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Question on handling postprandial hyperglycemia. (26.01.2016)

Bluemarine Josephine

Bluemarine Josephine

Well-Known Member
Messages
259
Location
Northampton
Type of diabetes
Type 1
Treatment type
Insulin
Good day everyone,
I hope that you are all very well.

During the DAFNE course, which I attended a couple of months ago, I raised the question about postprandial hyperglycemia.

According to guidelines, 2 hours after a meal, the blood sugar levels should not exceed an 8.0.

Considering that I do not have a pump (yet) and I am managing my Type 1 diabetes through injections (Levemir/Novorapid as basal/bolus scheme) I wondered how may I achieve a postprandial level of (maximum) 8.0. Usually, I am around 9 or 10, which is not that bad considering… yet, it is not within target.

Both of our educators, a Diabetes Nurse and a Dietician, suggested that this is very difficult to achieve without a pump so, we might as well let our blood sugar rise so long reaches the target at our next meal (or, as an estimation, some 5 hours later when the Novorapid has finished working).

I understand this approach. I can see it is not the ideal approach but, I respect the fact that we can do so much…

Neverthless, I have come across experienced diabetics who inject extra insulin with their meals to minimize the glucose spikes after meals and then they eat a snack 2 hours later due to the hypo risk of the extra insulin.

I must admit that this is not an approach that I am, yet, comfortable with myself however, I can see the benefit from it in the long run.

Would you please offer me your opinion regarding this management strategy? Is it something that you have tried and agree with? Is it something you would prefer not to consider?

Thank you
Diabetic hugs to all
Josephine.
 
@Bluemarine Josephine Many of us with Libres have discovered that the DAFNE guidelines are inadequate as they talk about a raise of 2mmol/l, 2 hours post meals. With the typical way of injecting, in the ten or so minutes before eating, this results in a much larger spike in the hour after eating.

What we have discovered is that the only way to manage post prandial spikes is to inject between just before and up to 45 minutes before eating, dependent on the food that you are eating. For the majority of combined food types that include carbs, fats and protein, I find 30 mins before eating usually stops a huge post prandial spike and generates a much flatter post prandial blood glucose profile.

In Gary Scheiner's article here http://www.diabetesselfmanagement.c...blood-glucose-management/strike-the-spike-ii/ he talks about bolusing 30 mins before when high. I find that I need to do that when at a normal level.

Personally, I've found that timing is the most critical aspect of managing blood glucose spikes and that's the only way to do it effectively.
 
I agree with Tim, using FreeStyle Libre opened my eyes to the fact that NovoRapid is really not that rapid at all, and I was seeing big spikes within the hour after eating when I was injecting just beforehand (as I had been taught).

I find that injecting 30 minutes before tends to nip the spikes in the bud and I can keep a nice flat line maybe 75% of the time, with a small peak to 7 or 8 mmol the other 25% of the time.

However, it depends hugely on WHAT you are eating and there is nothing but trial and error that can help with that.

By way of personal examples, my "two ends of the spectrum" are as follows:

if I am having a very high fat / high carb meal (e.g.) pizza then I've learnt that I will 100% spike into doubles figures unless I have multiple correction doses after eating. Typically for a very high fat / high carb meal I'll inject 15 to 30 mins before then I will follow-up with multiple top-up injections 1, 2 and sometimes even 3 hours after the meal. If I were to take the "full" dose at the initial injection before eating I will badly hypo at 1 hour or so and then start spiking again at 3-4 hours. For me, multiple injections is the only way to attack this.

Conversely, if I have a salad/low-carb option with maybe just circ.20g of total carbs from vegetables and dressing and some protein, I find injecting 5 mins before does the job perfectly well and can keep a flat profile.
 
I've had my pump 12 years so I don't remember every detail of spikes on MDI but I was able to control them to some extent (I tried to stay below 8.5) by having enough insulin to get my sugars in range two hours after eating, and then topping up with a small snack if necessary ('small' could mean as little as an extra 5g). I found I felt better doing this - less tired, more 'normal'. I didn't have to do it after every single meal, only the ones that caused me problems.

Then I read about timings of bolus injections and that helped too, especially with breakfast.

So yes, getting enough insulin in and topping up with a snack does work for me. I put 'does' there not 'did' because I used exactly the same method in order to get very tight control during my recent pregnancy.
 
Of course the fun with this is that it never works every single time, so you have to go with a most approach.

I generally eat a very low carb breakfast which I bolus for protein. I do that at the point of eating and get a fantastic flat line for the rest of the morning. If it is truly no carb (Bacon and Eggs) I can do the bolus post eating.

On the other hand, on Sunday morning, I had a Sausage and Bacon roll in a white bap. I deliberately didn't bolus for it to show the spike, but it does demonstrate that in spite of what we are told, foods in combination don't necessarily have a lesser impact on blood glucose. First pic below is the meal content, second the blood glucose trace.

b73aecc1e732e29e1d4b06f7fb57be0c.jpg


7cdfbbecce8d4371aab105e360de3304.jpg


And this is how it landed:

a2c8a51aaa7c17e0eb46c7ca0b5fae63.jpg
 
Timing as @tim2000s said is important. You could also inject and split your lunch into two parts if you can (if you eat fruit with your lunch eat it an hour later). You can do with extra snack as you say but I would prefer to save a bit of my lunch for later (which is actually the same but you eat less)
 
I have managed a full day below 7.5mmol just with moderate carb amounts and insulin timing.....

when I say full day I mean tests every hour/hour and a half..........

so it is achievable, its just everyone needs to fine tune their own doses.....:)
 
azure said:
I've had my pump 12 years so I don't remember every detail of spikes on MDI but I was able to control them to some extent (I tried to stay below 8.5) by having enough insulin to get my sugars in range two hours after eating, and then topping up with a small snack if necessary ('small' could mean as little as an extra 5g). I found I felt better doing this - less tired, more 'normal'. I didn't have to do it after every single meal, only the ones that caused me problems.

