReactAdjustMoveOn (although she'd say Test!) to great effect, it's an important mentality which seems to help her deal with fluctuating levels.
    Totally agree that there's a lot which can be done to help and knowing that perfection is not possible is a great place to start.
    Lots of people could benefit from the simple messages in this blog, I hope they get to read it.

  3. What an interesting article Mike - thank you ever so much for blog - I learn something new every time I read it :)

    I think a lot of 'diabetes weariness' comes from the unpredictability of managing it - and that a lot of health professionals don't really seem to appreciate this.

    There's a sense that you're at fault if the BGs don't behave as predicted. I certainly found that when I was first coping with managing Type 1 DM.

    Understanding the mechanisms of the unpredictable insulin response has helped me a great deal. I was chatting to one of our hepatobiliary (liver) surgeons a couple of years ago about this, and I hadn't appreciated that all the blood flow from the pancreas goes straight into the liver blood supply - a relatively small volume of blood in the hepatic portal vein. So the concentration of insulin that the liver 'sees' is about ten times higher than the rest of the body. The insulin then gets diluted into the total blood volume (about 5L for a 70 Kg adult). There's no way to duplicate this when giving insulin subcutaneously, so the liver just isn't as effective as it normally would be at catching glucose as it comes in from the intestines. There are physiology papers in the journals about this if you're interested.

    Hence the importance of exercise after a meal - to use muscle mass to both burn and store the glucose.

    From what I've read so far, muscle sensitivity to insulin varies quite a lot, depending upon previous levels of exercise and existing glycogen stores. Athletes can readily double the glycogen storage capacity of the muscles by regular training. This is probably also why high intensity exercise is good at increasing insulin sensitivity.

    CGMs really make day-to-day management so much easier, particularly those with a hypo alarm (or even better, the predicted hypo stop facility on your pump) as a safety measure. They really reduce 'diabetes weariness' too. I think we'll see more funding becoming available for them over the coming years, as more and more research papers prove their worth.

    With best wishes,