DAFNE Rules and Hypos: Accurate?

[Bluemarine Josephine]

Good morning my beautiful friends!
I hope that you are all having a lovely day!

Do you find that the DAFNE suggested waiting time for treating hypoglycemia isn’t working?

Here is what happened to me yesterday evening.
Pre-dinner time I was at (a non flattering) 10.4. I had 30 grams of carbs, 3 units Novorapid and I added ½ unit more for a small correction aiming around a 8.6. There was no vigorous exercise during the day (and I prefer sleeping with an 8 than with a 6. )

One and a half hour later, I was at a 4.8. Clearly something was not right and I suspected that an unexpected hypo was on the way.

I treated with 3 glucotabs (overall 12 grams sugar as each glucotab accounts for 4 grams) I thought I would wait for the rise and add a slow acting carbohydrate as well, a digestive biscuit.
So I am following the suggested DAFNE rules.

Here is where things become complicated for me.
20:30: at 4.8 I treat with 3 glucotabs.
20:50: 3.8 (I wait)
21:00: 3.4 (still waiting)
21:15: 3.8 (thankfully…)
21:45: 4.4 (1 digestive)
24:00: 9.7
Fasting: 6.8

According to DAFNE rules, at 21:00 I should have treated again with another 15 grams carbs but, out of fear of not overtreating I decided to wait.

I have noticed that even quick acting glucose like glucotabs, take at least 30-45 minutes to stabilize my BG and push for a mild rise, unlike the DAFNE suggestions. And up until this point (and for 30 – 45 minutes) my BG keeps droping. It is not the first time that this is happening to me, in fact it is the normal situation. Eventually, my BG will rise, but this hour (almost) until it does feels like forever...

Do you experience a similar effect as well?
Do you also feel that quick acting glucose is not as quick as we are told/we assume it is?
Is it a matter of physiology and body function? (For example, some people have a faster glucose absorption whereas others don’t?)
Is it a matter of insulin sensitivity which hinders the quick absorption of glucose?

Thank you so much in advance for your replies!
Have a lovely day!
Josephine

 

[Brunneria]

I am no expert on insulin, but I AM an expert at knowing how food affects my blood glucose (I am T2 diet and exercise, and food is pretty much the best control method I have)

What you did was take a fast absorbing source of glucose on top of a meal that (presumably) had some protein and fat in it.

Both protein and fat slow down glucose absorption, so while the glucose got there in the end, your delay was caused by the other food slowing it down.

Please bear in mind that this is speculation, because I don't know what you had for dinner.

If your meal was high in fat and protein that will have slowed the digestion of any carbs contained in it, too. Try googling 'pizza effect' and you will see what I mean.

One other thing - if you want to get glucose into your bloodstream really quickly, then chew up a glucotab until it is dissolved in your saliva, and hold the liquid under your tongue. Some (a small amount) of it will be absorbed through the lining of the mouth (there is a vein that runs under the tongue).

 

[Juicyj]

Good morning Josephine,

I personally think for newbies it's a system for them to work towards, as a type 1 diabetic and knowing my body as well as I do I have developed my own system which works perfect for me. I can sometimes feel a hypo coming on at 4.2 as it's the speed of which I can sense my bg dropping so at this point would eat 10g of carb, I also eat 10g of carb from 3.6 upwards, lower than 3.6 and its 3 jelly babies but I then wait 10 mins retest and retreat again with jelly babies if still low.

DAFNE is great for empowering people to manage better but they are guidelines

 

[tim2000s]

Hi @Bluemarine Josephine - it's a bit of swings and roundabouts. The only thing that I find can guarantee a quick result is Lucozade, Glucojuice or sugary drinks (Coke, Orange juice, etc). The liquid form means it is absorbed much quicker, especially when there is food already on board.

Glucotabs/Dextrosols are pretty good, but can vary more dependent on where your digestion is at and to some extent, what your stomach is doing!

 

[Bluemarine Josephine]

I am no expert on insulin, but I AM an expert at knowing how food affects my blood glucose (I am T2 diet and exercise, and food is pretty much the best control method I have)

What you did was take a fast absorbing source of glucose on top of a meal that (presumably) had some protein and fat in it.

Both protein and fat slow down glucose absorption, so while the glucose got there in the end, your delay was caused by the other food slowing it down.

Please bear in mind that this is speculation, because I don't know what you had for dinner.

If your meal was high in fat and protein that will have slowed the digestion of any carbs contained in it, too. Try googling 'pizza effect' and you will see what I mean.

One other thing - if you want to get glucose into your bloodstream really quickly, then chew up a glucotab until it is dissolved in your saliva, and hold the liquid under your tongue. Some (a small amount) of it will be absorbed through the lining of the mouth (there is a vein that runs under the tongue).

Good morning Brunneria and thank you for your reply.

I generally avoid fat. My meal was a cucumber/tomato salad and 83 grams of (slow release) rye bread. No olive oil nor butter added. I would suspect that such a meal does not consist a heavy or fatty meal so as to influence the glucotabs.

