Avoiding post prandial spikes (type 1)

[Redkite]

I've copied this over from a reply buried in another thread in case it's helpful to anyone 🙂

The following tips are what I gleaned from a presentation by Gary Scheiner (Certified Diabetes Educator, author of Think Like A Pancreas, and type 1 himself) - this was his "Strike the Spike" presentation.

1. One of the most important considerations is the relatively slow action of our so-called rapid-acting insulins. If you have a working pancreas, insulin reaches the bloodstream in seconds and is finished and gone in minutes. Whereas insulin infused or injected into subcutaneous fat can take up to an hour to circulate to where it's needed (and can still be active 3-4 hours after injection), meaning that glucose from digested food gets a head start on the insulin. Advice is to pre-bolus 20-30 minutes before meals.

2. Type of food eaten also has an impact. I know some people on here eat low carb or no carb meals, but assuming somebody wants to eat a reasonable portion of carbs, opting for lower GI foods makes sense, e.g. for breakfast replace cereals with yoghurt and berries, which will take a bit longer to digest and perhaps match insulin action a bit better.

3. Eat veg before carbs. Can't remember the reason for this one, but I wrote it down!

4. Make lunch the highest carb meal (lower carbs at breakfast and dinner). The idea being that most people are more insulin sensitive during the day when they are active. As always with type 1, this won't work for all!

5. Increasing the acidity (e.g. by including a glass of tomato juice or sprinkling vinegar on a salad or chips) of a meal helps delay digestion, so the rise in blood glucose isn't too steep.

6. If pre-meal levels are high, injecting insulin into a muscle will get the insulin working twice as fast as if it's injected/infused into subcutaneous fat. The recommendation was to use longer needles than you usually use, and inject into forearm muscle or triceps. It stings a bit apparently! Don't think my son would want to try it...

7. Some people have benefitted from also injecting the hormone amylin, which is absent in people with type 1. This is an appetite suppressant, delays the emptying of the stomach, and while it is active, suppresses the liver from releasing glucose. Very helpful for eliminating a post prandial spike, but risks hypos if you're not very careful indeed, and nausea is a side effect (so it's a no thanks from us!). I think "Victoza" is amylin, though I may be wrong.

That's all I can remember atm! 🙂

 

[HOBIE]

For the last 30 yrs I have bloused 20/30 mins before meals . It makes me feel better to. With the pump its great, I can put what % & what time delay. If I get halfway through a meal & not keen on it. Stop the pump. All my life I have never been able to do that 😛 Thanks Redkite

 

[Annette]

For the last n years (many) I have done as instructed and bolused 30 mins before meals. And for the last n years I have struggled with hypos that happened half way through a meal. Not until I got my pump, and the ability to bolus over a longer period of time (square wave) at a point to suit me (I now bolus immediately before eating -once my food is in front of me - over 30 minutes) that I realised that I had inherited my mothers slow digestion and what effect it had on my post prandials. Just shows, not all advice is good for all people!

 

[TheClockworkDodo]

I don't think anything works for all people, but it's interesting to hear some actual suggestions from someone rather than the usual "you shouldn't be having hypos/spikes" or whatever, with no helpful advice about how to stop them.

Annette, I also hypo half way through a meal if I bolus more than a few minutes before I eat.

 

[Redkite]

For the last n years (many) I have done as instructed and bolused 30 mins before meals. And for the last n years I have struggled with hypos that happened half way through a meal. Not until I got my pump, and the ability to bolus over a longer period of time (square wave) at a point to suit me (I now bolus immediately before eating -once my food is in front of me - over 30 minutes) that I realised that I had inherited my mothers slow digestion and what effect it had on my post prandials. Just shows, not all advice is good for all people!

Interesting! When I first heard this advice about pre bolusing, my son was 9 years old. We tried it (already had the pump so basals were tailored to him) - insulin given 20 minutes before breakfast resulted in a hypo in the 2's halfway through eating, and the poor boy face down on the carpet feeling awful. Took a while for hypo treatment to bring him up, and then later he was massively high. We didn't pre bolus again for a long time! I think in his case it was because he was small and skinny, and insulin absorbed really quickly. Now he's 14, still skinny but much taller and with adolescent hormones circulating, we're cautiously trying pre bolusing again and it's working really well. I think testosterone causes a degree of insulin resistance. If he wakes with a BG in the 4's or 5's I don't want him bolusing until he's about to eat. If he's in the 6's to 8's he can do it 15 minutes early, and if higher he should prebolus by at least half an hour. It's a case of each individual PWD experimenting.

