Night time dual wave?

Hi All,

my son is 8, was diagnosed a year and a quarter ago and has been on the pump for about  6months. We've gotten most of his numbers sorted out, but still struggle in the evenings and night. We found he would go low an hour or two after dinner (say dinner at 6:30 and low at 8:30), then very high around 10:30 or 11:30. We ended up having some crazy pump setting with a very high carb ratio (over 40) and also very high basals (about twice what he has during the day), which makes no sense to me, since if he's less insulin resistant at night he should need lower basals, right? Anyway, my new theory is that the carbs just get into him slower from dinner time on, and that we need to dual wave him for every dinner and dessert/snack. Has anyone else experienced this? That carbs are a lot slower getting into the bloodstream in the evening and night?



I have a similar problem with dinner.  Does he eat different types of foods at dinner than he does earlier in the day? I experience delayed absorption (with the low 2 hrs after dinner and then a high 4 hours later), but I usually eat more protein and fat with dinner than I do with breakfast and lunch. Protein and fat cause food to be broken down/enter the bloodstream at a slower rate, which is what causes the delayed high. I often have to use a dual wave or a square wave with dinner, but rarely, if ever, have to use them earlier in the day.

I don't think there is a consistent difference, but maybe he does eat more protein. It seems that no matter what he eats it gets in slower than at other times of the day. What do you use for the dual wave? How much up front, and for how long?



What you're experiencing is common.  A couple things could be going on:

- Basal rate needs to be adjusted.  My basal from 5pm - midnight is less than 1/3 what it is in the afternoon.

- Food digests slower in the evening and most people eat higher carb and fat foods that delay digestion.  A dual wave is a good way to deal with that.  You'll probably have to experiment to find what works for each meal.  I've also started avoid stuff like baked potatoes for dinner because they're so high carb.      

- Not sure about the carb ratio.  The morning usually requires a lower carb ratio because of dawn phenomenon, but the rest of the day can be the same.  A 1/40 carb ratio sounds okay for evenings, but adjust if it's not working for you.

A couple months ago I did the Gary Scheiner (author of Think Like a Pancreas) online class on Mastering Pump Therapy and it was helpful.  You can type in questions for him to answer.  Classes are usually $40 each, but noticed that January ones are free and pre-recorded sessions are $20.  Totally worth it to get help from an experienced diabetes educator and longtime diabetic.  

Thanks Jenn,

what doesn't make sense to me is that he would night a high basal AND a high carb ratio. If the bolus insulin is more effective at night, presumably the basal should be too, so it doesn't make sense to be giving him less bolus insulin and more basal insulin than at other times during the day. Now I'm thinking that it's because the food gets in slower across the board. The problem is knowing the timing. We've tried different types of dual waves, but have yet to settle on one that works, particularly since he sometimes goes high 4-5 hours after dinner, and we *really* don't want to have insulin going into him then (after we are asleep).


The high basal and high carb ratio sounds messed up.  Not sure why the doctor put that setting in and think you should talk with him/her about it.  

Your concerns about the long dual wave make sense.  I started doing them just by trial and error.  If I ate pizza and my blood sugar was normal went I went to bed, but 300 when I woke up the next morning, I used my correction factor to estimate how much extra insulin I'd need the next time I ate pizza.  The next time I had pizza I timed the square wave to end about 3am.  Then I woke up around 2am and test my blood to see if I guessed right and adjust as needed.  

Always err on the side of being high.  You could start with 1/2 the rate of insulin needed and go from there.  And avoid square waves if your son got a lot of energy that day.    

thanks. I think we need to reduce the basals, reduce the carb ratio and lengthen the dual wave, and probably most importantly, convince him to not have many carbs after 8:00 (that will be the hardest). It's always a balancing act - not wanting him to feel so restricted that he rebels and does something foolish when he's old enough vs. trying to keep him in good numbers and good habits. In any case, I appreciate the advice.