Additionally, I have noticed that the sugar absorption from treating a hypo is, generally, slower than the guidelines. I have the same pattern when treating at midnight, at 03:00 am (on an empty stomach) or during day.

The under the tongue suggestion is a nice tip, thank you for it. I have heard that people with heart condition take their pills like this as they are absorbed faster but, it had not occurred to me to do it with glucose.

Have a nice day!
Josephine

 

[tim2000s]

My meal was a cucumber/tomato salad and 83 grams of (slow release) rye bread.

The Rye Bread is also likely to be the reason that you overshot on your correction. I find that it takes a very long time to absorb and when using MDI requires about half the insulin with the meal and the other half about an hour later, else I end up hypo. I wouldn't be at all surprised if this was also the reason why your absorption of glucotabs was slower as there's a lot with Rye bread mixed with glucose to slow it down!

 

[Bluemarine Josephine]

Hi @Bluemarine Josephine - it's a bit of swings and roundabouts. The only thing that I find can guarantee a quick result is Lucozade, Glucojuice or sugary drinks (Coke, Orange juice, etc). The liquid form means it is absorbed much quicker, especially when there is food already on board.

Glucotabs/Dextrosols are pretty good, but can vary more dependent on where your digestion is at and to some extent, what your stomach is doing!

Hello Tim and thank you for your reply.
Here is a “gossip” I am sure you will enjoy.

Some time ago, I explained the situation to my DAFNE educator. Her comment was “You do not need to treat with quick acting glucose like glucotabs a mild hypoglycemia.”

So for my next mild hypo I decided to treat with an apple.
Considering this pattern of absorption that I have, you can imagine it took AGES for the apple to work…

Have a nice day
Josephine

 

[AndyS]

I tend to treat with mainly glucose tablets (Lucozade sweets) since for me 1 tab = +1mmol/l so it works nicely.

That said I have seen occasional slow response to hypo treatment especially if it is after a meal where my bolus maybe peaked before the food did, in those instances I have tended to go with one of Tims suggestions and treat with something liquid since it does react faster.

In general, if I don't have a full stomach already, 20 minutes is about the minimum response time I have seen for a hypo treatment.


Hope you all have a great day,

/A

 

[Bluemarine Josephine]

I tend to treat with mainly glucose tablets (Lucozade sweets) since for me 1 tab = +1mmol/l so it works nicely.

That said I have seen occasional slow response to hypo treatment especially if it is after a meal where my bolus maybe peaked before the food did, in those instances I have tended to go with one of Tims suggestions and treat with something liquid since it does react faster.

In general, if I don't have a full stomach already, 20 minutes is about the minimum response time I have seen for a hypo treatment.


Hope you all have a great day,

/A

Hello Andy!
Nice to see you here!!

Please help me, I have the Lucozade tabs here.
According to the packaging, 100grs of product have 89.5 carbs.
The package weights 47 grams hence contains 42 grams of carbs
The package contains 14 tablets therefore, each tablet has 3 grams carbs.

So, 1 tablet of 3 grams of carbs is giving you 1 mmol or rise? So, in theory, 3 tablets give you 3 mmols of rise?
(Basis DAFNE, in theory, you would need 3 tablets just for 1 mmol...)
This is brilliant!

 

[1abRat]

For quick-acting glucose I find one mouthful of orange flavour Lucozade can't be beaten; it's got 58 g of carbs in a single 380 mL bottle!

I find that glucose tablets can take upwards of 15 min to work whereas the Lucozade is kicking in after just 5 min. I also find that eating something fatty like chocolate or low GI like oatcakes slows the whole affair down.

Sadly this does mean that I'm often drinking flat Lucozade for hypos as a bottle lasts me a long time!

The DAFNE guidelines are just that, a set of suggestions based upon the most cautious estimations rather than tailored specifically to an individual. It sounds like you've got a good idea of how your body responds so now you can tailor your treatments to suit you best.

 

[tim2000s]

(Basis DAFNE, in theory, you would need 3 tablets just for 1 mmol...)

It's an interesting one isn't it. DAFNE helps you define an insulin sensitivity factor and an I:C ratio. In theory, if you have an I:C ratio of 1u:10g and an ISF of 1u:3mmol, then 10g of carbs would raise your glucose levels by 3mmol/l. That would be logical.

And you know what? 10g carbs raises my bg by 2.8 mmol/l, which it just so happens is my ISF!

 

[himtoo]

Hi Josephine
another thought could be that your insulin to carb ratio ( I:C) is not exactly 10
if it were about 1:12 perhaps you did not really require that extra 1/2 unit correction.

 

[azure]

IF I feel I'm dropping, I tend to go for Lucozade as it works very quickly indeed. I timed it once (before bed, so not after a meal) and my BS started rising in 5 mins. I use glucose tablets too, but after a meal I'd probably go with Lucozade as I think it would be more effective on a full stomach than glucose tablets.

