'Acceptable' post meal spikes

[pawprint91]

After my foundation course yesterday, the advice given by the team was basically just 'play around with your own doses but be mindful of hypos' which to be honest, I'm happy we've had the permission to do.

Off the back of this, I'm thinking of adding a bit of extra novorapid into my day (was originally just told to do biggest meal, but think my body has a bit of a struggle when we go over 40g of carbs to be honest). I'm probably only going to inject a unit before lunch to begin with, with the attitude 'every little helps', but my question is how high should a normal spike be? I went up to 12 after breakfast (20g carb) but seem to have come down to under 10 pretty quickly, even though my partner walked the dog this morning (usually my job in the summer holidays), so thinking I'll leave off the novorapid there. After lunch I can be 12 or 14 even 2-3 hours later - is this normal? I know as T1 we don't have to test after meals like T2 but it'd be good to see where people think a spike should maybe top out at to see if I need anymore than one unit of insulin to assist me along!

 

[Bruce Stephens]

After lunch I can be 12 or 14 even 2-3 hours later - is this normal? I know as T1 we don't have to test after meals like T2 but it'd be good to see where people think a spike should maybe top out at to see if I need anymore than one unit of insulin to assist me along!

Those aren't a problem. The current advice is (copying from the AGP page of LibreView):

Glucose Ranges	Targets% of Readings (Time/Day)
Target Range 3.9-10.0 mmol/L‬	Greater than 70% ‏‪(16h 48min)
Below 3.9 mmol/L	Less than 4% ‏‪(58min)
Below 3.0 mmol/L	Less than 1% ‏‪(14min)
Above 10.0 mmol/L	Less than 25% ‏‪(6h)
Above 13.9 mmol/L	Less than 5% ‏‪(1h 12min)
Each 5% increase in time in range (3.9-10.0 mmol/L) is clinically beneficial.

‪

Going over 14 after a meal can be consistent with those targets, so long as it doesn't last too long. (And obviously you're just beginning with insulin so nobody's expecting you to hit those targets yet anyway.)

 

[helli]

A few thoughts
- are you looking at Libre numbers? High Libre readings are unreliable on Libre.
- if your numbers go down to "comfortable" numbers within 4 hours, it is likely to be a question of timing of your pre-bolus. In an ideal world, we want to match the peak of the insulin profile with the peak of the food digestion. This is not easy and not something I considered in my first year after diagnosis - getting your dose correct is more important to focus on.
- if you increase your insulin dose you may hypo after the 2 hours so I would avoid it
- getting the correct basal is important before tweaking your bolus. Does your basal keep your levels stable in the absence of any exercise, food, etc?

 

[Ivostas66]

I think it really depends upon your starting point. If you check your BG prior to eating and it is 9 or 10, then I wouldn't call a 12 a 'spike'. If it was 5 or 6 and jumped to 12, then I would be looking at when I injected (pre bolusing by about 25 minutes always helps me at breakfast to avoid spikes and 'crashes) as well as the other usual factors.

 

[helli]

To add to my comments above, it depends whether your spike is a spike (goes up and comes down again) or a plateau (goes up and stays there).
I would be concerned about plateaus but not spikes.
Being at 12 for 30 minutes, much much less of a concern than being there for 4 hours.

 

[Finn]

I found I could avoid post-meal spikes or hypos by adjusting my pre-bolus time and that time varies meal to meal.

This is what I found for me (just for an example of how pre-bolus times change over the day, not a recommendation).

Breakfast I give a 30 minute pre-bolus
Lunch I bolus right before I eat
Dinner I 'post-bolus' 20 minutes after I start eating

I was getting a lot of post-breakfast spikes, so I kept increasing my pre-bolus time until I found what works.

I was also getting a lot of post-dinner hypos, so I decreased my pre-bolus until I found the sweet spot (for me) of 20 minutes after I start eating.

I vary my bolus time depending on if I'm going into the meal high or low.

There was one day a few weeks ago when I had a lot of insulin resistance and breakfast was a 1.5 HOUR pre-bolus. The another day where I went into dinner a bit low and I bolused 40 minutes after eating.

When something I out of the ordinary (illness, stress, general unexplained insulin resistance), I bolus to my meter, and eat to my meter.

