How to avoid peaks after one hour of eating

[Nicklenocky]

Hi all

I am currently 14 weeks pregnant, T1, recent hba1c of 6.4.

My doctor says I am doing well in terms of controlling my blood sugars except for my numbers at 1 hour within eating. He says it is this figure that is the most important since it represents the peak of the food. My targets are something like 7.6 or below within 1 hour of eating and 5.5 or below 2 hours after eating. Now I can get to my 2 hour target probably 70% of the time, but I never get to my 1 hour target, it's always in the 9s or 10s, even 11s at times....however even with these high peaks I can still reach my 2 hour targets. On the very rare occasions I have reached my 1 hour target, I will hypo soon after.

Does anyone have any advice-experience on how to get to the 1 hour target. Obviously pregnancy is such a anxious time that I am desperate to do everything correctly for the sake of my baby.

Any help would be much appreciated.

 

[Riri]

Sorry firstly as I'm not pregnant and don't have the answer but just to say I have exactly the same issues as you and am very keen to know if any members have the answer to this. Take care and keep up the good levels

 

[iHs]

I've never been pregnant but this is what I would try to do and that is to inject insulin and just eat very small amounts of carb every 90mins - something like 5-10g carb. This might not be enough nourishment for the baby though even if bg levels are more tightly controlled and the carb amount will have to be adjusted a bit.

If the modern bolus insulins were very fast in their onset but had a short duration of action most diabetics would have far better control but at best bolus insulins last anything from 4-5hrs........... roblem: so it's hard to get the balance right.

 

[AMBrennan]

I am using a continue blood glucose meter so I may be able to give you some advice (all numbers 1h pp)
1) Some foods are better than others - I tend to get much larger spike with weetabix + milk for breakfast (9ish) than typical lunch/dinner consisting of beans, vegs and corned beef (6ish).
2) Fat should, in theory, slow down the absorption of carbohydrates; I've managed to get the breakfast spike down to 7ish by adding 50g of creme fraiche. However, the initial increase in BG is at least partly due to glucose released by the liver so this may be of limited effectiveness (Metformin might help???)
3) Finally, if you have a high after one hour, and normal BG 2h pp; and normal BG after one hour with a low 2h pp, then it should be possible to eat a meal and take a sufficiently high dose of insulin that will result in normal BG 1h pp (and a hypo after two hours), and then eat a snack after one hour to prevent the hypo - basically eating half your lunch immediately, and the other half after one hour; hardly convenient but I can't think of anything better.

 

[weeezer]

nicklenocky

wow, sounds like you've got some very strict goals to aim for...i just wanted to let you know that during my pregnancy in 2009, i was never advised to be as hot on it (i would've, had a doc suggested it, i know you want the very best control for your developing bub) i only tested 2 hrs after every meal (as well as testing before every meal & several other times just to see where i was at!)and if this was in range (anything under 9) i was happy. however, there were plenty of times when this unavoidably wasn't achieved, if it was higher, i'd adjust by 'popping a couple of units in', and moniter BG over the next hour or 2.

main point of writing this was to let you know my control was very good, but far from perfect, and my baby girl was born 100% healthy & 6lb 15oz. new to the forum, but please contact me if i can help in any way. it took me 5 years of trying to get my lil girl (after having a boy 7 years earlier) and i was extremely anxious about maintaining BG near perfection as i could get it.

weezer x

 

[Snodger]

I'm with weezer on this: I totally understand that you want the best for your baby, but the targets your doctor has set are stricter than anything I've heard before. Non-diabetic women can go up to about 8 one hour after eating, or even 9 if they're eating a lot of carbs. I would be very surprised, to be honest, if there is genuine evidence to support such a strict regime, because I can't imagine they could get statistically significant numbers of pregnant T1s to hit the targets you are being asked to hit! Seriously - ask your doctor where the evidence is coming from for the 1 hour targets. If you need help getting the academic/medical articles, PM me or post on here, and I'll find them for you (I'm a student so have access to academic stuff that would normally have a cost).

Also important to balance out is the fact that if you are having lots of hypos, you are more at risk of losing your warning symptoms. There's no point having incredibly tight blood sugars if you end up having dangerous hypos. That's no good for you or your baby.

