sugar surfing by Stephen Ponder

[tim2000s]

As an example I'm thinking of my daughters spike after breakfast, I pre bolus and give her the meal when she starts to drop and I'm sure the insulin is working, she spikes sometimes 8-9 mmol. .. its a very steep rise followed by a very steep drop which eventually keeps going until she goes low. I get that normally such a spike suggests not enough insulin was given but if she eventually drops then obviously not...

Is the only way to stop this to change what she has for breakfast? The team are extremely reluctant to suggest I change her from a carby breakfast

There's a carby breakfast, and there's a carby breakfast. Anything that's relatively quick acting is really hard to balance timing with. Let's also bear in mind that the other piece of T1D is that in the early stages, you tend to have faster gastric transit than a T0. You will find that if you continue with her current breakfast, you may need to bolus even earlier in advance.

Secondly, your team won't be up with the idea of not eating huge amounts of carbs making avoiding spikes much easier to live with, but then, they aren't T1D so don't really know what it's like to be T1D or a T1D child. The only people at my clinic who accept that is okay are the two consultants and oddly, the dietitian. And one of them is still a little reticent about it.

The alternative is to modify the breakfast to maintain the number of carbs but make it slower absorbing, so fruit and cream, or yoghurt, etc. If you are feeding breakfast cereal and toast as the main food stuffs, they are two of the fastest acting food types outside of pure sugar. Sadly.

So the spike is going to be difficult to manage, and you definitely don't need to try and surf it down if you are already returning to a low level. That's a sign that too much insulin was given not too little, & that the timing wasn't right.

 

[shivles]

Could be an interplay with basal?

Could be worth playing around with macros (adding in fat/protein) or just looking at lower go carbs - equal amount of carbs that release a bit slower/steadier.

So she needs less basal in the morning maybe? She has 1 unit in the morning and 2.5 in the evening now her overnight last night looked nice and steady once she came down from her tea

 

[shivles]

There's a carby breakfast, and there's a carby breakfast. Anything that's relatively quick acting is really hard to balance timing with. Let's also bear in mind that the other piece of T1D is that in the early stages, you tend to have faster gastric transit than a T0. You will find that if you continue with her current breakfast, you may need to bolus even earlier in advance.

Secondly, your team won't be up with the idea of not eating huge amounts of carbs making avoiding spikes much easier to live with, but then, they aren't T1D so don't really know what it's like to be T1D or a T1D child. The only people at my clinic who accept that is okay are the two consultants and oddly, the dietitian. And one of them is still a little reticent about it.

The alternative is to modify the breakfast to maintain the number of carbs but make it slower absorbing, so fruit and cream, or yoghurt, etc. If you are feeding breakfast cereal and toast as the main food stuffs, they are two of the fastest acting food types outside of pure sugar. Sadly.

So the spike is going to be difficult to manage, and you definitely don't need to try and surf it down if you are already returning to a low level. That's a sign that too much insulin was given not too little, & that the timing wasn't right.

I've waiting so long before giving her her breakfast before that she had a mild low and she still spiked to 14mmol! I mean I don't want to low carb her really but it just makes sense to give scrambled egg or something first thing so she's not going through the roof however my orders are that eggs must be served with toast

 

[tim2000s]

I've waiting so long before giving her her breakfast before that she had a mild low and she still spiked to 14mmol! I mean I don't want to low carb her really but it just makes sense to give scrambled egg or something first thing so she's not going through the roof however my orders are that eggs must be served with toast

Well, the alternative is to give less toast....not none, just less, and you could also try pumpernickel or rye bread, which I've found has a much less spikey carb absorption profile.

 

[catapillar]

So she needs less basal in the morning maybe? She has 1 unit in the morning and 2.5 in the evening now her overnight last night looked nice and steady once she came down from her tea

Sorry, I wasn't suggesting a solution by changing her basal. Really I was just flagging up another thing to consider. Unfortunately, type 1 isn't a binary state: it's often really difficult to figure out where the problem is coming from. In your breakfast problem, it seems obvious the problem is food + bolus amount + bolus timing (so just three complex questions to consider) but just don't exclude the possibility that basal rate might also be playing a role here too, unless you can actually exclude it with a basal test (which isn't viable with a toddler, so it's just something to bear in mind, along with the 7,000 other things you are having to bear in mind - is robably not that helpful, sorry )

 

[iHs]

Another way to use sugar surfing is to inject the insulin but eat smaller amounts of carb. Inject insulin but surf it with food instead of multi injections. Food is usually social friendly whereas multi injections with a pen or pump isn't.

 

[shivles]

This is a perfect example of what happens at breakfast, doesn't matter how far in advance I give her insulin she will predictably spike like this then plummet but from what I gather this doesn't make sense. At lunch her dose right now is spot on and we get and nice gentle rise when I pre bolus and she doesn't go out of range even. (Please ignore the high readings later in the day, I think she got snuck a treat lol )

 

[iHs]

Looks like a bit of basal adjusting needs to be done to prevent the dip

 

[tim2000s]

You also have to bear in mind that she's still in honeymoon, so what can happen with food is that you lose the first phase response from the pancreas, but the second phase kicks in, which means that she ends up with both injected and pancreatic insulin working at the same time. It may not be much, but in a little 'un it will be enough to push the low.

