This blog post is about my new found appreciation for cortisol:
“Cortisol is a steroid hormone also secreted from the adrenal gland. It makes fat and muscle cells resistant to the action of insulin, and enhances the production of glucose by the liver. Under normal circumstances, cortisol counterbalances the action of insulin. Under stress or if a synthetic cortisol is given as a medication (such as with prednisone therapy or cortisone injection), cortisol levels become elevated and you become insulin resistant.”
One of the large frustrations we were facing during this school year has been a wicked spike during school mornings…but not every morning. But, many mornings I’d be seeing her spike to 200+ without food and invariably starting around 9:30-9:40am. The spikes were so fast and aggressive that they have outpaced any looping algo despite the settings we’d have. How many diabetes frustrations start with “I spike when _____, but not every time. I wish I knew the pattern. If there is a pattern. Oh damn, hand me a diet coke, my head hurts. This sucks.” We were there.
I knew it wasn’t food. Anna is a really diligent food boluser and was actively doing manual actions (on top of looping) to try to blunt the spikes in the mornings. It was just stumping us. LUCKILY for me, as I’ve been discussing algorithms with my friend Ken, I bemoaned that looping is not very effective against this school spike thing. He mentioned that this was looking like a cortisol issue and it suddenly lit a lot of lightbulbs in my head. Here’s what I was FINALLY able to put together:
(Note: I am [un]lucky to have a kid that doesn’t really eat breakfast on school mornings…so the data was uncomplicated by food/boluses for most days.) Mondays are way worse than Fridays..and these Monday graphs include extra insulin from looping and manual corrections. Weekends were zero issue. Here’s the data…
What was happening for months now? Weekends were great. I’d send her to school on Monday. We’d see a huge spike starting at 9:30am (school starts at 8am), but get there too late to prevent going above 200. (and even while Looping…we never avoided the spikes above 200) Loop wasn’t enough and why would we be late? Well, dosing 3 units of insulin proactively at 90 mg/dL is a bit daunting without food involved. Especially if you aren’t seeing it every day. Some days that spike wouldn’t materialize. So we wouldn’t really correct with “extra” until she got to 180 mg/dL and climbing still aggressively. By the time we’d corrected for the spike, we’d have a problem usually fighting a low between 2-4pm.
So, after seeing that big spike on a day, I’d increase basals and adjust ISF and try to account for what we’d seen the day before. The day after a spike would be a little better. Then the next day might have not so much of a spike. Then suddenly I’d be pulling back on the morning basal adjustments because the spike seemed gone, and still overshooting the adjustments and having lows 2-4pm.
Here’s the problem though…my brain never realized this was happening on a Monday-Friday pattern. I just wasn’t realizing it until Ken mentioned cortisol and sleep patterns. So until I realized that, it just seemed like we were chasing a semi-random spike and I was very hesitant to give large corrective actions without knowing exactly what was going to cause them.
Addressing this spike meant near constant basal/profile adjustments and this was destroying our relationship. “Anna, can I see your phone again?” or “Anna can you change your 8am basal to 9am and make it 2.7 instead of 2.5?”…either one of those texts is NOT how I wanted to spend my time. I didn’t want to hound her to pay attention to the spike either. I was utterly SUPER frustrated with Loop’s interface to make these adjustments (hourly changes to basals and ISF on back-to-back days are NOT Loop’s strong point in terms of quick actions). I desperately wanted an easier way to make these changes faster with multiple profiles…because I definitely knew that weekends vs weekdays were one of the underlying needs to address.
Frustrations were at an all time high until cortisol understanding came along.
So, armed with the new info…I watched for patterns. I realized Anna’s spike is like clock work…I just hadn’t been recognizing the clock! DOH! Worse on Monday…decreasing day-to-day until Friday when it is minimal. Non-existent on weekends when she sleeps in about 3 hours later than a school day.
Reading the cortisol/sleep cycle literature and research…Anna’s experiencing insulin resistance tied to her morning spike of cortisol upon waking up. I hadn’t realized that a 2 hour delay from getting up out of bed was still possibly a cortisol issue. I’d always thought of it only tied to feet hitting the ground getting out of bed…but turns out there’s quite a bit of research showing that cortisol-related blood glucose spikes can be at play 2 hours after wake up. The phenomenon is worse on Mondays since (1) her sleep pattern is most disturbed suddenly that day (3 hours shift from the previous day) and (2) highest stress as it is the first day back at school. By Friday, she has acclimated to the wake up time and stressors of school…and the cortisol impact is less pronounced.
Armed with this knowledge, Anna has a better chance of avoiding lows/highs in this scenario.
Option 1: She could choose to wake up early on weekends and therefore avoid the extra cortisol response from the inconsistent sleep schedule…but she’s opted to not use that option lol.
Option 2: She can now more confidently choose to keep a moderate school vs. weekend profile and just manually correct on Monday and Tuesday at 9:40am-ish when she sees a spike building. We know Mondays are an early 3 unit correction, Tuesdays are an early 2 unit correction and Wednesdays are 1 unit correction, with Thursdays/Fridays can be handled pretty well by a looping option with a school profile with increasing time-in-range as those days go.
Option 3: She can choose to accept that Mondays and Tuesdays will be spikes over 200 for an hour or more if she doesn’t want to manually correct…that’s her choice too.
No matter which option she chooses, at least now we have a much safer operation for the 2-4pm timeframes now that we know what’s happening earlier. That’s the most important part. And we have been having increasing success with Mondays and Tuesdays spikes too…which is also nice.
Cortisol. What a beast.
If you want interesting reading on cortisol to start down your rabbit hole of research:
If you want to really amp up the reading, add some reading about the effect on cortisol from disruption of natural sleep cycles/circadian rhythms. There’s a lot to unpack in the research, but I sure learned a lot and it’s made a tangible difference for us now.