 

[rebrascora]

At the moment I don't think the prebolus info is relevant as @pawprint91 is not using insulin for those breakfast and lunch meals but is trying to assess if insulin is necessary. I agree with @Ivostas66 that the starting reading is very relevant as is having the basal dose right but always a bit tricky in the honeymoon period when endogenous insulin is kicking in in fits and spurts, but I would say, that if your body is bringing levels down promptly at breakfast then it is managing OK. If it is taking 2-3 hours to bring you down after lunch then it is struggling and could probably use a bit of help from your bolus insulin. Start very small and carefully experiment. The injected insulin is usually slower to work than your own which is why we have to inject in advance of food, so whilst we would say that you should be back down into range 4 hours later with your bolus insulin, you would expect your own insulin to work more promptly, hence why I am saying that it looks to need help at lunchtime.

 

[pawprint91]

A few thoughts
- are you looking at Libre numbers? High Libre readings are unreliable on Libre.
- if your numbers go down to "comfortable" numbers within 4 hours, it is likely to be a question of timing of your pre-bolus. In an ideal world, we want to match the peak of the insulin profile with the peak of the food digestion. This is not easy and not something I considered in my first year after diagnosis - getting your dose correct is more important to focus on.
- if you increase your insulin dose you may hypo after the 2 hours so I would avoid it
- getting the correct basal is important before tweaking your bolus. Does your basal keep your levels stable in the absence of any exercise, food, etc?

I have been looking at finger prick numbers due to only getting my libre yesterday 🙂
I think I need a .5 pen to really nail the basal - I can be steady in the morning but drop in the early evening pre dinner (although to be honest I think the drop could be due to activity level) - didn't realise these were an option till yesterday! I think my spikes plateau for a few hours but then do come down before dinner. If I do this, it's going to be a tentative one unit for sure.

I found I could avoid post-meal spikes or hypos by adjusting my pre-bolus time and that time varies meal to meal.

When something I out of the ordinary (illness, stress, general unexplained insulin resistance), I bolus to my meter, and eat to my meter.

I have not managed to work out my 'peak' time for bolusing yet. I tend to do it 10 mins before (evening meal) and have relied on fingerpricks to tell me that within 4 hours I do generally come back down to in range so will take that for now. Hoping my libre will settle and I can get a slightly more insightful picture.

At the moment I don't think the prebolus info is relevant as @pawprint91 is not using insulin for those breakfast and lunch meals but is trying to assess if insulin is necessary. I agree with @Ivostas66 that the starting reading is very relevant as is having the basal dose right but always a bit tricky in the honeymoon period when endogenous insulin is kicking in in fits and spurts, but I would say, that if your body is bringing levels down promptly at breakfast then it is managing OK. If it is taking 2-3 hours to bring you down after lunch then it is struggling and could probably use a bit of help from your bolus insulin. Start very small and carefully experiment. The injected insulin is usually slower to work than your own which is why we have to inject in advance of food, so whilst we would say that you should be back down into range 4 hours later with your bolus insulin, you would expect your own insulin to work more promptly, hence why I am saying that it looks to need help at lunchtime.

Thank you - this is definitely what I am thinking. As I said above I am definitely only going to try a tentative one unit - not much but maybe just a helping hand to try and ride the spike out a little quicker.

 

[Finn]

I have not managed to work out my 'peak' time for bolusing yet. I tend to do it 10 mins before (evening meal) and have relied on fingerpricks to tell me that within 4 hours I do generally come back down to in range so will take that for now. Hoping my libre will settle and I can get a slightly more insightful picture.

I started with a 10-20 minute pre-bolus for each meal, then gradually increased the pre-bolus time to tamp down spikes, and decreased the time to avoid hypos. It takes some time (don't base anything off just one data point), but once you start to notice patterns, you will be able to make adjustments. FSL certainly helps a lot!

 

[nonethewiser]

Pre bolus, meals you think are impossible can be overcome with right timing of insulin.

 

[SB2015]

It sounds like you have a plan @pawprint91
With a half unit pen to refine doses of both basal and bolus as well as experimenting with timing of boluses for meals the spikes could be reduced. My timing for boluses varies through the day.

It was when I got the Libre I realised how big some of my spikes were for particular foods. I hope that you find it equally useful.

I look forward to hearing how you get on

 

[everydayupsanddowns]

Good luck with your plan @pawprint91 - and hope you are able to get a 0.5u pen (for both basal and bolus/corrections) to help you fine tune things.

Ideally I prefer to stay below 9-10ish after meals, but have to bear in mind that if I check at 2hrs, then I probably have half my dose still active.

I think it’s much trickier when honeymooning, but it does sound like a little cautious insulin addition might help keep you out of double figures.

As others have said it’s more about the general picture and trying to reduce glucose instability (rapid changes) and variability (the difference between the high points and the low points). The odd wobble is more or less inevitable, but it helps to try to keep things as gently meandering as possible.