It sounds to me as if you need a doctor who'll tell you how incredibly, breathtakingly well you are doing, and who will remind you that the risks to your baby, particularly with the good work you're already doing, are very small indeed.

 

[Pneu]

If you are getting high 1 hour spikes then you could try double waving your novo. This takes some trial and error and can be a bit hit and miss if your not sure of the release profile of the meal you are eating..

The general plan is to calculate your dose for the meal you are going to eat.. if your meal is mostly carbohydrate then you might look at a 50/50 split.. if the meal is heavy in fat or protein then anywhere from no split to somewhere in between.. its a bit of a dark art!

The idea is that you are going to do a first injection to coincide with your 1 hour peak and help to manage it.. I note you are on Novorapid so you probably want to aim to inject the first wave 1 hour before you finish the meal (so probably 30 mins before you start).. the second wave you will inject at either the start or end of the meal (start of the meal for low fat / protein, end for higher fat / protein)..

These figures and times are all a bit guestimation based on my own experiences of novo.. When I was working mine out I done a test every 15 mins from the point of the first injection through to 3 hours post meal.. this gave me profiles for different meal types and allowed me to refine the double wave.

You may also need less insulin this way as your blood glucose will not spike so high and the insulin will be more effective.. I tend to drop anywhere between 10% - 20% of what I would need for 1 injection if I plan to do two for the meal as my 'spike' may only hit say 6 mmol/l rather than 8 mmol/l, when your blood glucose go much above 8 mmol/l then your insulin becomes less effective.

 

[AMBrennan]

but the targets your doctor has set are stricter than anything I've heard before

Really? NICE says this:

If it is safely achievable, women with diabetes should aim to keep fasting blood glucose between 3.5 and 5.9 mmol/litre and 1-hour postprandial blood glucose below 7.8 mmol/litre during pregnancy.

Further,

[Various medical conditions] are more common in babies born to women with pre-existing diabetes.

I'm glad that your daughter girl is healthy, but that doesn't mean that there isn't an increased risk.

 

[weeezer]

didn't know this at the time of my pregnancy, and would've strived to achieve. its a shame all HCPs don't sing from the same songsheet. maybe it's updated info? anyway, in no way am i advocating less control, i just wanted to throw some reassurance the way of the pregnant nicklenocky, i found early pregnancy to be not only a nightmare as far as blood sugars were concerned (really low bs, unconscious one time) but also an extremely anxious time, and only wanted to share my experience.

n - hope your pregnancy is as trouble free as poss, lots of love & best wishes

weezer xx

 

[Snodger]

AMB, note that it says "if safely achievable" - if the OP is getting lots of hypos that is *not* safe. Also note that it says "women with diabetes" - there are huge differences between what T1s and T2s manage to achieve, because T2s still have their own insulin and T1s do not. And if you can point me to the research that demonstrates that there's a significant difference between bgs at 1 hour and 2 hours after meals during pregnancy, I'll eat my virtual hat. Again, non-diabetics don't even manage to stay below 7.8 1 hour after meals.

Of course there's more risk to our babies than to babies of non-diabetics. But
a) the risks to all babies born in this country are very, very small.
b) when they talk about the risks to babies of 'women with diabetes' they mean *all* women with diabetes, including those who didn't plan their pregnancy and went into it with high bgs, those who are running high all the way through pregnancy, those who got diabetes part way through and those who genuinely don't care. The risk to Nicklenocky's baby is much, much, MUCH smaller than that.

It worries me on this forum when I see people over-worrying about risks, trying hard to get "normal" bg levels even though they don't have a fully-functioning pancreas, and feeling guilty, or being made to feel guilty by HCPs. It's very easy with this disease to feel a failure and Nicklenocky needs to know, IMO, that she is *not* a failure and that what she's already achieved is spectacular.

 

[AMBrennan]

You are right, of course; this is why I suggested some things to try to reduce the 1h pp BG while reducing hypos (smaller meal and snack after 1h, rice and beans for breakfast if cereal isn't working at all, etc).

However, my point was a bit more subtle than that - you alleged that this advice is uncommon when it is exactly what the NICE guidelines recommend. I never said it was good advice; however, I, being a non-expert, would defer to the judgement by the group of experts that wrote the guideline.

