question about bedtime snacks

[Ariel22]

i take levemir split up between morning and night doses. since i was diagnosed i was always told i needed to have a snack at bedtime to hold me over till morning.

i'm currently doing a diabetes education review, and the nurse told me that i don't need a bedtime snack if i'm on levemir. apparently that was only needed for NPH or something.

it's very strange to go to bed without a snack. i'm reluctant to do it actually. i have a fear of lows, although i guess it shouldn't happen.

but, tonight i checked my BG and i'm at 145. if i were to go to bed with no snack, ideally this should stay in the range it is right now? or will it drop? i gave myself my levemir already.

or, should i do something like a small snack, like a glass of milk? and if i do that, should i give myself novolog for it, or just take the milk and then go to bed?

the nurse also told me some stuff about how if my BG is fine, a snack of about 15g of carbos doesn't need an insulin shot.

i just don't want to go to sleep and have my blood sugar dropping while i'm sleeping. how can i get it to stay right where it is?

[UpNorth]

If your levemir dose is right, your bloodsugar *shouldn't* drop, or only drop very little. Some people have a tendancy to drop overnight nomatter what and others might go up during the night. My nights are pretty stable so if my bloodsugar was 140 at bedtime i wouldn't need to snack no matter if i'm pumping or on MDI :)

But really, it's all about how your body acts at night and how levemir works for you. Some people do have a peak with levemir and others don't. Basal testing is the best way to know. And also test during the night sometime to see what's happening.

[Ariel22]

well, it's been about an hour and i just checked it again. now it's at 114.

obviously that's not a bad number, but my feeling is that i can't just go to bed without eating because that's still a 30 point drop over an hours time.

am i wrong on this and just irrationally panicking?

[Subby]

i take levemir split up between morning and night doses. since i was diagnosed i was always told i needed to have a snack at bedtime to hold me over till morning.

i'm currently doing a diabetes education review, and the nurse told me that i don't need a bedtime snack if i'm on levemir. apparently that was only needed for NPH or something.


I don't agree with the "cookie cutter" mentality the nurse appears to be applying... when it comes to tactics around making your insulin therapy work (and your life work with insulin in it), it should be guided by what is actually occurring for you, what you require, and not by generalisations and guesses.

That said, there are three things you need to consider when it comes to such a question as "Do I need a bedtime snack?"

One, is the action of the insulin. Levemir is indeed much flatter than NPH, although not by any means "flat", which means that it's action is far less and in itself less likely to need balancing food through the first 4 or so hours as NPH might.

Two, is your background basal requirements. This is the "natural" or 24 hour repeating ebb and flow of how much insulin is required by your body to sustain its normal operation at a steady BG rate.

Like many things, there are generalities, and then there is you. There is enough variety in background basal requirements to mean that it's foolish and dangerous to say "you'll probably do X". many people have lowered requirements overnight, potentially leading to a low given a flat insulin action. I am sure others get resistances and go the other way, too. You need to work out your body for yourself. The answer is to test and observe trends and test some more. A structured way to get insight is what is called "basal testing".

Some people find they are relatively steady. Others, like me, see a big variation through the day/night and need to employ more tactics. For someone on MDI that might be splitting dose and eating snacks at strategic points. For me on a pump, I have basal rate settings through the day to utilise.

In general, there may be little that can be done about such fluctuations, except to manage them.

Third, is what I'll call here "temporary" basal influences. These are activities that impinge on your background basal needs. Things such as exercise before bed, eating certain foods, overlapping or incorrect boluses, being active or stressed in the evening, that kind of thing. Such things might have an impact some hours later in the night.

They are worth mentioning in their own category I think, as they can be changed by us, they are aspects that affect things and they can either cause issues, or be used as tactics to help improve our stability.

So, after all that, what I'd perhaps suggest right now, is to experiment, with small changes at each point. For example, if you normally have a whole glass of milk, but you wonder if the idea that you should not snack is a good one, I'd suggest having half a glass of milk and comparing results. Do it over a few nights, test the theory a few times.

The whole point of basal insulin is to maintain even levels. But in the real world, it may or may not need some help. Whether that is with big snack, small snack, no snack, less insulin, more insulin, etc, is your task to work out, using observation and tools like basal testing if you so wish :)

Sorry that's not a simple answer but if you consider it, I hope it's a useful one.


the nurse also told me some stuff about how if my BG is fine, a snack of about 15g of carbos doesn't need an insulin shot.


I'd treat such statements with care and test them thoroughly before trusting them as useful for you. 15g of many types of carbs is enough to throw my sugars out substantially (by that I mean in magnitude of say 4 mmol/l / 70 mg/dl). It's different from person to person.

Do you use an i:c ratio to work out your doses? A better approach would be, bolus for everything (ok, maybe there is a point, for example 4g, where it is not worth it) UNLESS the point of the snack is to bring up or sustain the blood sugar - such as hypo fixes, or longacting bedtime snacks to counteract basal.

[Subby]

well, it's been about an hour and i just checked it again. now it's at 114.

obviously that's not a bad number, but my feeling is that i can't just go to bed without eating because that's still a 30 point drop over an hours time.

am i wrong on this and just irrationally panicking?

It's tricky with that, as in built tester inaccuracy has to be taken into account for both readings (commonly, it's about 10% inaccuracy in either direction).

If you test again in an hour you might get more definite indication. Then again it might be close again! If I were you I'd take a slightly reduced snack tonight and see how that works out. Don't just throw out what's been working for you: if you want to test and challenge it, do so slowly and methodically.

I hope you get some good sleep.

[xMenace]

Check this poll out.

http://www.diabetesforums.com/forum/monitoring/23021-nighttime-basal-tendency.html

A competent DE should understand these variations.

[jenb]

Hi. If you're concerned that taking Levemir at night and not snacking will cause a serious drop in BG I'd suggest that you spend a few nights doing basal tests. That will tell you how your Levemir dose is working.

As for the advice about "if your blood sugar's OK a 15g carb snack shouldn't need a bolus" - wow. 15 grams would send me up about 90 points! Do you know how much a gram of carb causes your BG to rise? You might test this also. That will inform you about whether you need to bolus for carbs.

If you haven't already gotten them, I'd recommend picking up Gary Scheiner's book "Think Like a Pancreas" or John Walsh's "Using Insulin'. They will take you through the process of doing the various tests that will make your insulin dosing more efficient.

Happy monitoring!

Jen