 

[novorapidboi26]

As with all things diabetic, trial and error..........

I think the majority of people do benefit from their insulin going in a good few minutes before....😉

 

[pottersusan]

I find it interesting how the time for the insulin to take effect varies through the day. For me (usually - if that word can be applied to diabetes) it's an hour or more at breakfast and about 20 mins in the evening. I've come to the conclusion that the diabetes goal posts are on motorised skateboards on an oily surface.😱

 

[trophywench]

LOL - that was the rule with Humulin - inject when I put the spuds on.

I VERY quickly discovered that THAT rule does not apply when I'm using Novorapid!

2 minutes before might be OK if I am sitting down to what's left of a trifle - but not for anything normal ! (NB I haven't actually had any trifle for donkey's years, as for some reason no kids or teenagers in our family will eat it - amazing - I still consider it a mega-treat!)

 

[pottersusan]

just to keep me on my toes only 30 minutes this morning🙄

 

[everydayupsanddowns]

I find it interesting how the time for the insulin to take effect varies through the day. For me (usually - if that word can be applied to diabetes) it's an hour or more at breakfast and about 20 mins in the evening. I've come to the conclusion that the diabetes goal posts are on motorised skateboards on an oily surface.😱

HA! I find exactly the same - at least 30 mins at breakfast and lunch, not much more than 5-10 mins in the evening. Even though basal tests never show any reliably different changes in direction of travel at those times. Sometimes you just have to go with what seems to work (for as long as it continues to do so) with diabetes.

 

[HOBIE]

As with all things diabetic, trial and error..........

I think the majority of people do benefit from their insulin going in a good few minutes before....😉

Agree novorapidoi. good job we are not all the same 🙂

 

[pottersusan]

I envy all you folk who think 10 is a spike. I have to eat carbs to get enough calories in to my system to maintain my weight. I try to bolus at least half an hour before meals, but I still have spikes of 14+. This is aggravated by the fact that I eat every two hours. Life is a roller coaster😱 I'm still searching for the answer (and please don't tell me to eat nuts - I hate them). I have a cow plumbed in for milk, butter and cream🙂.

 

[SB2015]

Thank you for bringing this up again. The list is so useful. When I was at my wits ends and getting no extra ideas from DSN it was this list that set me on track and helped me to improve my profiles and therefore HbA1c.

 

[Radders]

Since I've had my Libre, I have realised that for me, the most effective way of keeping spikes reasonable is to bolus about 50% more insulin than I need, then top up with a snack after two hours. This means I necessarily have to keep the carbs low otherwise I will soon be the size of a house!
I know that the DAFNE approach is to eat normally but post meal spikes were glossed over when I did the course in 2008. All the focus was on levels before the next meal. I dread to think what my two hour readings used to be when I was eating high carbs, as I used not to test because I couldn't seem to avoid spikes without having later hypos.

 

[everydayupsanddowns]

I envy all you folk who think 10 is a spike. I have to eat carbs to get enough calories in to my system to maintain my weight. I try to bolus at least half an hour before meals, but I still have spikes of 14+.

I try to be relaxed about 10s an hour or two after eating as I know my bolus has only just got going and has quite a lot of juice left in it. If I don't check until more like 3 hours after eating I tend to find my meal dose is slightly running out of legs.

If I check at an hour or two and find I'm more like 12s or 14s I might think about a correction that aims to get me back down to 9, since, strictly speaking, that's where I am *supposed* to have been at that point. 🙄

 

[Smiric]

For the last n years (many) I have done as instructed and bolused 30 mins before meals. And for the last n years I have struggled with hypos that happened half way through a meal. Not until I got my pump, and the ability to bolus over a longer period of time (square wave) at a point to suit me (I now bolus immediately before eating -once my food is in front of me - over 30 minutes) that I realised that I had inherited my mothers slow digestion and what effect it had on my post prandials. Just shows, not all advice is good for all people!

Could be gastroparesis? Glad your pump has helped you with post-prandial spikes! =)

 

[Sara W]

I'm still struggling to understand why spikes are so bothersome: should I be worrying about them more? Most of my readings are in the 12 to 16 range, a few still 17. But how I feel seems to bear no relationship to these high readings!

