How to Treat Foot to Floor Phenomenon

Dear Dr. Edelman,

I need some help managing “foot on the floor”, NOT dawn phenomenon.  My blood sugar is great when I wake up, but as soon as I start moving around it starts rising and continues to rise, even if I don’t eat anything.  I am on a pump.  I know I need to increase my basal.  How far ahead of waking up should I increase my basal?

Dr. Edelman: Rising glucose levels after awakening is very common. It may be just the act of waking up as it raises your counterregulatory hormones (hormones that elevates your glucose values) like glucagon, epinephrine, growth hormone, etc. Raising your basal could be a solution, but you should test to see if your BG goes up if you sleep in. If it doesn’t, then raising your basal is not the answer. You may need to give a small bolus when you wake up, even if you do not eat or drink anything. It’s a very common problem. A hybrid closed loop system will help because the basal rate will increase to compensate for the rising glucose levels. For anyone not on a sensor augmented pump like the Control IQ, Medtronic 670G or Looping, you will need to give yourself a small bolus when you awaken.


Additional Resources:

Overbasalization in Type 1 and Type 2 Diabetes: You Can Have Too Much of a Good Thing!

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    I am on Control IQ and still do take a small bolus upon rising because otherwise my BS goes up without eating a thing. This can occur immediately or an hour or two later. I find the added basal from Control IQ doesn’t start early enough or is not sufficient to avoid the incease in BS. Occasionally my small bolus isn’t enough! So a second small bolus is needed to cover the increase. This is unpredictable and requires a degree ov vigilance to avoid this peak.

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    Thanks! I also have bg go up when I get up. I assumed it was from my 1 cup of coffee, and since I am not hungry for a while, didnt worry abt it. This makes more sense!😊

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    How would one treat this if they’re not on insulin? I’m on metformin and notice 90 in bed, and then 120+ when I test in the kitchen.

    • Hi Ashley, good question. Talk to your doctor and see if you can take most or all of your metformin at bedtime, i.e. 300 in the morning and 1500 at bedtime. This sometimes helps. Also, if you are on a sulfonylurea you could also shift that to bedtime. If your A1c is good, then it really does not matter that much. Do not change your medication without talking with your doctor first. Good luck!

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    I also have a high blood glucose when I first get up in the mornings. I walk a few steps to my desk to test my blood sugar, but not far. My blood sugar will be 107 or so when I take it in bed, but 125 or 130 if I get up & go to my desk to check it. Should I be worried about the difference?

    • No you should not be worried about the difference. These are normal differences as the meters we use can vary a bit.

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    Thank you for all of your comments! After I get up in the morning, my blood sugars rise too. I thought is was the vitaminsI took in the morning, but they are gluten free. Still wonder??? I up my insulin dose in the AM on my pump and recheck hours later to see if I need more. Sometimes I do need more insulin depending on what I eat. I currently don’t use a CGM, but am waiting for insurance approval. I have used CGM in the past, but finances don’t allow me most the time.

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    I can’t believe I never heard of this before. Sometimes I get up and by the time I get to work I am 80 points different. So glad I know it’s a thing.

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    I only have this sometimes-not every day. It seems to be worse if I wake up with higher blood sugar. If I wake up to a BG of 90, I usually don´t see a significant rise. However, if I wake up at 140 and just walk to the bathroom, I get back to bed and I am at 160. Does anyone else notice this? Why can´t it just be consistent? :/

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    I am so happy you posted about this as I had no idea (and I have read a lot of books and articles since my diagnosis), thank you!
    I always figured it was my coffee, which I thought was a bit extreme, or my thyroid meds, and just took it as a fact of life. Now I know!

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    Feet on the floor usually only happens to me if I wake up with a bg over about 110. I usually have a couple of hours to go to complete my fasting window so even with green tea, zero carbs, it will go up to about 160. However, if I wake up in the 70s or 80s, I am OK and sometimes even have to lower my basal to be sure I can finish my fast. So weird. What is that all about?

    • I don’t know for sure… it sounds like you may be on too much basal insulin, but for sure talk to your doctor about it.

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    So grateful to read this. I had no idea that it was a “thing” and blamed it on my coffee too. Thank you to all ho posted:so supportive!

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    Should we be eating protein as soon as we get up?

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    A hybrid closed loop system doesn’t help with this. A closed loop system will respond too late with an increased basal rate to prevent blood sugar from a sharp rise. My current system, just started a week ago (Omnipod 5), also likes to keep me at 120 overnight, which sets the stage for foot-on-the-floor increases of up to 160, 170 or even 180. It’s extremely aggravating, and I’m thinking of turning off automated mode so I can start off at a more reasonable rate when I wake up — say, below 100.

    • You can raise your ISF at that time (an hour before you get up) or give yourself a bolus the second you wake up, or a hit of Afrezza works great.

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    I am a type 1 diabetic, diagnosed in 2004 at age 14. From 2009 I developed Foot on the Floor syndrome. I asked my Endocrinologist for Metformin 850mg as I know this drug increases insulin sensitivity and stops the liver from releasing its glucose reserves. I was correct; now when I wake in bed I take a Metformin and also 1.5 to 2 units of Novorapid insulin for good measure and give these 5 minutes to work BEFORE putting my feet to the floor. The result is that I do not have a spike in my BG level.

    Before employing the above method my BG would always rise above 11 m/mol L and would not respond to any correction blouses for around 1 hour. It was sheer hell to live with!

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    I have FOTF and realized my later into my life thank goodness I was always a late late eater… if I’m low in the morning thinking I needed a raise in basal that doesn’t work that’s when I’ll be low upon waking but it if wake at 80 within 10-20 minutes I’m raising to past 160 I really don’t know how high I’d go because I intercepted it, I’m on CIQ or basal iq but that doesn’t work fast enough so I immediately take a unit or more if it keeps rising, so no pump fixes it… lucky me… when I normally eat well into late late morning then I’m running a nice flat line. I tried it all but a bolos or two is the only way. And my doctor 15 years ago told me it was coffee, I may try and lower my sensitivity and see it that helps with my closed loop…

    • It’s very difficult to deal with Foot to Floor. Typically a bolus before you get out of bed can help, and lowering your sensitivity may also help once your blood sugars start to go up.

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