I second the comment about rye bread. I find the carbs from that absorb slowly.

 

[Bluemarine Josephine]

Hi Josephine
another thought could be that your insulin to carb ratio ( I:C) is not exactly 10
if it were about 1:12 perhaps you did not really require that extra 1/2 unit correction.

Hello Himtoo!!
You have me wondering now...

Basis the 100 Rule, my Total Daily Insulin Dose is 24 units (Basal + Bolus) therefore, 100 divided by 24 gives me 4.1 so, in theory 1 unit of quick acting is giving me 4.1 mmols correction.

Provided that the above theory is correct, that is...

On average 1 CP (10g carbohydrate) can raise blood sugars by 2-3mmol/l but the effect is individual. Is there a relevant rule for that to help us estimate the exact carbs to insulin ratio (instead of guestimating basis the DAFNE 1:10?)

 

[Bluemarine Josephine]

It's an interesting one isn't it. DAFNE helps you define an insulin sensitivity factor and an I:C ratio. In theory, if you have an I:C ratio of 1u:10g and an ISF of 1u:3mmol, then 10g of carbs would raise your glucose levels by 3mmol/l. That would be logical.

And you know what? 10g carbs raises my bg by 2.8 mmol/l, which it just so happens is my ISF!

Tim please, I want to ask you the same thing that I asked Himtoo,
Do you use a rule to estimate the insulin correction ratio and the carbs to insulin ratio (instead of using the DAFNE guidelines?)

 

[tim2000s]

Do you use a rule to estimate the insulin correction ratio and the carbs to insulin ratio (instead of using the DAFNE guidelines?)

The basic rules for ISF are Rule of 100 (Divide your Total Daily Insulin Dose into 100 in order to calculate how many points of glucose will be lowered by 1 unit of rapid-acting insulin.) and I:C ratio, rule of 500 (Divide 500 by the total daily dose of insulin. The result is the grams of carbohydrate that are approximately covered by 1 unit of insulin.).

These are supposed to deliver you a starting point for working out your ratios, but from there you have to modify based on observation.

 

[himtoo]

Hello Himtoo!!
You have me wondering now...

Basis the 100 Rule, my Total Daily Insulin Dose is 24 units (Basal + Bolus) therefore, 100 divided by 24 gives me 4.1 so, in theory 1 unit of quick acting is giving me 4.1 mmols correction.

Provided that the above theory is correct, that is...

On average 1 CP (10g carbohydrate) can raise blood sugars by 2-3mmol/l but the effect is individual. Is there a relevant rule for that to help us estimate the exact carbs to insulin ratio (instead of guestimating basis the DAFNE 1:10?)

I suppose I would prefer to say it is research for me based on many many times eating the exact same meal and trying different bolus doses and loads of post meal testing until I am happy with my results.
I taught myself dose adjusting starting in 1996 about 8 years before I ever went on a course

 

[PseudoBob77]

Tim please, I want to ask you the same thing that I asked Himtoo,
Do you use a rule to estimate the insulin correction ratio and the carbs to insulin ratio (instead of using the DAFNE guidelines?)

From my perspective, a general rule is 1 unit novorapid lowers 0.75-1.5mmols depending on how high the starting point is. If it's under 10mmol then 1 unit will on avrage lower my blood sugar 1.5mmol.

Raising blood sugar is the opposite, 10carbs should raise levels by 1.5mmols, if there's saturated fats in what i've eaten then this can cause spikes several hours after especially if even marginally overtreating.

As always things are subject to change, you just need to know your average response and use that as your benchmark rule.

Chris

Sent from my SM-G900F using DCUK Forum mobile app

 

[azure]

The 100 rule doesn't work for me. I tend to use rules like that as a rough guide only.

@Bluemarine Josephine If this drop and difficulty in getting your BS up is a reasonably frequent occurrence, then maybe look at your insulin dosages rather than the effect of glucose. I know it's much trickier to make tiny adjustments when you're on MDI rather than a pump, but what I used to do is find a way that worked for each meal/high sugar/whatever, even if my way was a bit of a hodge-podge of things.

What works for you is what's important

 

[Bluemarine Josephine]

The Rye Bread is also likely to be the reason that you overshot on your correction. I find that it takes a very long time to absorb and when using MDI requires about half the insulin with the meal and the other half about an hour later, else I end up hypo. I wouldn't be at all surprised if this was also the reason why your absorption of glucotabs was slower as there's a lot with Rye bread mixed with glucose to slow it down!

If the problem was on the low glycemic load of the rye bread then, I am thinking that, indeed the Novorapid acted faster than the rye bread hence the lower numbers however, here is what I am wondering:

At some point, even with a delay, the rye bread should have worked…maybe 2 hours later…3 hours later.... but it should, at some point, work…
Given the fact that the rye bread accounted for 30 grams
And the treats for another 22grams
And the Novorapid was 3.5units...

Then, shouldn’t the overall end BG result be more than 9.7 by midnight?