 

[azure]

I've waiting so long before giving her her breakfast before that she had a mild low and she still spiked to 14mmol! I mean I don't want to low carb her really but it just makes sense to give scrambled egg or something first thing so she's not going through the roof however my orders are that eggs must be served with toast

You could try a change of cereal? I stay below 6.5 after a large bowl of cereal but I do stick to similar cereals as some have caused larger spikes than others. I now weigh a mixed cereal of my own recipe (if you can call it that!) and along with pre-bolusing that works well.

I second the rye bread suggestion as I find it very slow acting. I'm not sure if it would be digestible for a very young child though so if you chose to try it, I'd start with a tiny piece. It's quite dense and filling anyway, so you need less than normal bread.

 

[shivles]

You could try a change of cereal? I stay below 6.5 after a large bowl of cereal but I do stick to similar cereals as some have caused larger spikes than others. I now weigh a mixed cereal of my own recipe (if you can call it that!) and along with pre-bolusing that works well.

I second the rye bread suggestion as I find it very slow acting. I'm not sure if it would be digestible for a very young child though so if you chose to try it, I'd start with a tiny piece. It's quite dense and filling anyway, so you need less than normal bread.

I've tried white bread, brown bread, 50/50, porridge and cereals (including high fibre types) and every single thing give the same reaction, it's really odd. I've not tried rye but I'm skeptical she will eat it tbh

 

[shivles]

You also have to bear in mind that she's still in honeymoon, so what can happen with food is that you lose the first phase response from the pancreas, but the second phase kicks in, which means that she ends up with both injected and pancreatic insulin working at the same time. It may not be much, but in a little 'un it will be enough to push the low.

I did wonder this, is her dose actually too low but she's adding her own insulin and driving her BS down

 

[iHs]

How many basal rate time slots has yr daughter got on the Vibe?

If you could adjust the basal around the 7am mark by probably 1 down button click, that then should make the bg level a bit higher 2hrs later and may be ok to not eat a snack but if not, might need to eat 5g carb and not the 10g.
The basal can then be adjusted the next day by another 1 down button click so that the 5g carb might not need to be eaten. It's a big learning curve unfortunately

 

[shivles]

How many basal rate time slots has yr daughter got on the Vibe?

If you could adjust the basal around the 7am mark by probably 1 down button click, that then should make the bg level a bit higher 2hrs later and may be ok to not eat a snack but if not, might need to eat 5g carb and not the 10g.
The basal can then be adjusted the next day by another 1 down button click so that the 5g carb might not need to be eaten. It's a big learning curve unfortunately

She's not on the vibe, the hospital just give it us as a receiver for the CGM trial

 

[iHs]

Ahhhh ok I see

Best thing atm is to adjust the carb a bit in the Breakfast or just eat a small snack mid morning or get DSN to help

 

[azure]

I've tried white bread, brown bread, 50/50, porridge and cereals (including high fibre types) and every single thing give the same reaction, it's really odd. I've not tried rye but I'm skeptical she will eat it tbh

That suggests it might be an insulin issue, as Tim mentioned. You should always check first, but if I got a result like that, I'd up my breakfast insulin slightly. When I was first diagnosed, I got a similar pattern (have I told you this already?? Getting déjà vu!) My consultant confirmed this was more than likely my own insulin kicking in too late. I then had a mid-morning snack to ward off the low.

I don't know how practical tiny changes in insulin are when your daughter is on small doses, but you could, if the DSN said it was ok, raise the bolus slightly and also make an adjustment to the weight of cereal portion. So if you worked out she needed 1/4 unit raise but can't do that because pens only come in half units, you can increase the amount of cereal by a few grammes and raise the insulin 1/2 unit.

Hope I've explained that in an understandable way!

 

[shivles]

Ahhhh ok I see

Best thing atm is to adjust the carb a bit in the Breakfast or just eat a small snack mid morning or get DSN to help

The dsn has been helping it's just that nothing seems to work lol

 

[shivles]

That suggests it might be an insulin issue, as Tim mentioned. You should always check first, but if I got a result like that, I'd up my breakfast insulin slightly. When I was first diagnosed, I got a similar pattern (have I told you this already?? Getting déjà vu!) My consultant confirmed this was more than likely my own insulin kicking in too late. I then had a mid-morning snack to ward off the low.

I don't know how practical tiny changes in insulin are when your daughter is on small doses, but you could, if the DSN said it was ok, raise the bolus slightly and also make an adjustment to the weight of cereal portion. So if you worked out she needed 1/4 unit raise but can't do that because pens only come in half units, you can increase the amount of cereal by a few grammes and raise the insulin 1/2 unit.

Hope I've explained that in an understandable way!

Yes we did have this conversation the other day haha, dsn upped the dose however it's made no difference to the spike but I am giving snack in the morning for the drop

 

[iHs]

You say that nothing seems to work but you haven't tried staggering the breakfast carb yet have you? Basal bolus is only ok to a certain degree so if adjusting the insulin doesn't work, adjust the carb to the action of the bolus

 

[azure]

Yes we did have this conversation the other day haha, dsn upped the dose however it's made no difference to the spike but I am giving snack in the morning for the drop

Lol - at least I noticed : D Anyway, my advice was so good I said it twice