 

[pawprint91]

Ideally I prefer to stay below 9-10ish after meals, but have to bear in mind that if I check at 2hrs, then I probably have half my dose still active.

I think it’s much trickier when honeymooning, but it does sound like a little cautious insulin addition might help keep you out of double figures.

Still had a few double figures, but now finding that I can stay below 10 when all variables are right do you manage this even when eating meals with a higher carb count, or do you try and reduce carbs at all?

 

[everydayupsanddowns]

do you manage this even when eating meals with a higher carb count, or do you try and reduce carbs at all?

Well… yes and no.

I generally eat around 150g-170g of carbs per day - that seems to be plenty to keep me full, and I seem to be able to dose relatively effectively for it most of the time.

But I will also quite happily estimate 120g on a single takeaway meal if I fancy it.

I accept that higher carb loads are a bit more high risk, but I’ve had huge carb blow-out days and stayed 4-9 all day… and other days I’ve been fighting to get out of the teens after a far more modest 45g meal.

Diabetes does love to move the goalposts!

If a high carb meal ends up with me chasing high BGs at least I know it’s something I went into knowing it was a bit of a punt

 

[pawprint91]

Well… yes and no.

I generally eat around 150g-170g of carbs per day - that seems to be plenty to keep me full, and I seem to be able to dose relatively effectively for it most of the time.

But I will also quite happily estimate 120g on a single takeaway meal if I fancy it.

I accept that higher carb loads are a bit more high risk, but I’ve had huge carb blow-out days and stayed 4-9 all day… and other days I’ve been fighting to get out of the teens after a far more modest 45g meal.

Diabetes does love to move the goalposts!

If a high carb meal ends up with me chasing high BGs at least I know it’s something I went into knowing it was a bit of a punt

Thank you - very helpful! 🙂

 

[rebrascora]

Still had a few double figures, but now finding that I can stay below 10 when all variables are right do you manage this even when eating meals with a higher carb count, or do you try and reduce carbs at all?

I had a cream scone today. It was a small (but delicious) scone with a rather large blob of jam and cream of course but I am not counting that. I was 5.0 when I bolused with a little bit of insulin already active in my system from a correction earlier to bring me down from 8.6. I shot myself 4units of Fiasp for an estimated 40g carbs and ate it about 10 mins later and I still hit 16.4 (finger prick) 2 hours later and needed a hefty correction. I eat a scone once in a blue moon and on this occasion it was an exceptionally good scone so well worth the BG upheaval. I am back on an even keel now at bedtime with my levels and I don't regret my decision. It would have been better if I could have prebolused earlier but it wasn't possible on this occasion.

Mostly I manage to keep things below 10 but it has taken me quite a bit of trial and error over a couple of years or more to achieve that.
The great thing about the Libre Time in Range targets are that they acknowledges that we will go under 3.9 and over 10 at times and over 13.5 or whatever the upper bracket starts at, very occasionally, but if we can keep it to a minimal amount of time, then we have done well.

 

[SB2015]

A day of temptations yesterday, and slightly colder weather, so some spikes (The Liebniz biscuit sat looking at me and I knew it would be sensible to wait after the bolus but they were just out of the fridge and …. A spike of 14 but back down later, and I enjoyed my biscuit with a delicious cup of coffee.

As @everydayupsanddowns finds, I have plans, but don’t always stick to them and then to add to that Diabetes has its own plan that it doesn’t stick to either. I tend to be content if I can keep in range a reasonable amount of the time and if Inknow the causes of spikes and dips, but there are still those days when diabetes takes me on a mystery tour.

 

[Tom1982]

I’m reading all this and sinking into despair! Whilst I know Libre figures go a bit wonky as the spikes arrive, but Jo goes from being in range to 17.2 three hours later (13.5 finger prick) she had a ham sandwich, a bag of crisps and some tiny cake thing that was supposed to be only 13.5g carbs. She waited her 15 minutes and after finishing lunch she rose to 8.9 then dropped back to 6.0 within about and hour and half….. then rose to 17.2! I’m lost!

 

[everydayupsanddowns]

A @Tom1982

Don’t give up! I think it’s so much harder for little ones. It’s a bigger ask to be careful with food choices anyway, and what with growth spurts, varying levels of activity and so many other things, it can be really tough.

Chat to your DSN and share your worries with them.

I think the best you can aim for is to try to find what generally works, most of the time.

If you have a sort of ‘rotation’ of meals which are the same, and can see a pattern - that might mean having some known exceptions to ratios/factors where you just end up with, when we eat this we need to do this...

I have a few of those myself!