Then I read about timings of bolus injections and that helped too, especially with breakfast.

So yes, getting enough insulin in and topping up with a snack does work for me. I put 'does' there not 'did' because I used exactly the same method in order to get very tight control during my recent pregnancy.
Click to expand...

I have had the same observation as well. Thank you for your comment.
After lunch, at around 15:00, when my blood sugar is dipping quite a bit more than I would like to, even 1 glucotab which accounts for 4 grams of carbs, evens out things... When I spoke to a fellow diabetic he replied "1 glucotab won't make any difference, I need at least 3-4." I was impressed by his reply as, when I tried 2 glucotabs I ended up at a 9.0 by 16:30...

So, you are ever so right... just a tinny bit of 5 grams can do the trick!
 
ewelina said:
Timing as @tim2000s said is important. You could also inject and split your lunch into two parts if you can (if you eat fruit with your lunch eat it an hour later). You can do with extra snack as you say but I would prefer to save a bit of my lunch for later (which is actually the same but you eat less)
Click to expand...

This is a nice startegy!!
Thank you Ewelina!
 
  • I think the guidelines are an impossible target achievable only if you are on an extremely low carbon regime. The levels they expect are almost non diabetic level. After 36 years trying there is no way I could ever achieve it. I tend to Er on the high side with my bolus dose knowing you can test and correct later with correction dose. Since retirement this approach works reasonably well but when I worked, it was a roller coaster , and would have been happy with a level 8 rather than lows of 2 and highs of 18. I rarely post but have read a few of your posts I, e DAFNE course. I attended one of these several years ago and after that convinced myself that some pepole are just born lucky,they never test din't or couldn't carb count and still had better hba,s than mine. I had a very physical job, and had I tried to achieve the sort of levels that some posters on here have, I would have been in A&E every week. Don't beat yourself up to much trying to match some of the levelson this site. They are a rare breed. Lol
 
@petdell I understand you post completely......

did you not find DAFNE helped with your adjustment for your active job.....?

I think the people who achieve the results you refer to are the people who keep carbs very low, that in itself for me, is the daily struggle....
 
I keep my carbs lowish and I don't actually really consider the timings of my injections either...
The only time I try to inject ahead of anything if is I'm going to have 150ml of fruit juice with my chia/flax/magnesium in it.

I used to eat one meal a day only. Nowadays I try to eat 4 or 5 small eats a day.. Ie avocado souffle for breakfast or a yakult followed by herby bread (10g carb) later followed by salmon n salad and later on may be a fruit juice with my seeds in or a kiwi with 4 teaspoons of coconut yogurt. All small portions...but except for the juice.. Everything else is bolused straight before eating..I do have days when I literally hover between 3.8 and 5.4 all day....and on 2 split doses of levemir and novorapid...
 
Wow DD......those bg levels are very low. My consultant would jump out of her skin and I would have to face the 40 degrees about my awareness of the hypo feeling and told to pack it in. I also do a bit of low carbing but at higher targets than yourself and so far life has been fairly good
 
Trying to keep levels up @iHs.... When first went back to MDI was on about 18 basal units I think and split.... Now down to just 6!!!! And still can't get levels up consistently. I'm not proud of them at all for being so low, just pointing out that highs after eating do not have to be thought of as normal!!
 
iHs said:
Wow DD......those bg levels are very low. My consultant would jump out of her skin and I would have to face the 40 degrees about my awareness of the hypo feeling and told to pack it in. I also do a bit of low carbing but at higher targets than yourself and so far life has been fairly good
Click to expand...


Where I live now.... You have to beg to see a consultant if you are T1....otherwise GPs do all T1's... Only getting referrals if your hba1c fallout of target range or too many hypo's.

Needless to say I begged.....
 
I think give it time, all type 1s will slowly go back to consultant care with any luck as many GPS don't understand the bolus basal regime very well and don't think using a carb ratio matters or testing bg more than 5 times per day. Seriously people might just as well use twice daily insulins and watch the carb a bit more
 
iHs said:
I think give it time, all type 1s will slowly go back to consultant care with any luck as many GPS don't understand the bolus basal regime very well and don't think using a carb ratio matters or testing bg more than 5 times per day. Seriously people might just as well use twice daily insulins and watch the carb a bit more
Click to expand...
I hope so. Far too little understood about T1D by GPs.
 
iHs said:
I think give it time, all type 1s will slowly go back to consultant care with any luck as many GPS don't understand the bolus basal regime very well and don't think using a carb ratio matters or testing bg more than 5 times per day. Seriously people might just as well use twice daily insulins and watch the carb a bit more
Click to expand...

I was shocked to find this GP practice considers itself able to handle T1's effectively. I have yet to find out how it scores with hitting DES targets for T1's and diabetic's....it may even be our whole CCG recommending GPs only for T1's...

Sorry to veer off... But it is possible to have lower post-prandial readings on MDI, that was what I was trying to say. I believe this for me is because I do not eat any processed foods... and as some of you know- I even used to weigh lettuce!!
 
I really struggle sometimes with post-prandial readings, even though I low-carb (under 50g carbs per day, usually nearer 30g). My main problem is that quite often the spike comes three, four hours (or more) after I've eaten. I'm trying injecting earlier before meals, and with a correction dose a couple of hours after I've eaten, but I'm wary about stacking insulin, going hypo and having to eat extra. (I'm trying to lose weight to improve my insulin sensitivity.) There doesn't seem to be a pattern with what causes a delayed spike, either.
 
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