 

[Nicklenocky]

Hi all, I really appreciate all the replies. I am currently travelling for work at the moment and will be in a position to reply in detail at the end of the week, in the meantime I am feeling slightly better and reassured reading all posters comments.

 

[Nicklenocky]

Hi All

Really appreciate all of the replies I had to my thread, much apppreciated. Its also reassuring to know that many of you feel that the targets (even though they are deemed 'official') are difficult to achieve, I thought it was just me and that I was being a big faliure even though I have tried the very best I can to achieve them.

However, since I originally posted the thread, I have a whole range of other problems with my blood sugars at the moment...getting to target within one hour of eating is the least of my worries! As I enter the 16th week of my pregnancy I would like to get my blood sugars down full stop! They have all of a sudden gone haywire,as my sensitive stage to insulin is over now starts the really, really hard work of maintaining stable-ish blood sugars and keeping them at acceptable levels. I dread to think what the last 2 weeks of my travelling, adjusting to times zones, dealing with flu and eating out because I am working has done to my hba1c.

I suppose I need to plod on the best I can, but i must say that the anxiety and overwhelming guilt when I get a high blood sugar reading never leaves. :sick:

 

[iHs]

Hi

Have just realised that you've got a pump. One way of getting your bg levels down 1hr after you've eaten is to ramp up your mealtime bolus and then manipulate your basals downwards after the 2hr mark. How much you will need to do this will depend on your bg levels and will be 'trial and error' until you get the results you want. I think it will make 'basal fasting' go out of the window for a while and you might find yourself being tied to eating within certain time frames but you should be ok I would think.

 

[Nicklenocky]

Hi IHS

Thanks for the advice.

I actually procured the pump roughly the same time I conceived...this was a conincidence and since the pregnancy was not planned at that stage I have not been able to experiment with the pump. I am also reluctant to experiment at the moment since I am pregnant.

Having said that, this doesnt mean I wouldnt mind testing your theory as a possibilty, although you are right, all basal fasting tests will go out of the window.

Could you give me an example explaining your theory...I would also still be worried that if I really ramped up my bolus, I would still hypo 1 hour after eating which has always happened on the rare occassions I managed to get to target.

 

[iHs]

Hi

Your bg levels are not really all that high 1hr after you've eaten so you would only need to increase the bolus by a small amount. Bolus insulin and basal insulin is the same thing. You are just using a fast acting insulin to work as your bolus and also your basal.

I'm not sure whether what I have said about ramping up the bolus will actually work...... it should do though but eveything is trial and error anyway even with a pump.

 

[Nicklenocky]

Hi Ihs

Noted with thanks.

I am aware that the bolus and basal on a pump are essentially the same thing, i found your suggestion interesting but just wasnt sure what you meant by manipulate basal afterwards hence why I asked. I assume you mean to bump up my bolus for the first 2 hours of eating and then perhaps slightly reduce my basal for a set duration after that meal, which is why you stated to eat within set times.

I think there are probably may possibilities to explore with the pump and your suggestion is certainly worth thinking about.

 

[iHs]

Hi

Another thought for you to consider that may work is for you to keep some of your basals the same and also your bolus ratio the same but eat less carbohydrate than what you bolus for. So you bolus for 30g carb but only eat 25g carb (example). Often carbohydrate is much easier to manipulate than insulin. You could test that out just to see what happens to your bg levels

 

[Nicklenocky]

Thanks IHS...that seems workable

 

[smaynard]

Hi there,

I agree with your concerns about going hypo 1 hour after eating if you ramp up the bolus.

My daughter has this problem with her lunch time meal, but interestingly not with breakfast (which we keep low carb as she is very carb sensitive first thing) or dinner. How I manage lunchtime is that I increase the basal (quite significantly) for the 2 hours surrounding the meal and then decrease the basal (again quite significantly) for the 2 hours post eating.

She wears a CGMS so we have complete transparency to the effect and the stability is more often than not very good indeed....on a particularly good day she stays completely flat between 5 and 6....that's a yee ha day!

We are also mindful to give her insulin 10 mins (more if her pre eating level is a little on the high side) before she eats.

Doing these two things has improved stability enormously for us.

Also, CGMS would be of huge benefit to you. Have you spoken with the clinic about that?

All the very best for the coming months.....what an exciting time for you!