I've never had a blackout, or felt I might - I never get sweaty though I occasionally feel 'wobbly' (which I've always put down to having ME, but now realise might be caused by the diabetes - they are going to test my blood for ME next week to be certain).

I did come a cropper down the escalator at Tottenham Court Rd three weeks ago, which was how I got diagnosed in the hospital after mentioning my severe weight loss - but that was due to drinking too much wine on an empty stomach, after a long period of barely drinking at all in recent years... It was a one-off event, if indeed it was caused by a super-spike and not just losing my balance due to drink taken...

 

[everydayupsanddowns]

I'm still struggling to understand why spikes are so bothersome: should I be worrying about them more? Most of my readings are in the 12 to 16 range, a few still 17. But how I feel seems to bear no relationship to these high readings!

In diabetes terms, regularly spiking up well into the teens after meals puts quite a lot of strain on the micro-vascular system over time, and increases the proportion of the day when you have higher than ideal BGs, which again can cause damage to blood vessels and nerves and, in the long term, increase your chances of developing long term diabetes complications. It's a sobering thought that only 20% of the costs of treating diabetes are spent on the regular check-ups and all the medications that we need. The other 80% is spent on the extra resources needed when people start to develop those nasties (eye problems, nerve problems, kidney problems etc etc). Of course it's not just money, there is also a huge personal cost involved.

Generally you can look at your HbA1c to keep a longer-term view of whether you are on track to avoid complications, but increasingly it is recognised that an HbA1c of the same value is very different when it is due to someone wildly spiking after meals and crashing down into multiple hypos, versus someone who is able to have a much lower glucose variability and potter along more gently.

 

[Amigo]

In diabetes terms, regularly spiking up well into the teens after meals puts quite a lot of strain on the micro-vascular system over time, and increases the proportion of the day when you have higher than ideal BGs, which again can cause damage to blood vessels and nerves and, in the long term, increase your chances of developing long term diabetes complications. It's a sobering thought that only 20% of the costs of treating diabetes are spent on the regular check-ups and all the medications that we need. The other 80% is spent on the extra resources needed when people start to develop those nasties (eye problems, nerve problems, kidney problems etc etc). Of course it's not just money, there is also a huge personal cost involved.

Generally you can look at your HbA1c to keep a longer-term view of whether you are on track to avoid complications, but increasingly it is recognised that an HbA1c of the same value is very different when it is due to someone wildly spiking after meals and crashing down into multiple hypos, versus someone who is able to have a much lower glucose variability and potter along more gently.

I appreciate I'm a type 2 and my situation is therefore different but this is a valuable discussion for me as I've been thinking about my control recently and probably taking stock now I'm 2 years in.
Being diet control only, I can't rely on anything but myself (and I'm not always as reliable as I'd like 🙄). I also sometimes feel guilty when others report much lower daily levels than mine, particularly waking. I'd say my average waking level is about 6.7 but I really have to work at it on a meal by meal basis.
I'm reassured therefore to hear everydays that it's better to potter along more gently with less extreme variations. I probably rarely register outside of a 6.3 - 8.5 level but occasionally hit a 9.8 with a big meal which I know isn't ideal. My GP seems to think anything under 10 is 'acceptable' but I'm unconvinced. I'm still of the belief that some complications have crept in and wonder if the development of the cataract I now have is more likely with diabetics?

These are useful reminders @Redkite so thanks 🙂

 

[trophywench]

Well even somewhat brilliant control can still cause cataracts to develop quicker were the person not diabetic - it's kind of like us being more susceptible to anything that's auto-immune. You have to be prone to getting cataracts in the first place though, so I understand, to get them at all.

So in my case when my optician told me I had one starting on one eye, I wasn't all that bothered - as I don't consider it to be a complication of D, nor caused by it, nor affected by my control. It's a certain fact that since the thing 'budded', I've had far better control than ever in my diabetic life before - and it still needed sorting within approx. 2 years instead of 'might not ever need it' as in the case of some non-Ds. Ironic really.

It's like the frozen shoulder thing, is all. Normals have a journey of 6 months from start to finish - we travel for 18 months to 2 years instead.

When they get round to doing it, you're only in theatre for approx. 20 minutes - and you can't either feel or see, a thing!

I don't count it like I do any of the '~opathies' at all.