Evening meal erraticness

[Jennyninja]

Hi, I'm T1 diagnosed about 6 months ago after 12+ years of a misdiagnosis of T2. On Novorapid and Lantus. Week 3 of using a Freestyle Libre. Also an active runner. All has been going reasonably well, I've been getting to grips with various quirks /variations and grateful for even more data with the Libre. So just to keep me on my toes a new phenomenon has appeared. I match insulin to carbs with generally not too many problems. I take my Novorapid about half an hour before breakfast to reduce the peak. Lunch is usually pretty good but for the last week after my evening meal I start heading towards a hypo and on a couple of occasions, had one. I take fast acting glucose followed by some starchy carbs. Bg starts to go up slowly and by the end of the evening I end up with a BG of anywhere between 11 and 15mmol. I'd really like to avoid this. Is it possible my insulin sensitivity is higher in the evening and I need to reduce the insulin ratio ? I've heard split doses being mentioned. Not done this myself or really understand what it is. Could this help and what should I do ? Any thoughts would be appreciated.

 

[Robin]

Oh dear, one of those 'Just when I thought I’d got it all sorted' moments! We all have them, just keeps us on our toes.
1) Yes, you could be more insulin sensitive in the evenings, and could try reducing your ratio to see if that fixes it.
2) Think about what you eat in the evening. Does it differ in terms of composition/balance of protein, fats and carbs from other meals? Insulin has been developed by boffins trying to match the rate of digestion of an 'average meal'…but there’s no such thing as average. This is where the 'split doses' come into play. If you find you’re going hypo an hour or two after the meal, it may be that the insulin is getting into your system faster than your body is digesting your food. This quite often happens with a fatty or high protein meal, which slows down the rate of absorption of the carbs, Some people find that taking half their insulin dose upfront before the meal, and the rest an hour, or two hours later, stops this mismatch. The ratio of the split and the timing is just a question of experimenting to see what works for you, there’s no set rule.

 

[Inka]

Hi @Jennyninja I’ve had this problem recently too. It’s very annoying! For me, it meant altering my basal insulin. What basal do you take and when?

 

[Jennyninja]

Hi @Jennyninja I’ve had this problem recently too. It’s very annoying! For me, it meant altering my basal insulin. What basal do you take and when?

Hi Inka. Lantus at about 10pm. I recently increased my dose from 6 to 7 units as I was going on the high side all day. It does kind of coincide with this new thing. I decrease my dose if I'm more active but 7 is my new normal.

 

[Jennyninja]

Hi 'ninja, this is where your Libre can really help you out. If you are heading toward a hypo the angle of the libre graph will give a good clue as to how much glucose is needed to head off the hypo. A very gentle downward trend just needs a couple of glucose tabs to level you off. A steep downward curve might warrant the addition of 'follow up starchy carbs' After a hypo It's very easy to rebound after eating too much recovery carbs. The libre graph will show the daily and weekly trends, and levels through the night, and provide a spotlight on difficult parts of the day. Always aim for gentle curves on the Libre graph.

If you are out running later in the day, your insulin sensitivity will definitely change. Take less insulin to cover the troublesome evening meal and then keep an eye on your Libre graph to help fine tune your progress.
If you are doing a lot of running, you may find that your basal dose also needs to be reduced to prevent tricky hypos. I switched from Lantus to Levemir to allow extra flexibility to basal dose.

Half unit pens help to shape small doses, and are very useful on running days. If you don't have a have unit pen ask your nurse or GP for one.

Thanks @Benny G. The Libre has certainly given me more info than ever before. All great advice and I've a number of controlled experiments to carry out . I'm currently on Lantus. What does Levimir do differently please ?
.

 

[Jennyninja]

Oh dear, one of those 'Just when I thought I’d got it all sorted' moments! We all have them, just keeps us on our toes.
1) Yes, you could be more insulin sensitive in the evenings, and could try reducing your ratio to see if that fixes it.
2) Think about what you eat in the evening. Does it differ in terms of composition/balance of protein, fats and carbs from other meals? Insulin has been developed by boffins trying to match the rate of digestion of an 'average meal'…but there’s no such thing as average. This is where the 'split doses' come into play. If you find you’re going hypo an hour or two after the meal, it may be that the insulin is getting into your system faster than your body is digesting your food. This quite often happens with a fatty or high protein meal, which slows down the rate of absorption of the carbs, Some people find that taking half their insulin dose upfront before the meal, and the rest an hour, or two hours later, stops this mismatch. The ratio of the split and the timing is just a question of experimenting to see what works for you, there’s no set rule.

Thanks Robin, great observations. As I just said to Kenny, below I've a number of controlled experiments to carry out. My evening meal is more proteiny and fatty than my usual cereal for breakfast and sandwich for lunch and I've wondered about his. However it wasn't a problem until recently. It could be my basal dose as Inka has suggested ...

 

[Jennyninja]

Thanks @Benny G. The Libre has certainly given me more info than ever before. All great advice and I've a number of controlled experiments to carry out . I'm currently on Lantus. What does Levimir do differently please ?
.

Oh and I should mention that my new Libre put on yesterday is reading about 2mmols out, to add to the frustration and worry. I understand they sometimes do this then calibrate better with the finger prick after day or so. I know there's a delay because it's not blood but my previous one was more accurate. Hey ho. Today is another day...

 

[Inka]

Hi Inka. Lantus at about 10pm. I recently increased my dose from 6 to 7 units as I was going on the high side all day. It does kind of coincide with this new thing. I decrease my dose if I'm more active but 7 is my new normal.

It’s possible that your Lantus is running out @Jennyninja Lantus is supposed to last 24hrs but it often doesn’t. This might explain your sugars rising in the evening, and would be my first suspect. Although one-a-day basal sounds great, they often don’t last as long as they should, particularly if you’re only taking small amounts. They’re also quite inflexible - particularly if you do a fair amount of exercise, as you do.

If you can’t sort things with the Lantus, I’d advise asking for a trial of a twice-daily basal for, say, 3 months. You could then decide which works best for you.

 

[Jennyninja]

Thanks @Inka . More food for thought (if you excuse the slight pun!). My main issue is the plummeting BG after my evening meal. Then I think it goes up high because I take the carbs (not too many) to correct it. I've got an appt on Monday so will discuss alternatives then

 

[Inka]

That’s exactly what happened with me @Jennyninja - the low post-meal, the extra eating, then high. It was an imbalance of basal. The food I ate to correct the low was minimal so I definitely didn’t over-treat. I experimented over more than a week to see if I could sort it some other way. I also found corrections dropped me less than they should (because my basal level was too low and the ‘push’ from the diabetes/glucose wasn’t controlled adequately).

I hope you find an answer soon. Do come back to this thread to say what worked 🙂 The hardest thing about Type 1 is that things are always changing. That’s part of what makes it hard work. I’ve had it many years, but that aspect still gets to me.

 

[rebrascora]

Thanks @Inka . More food for thought (if you excuse the slight pun!). My main issue is the plummeting BG after my evening meal. Then I think it goes up high because I take the carbs (not too many) to correct it. I've got an appt on Monday so will discuss alternatives then

I would agree. You mention prebolusing 30 mins before breakfast, but when do you pre bolus for your evening meal? I need 45 mins before breakfast but much less at lunchtime and evening.

Exercise before the meal will certainly make you more sensitive to the insulin so you may need to change your carb ratio for your evening meal, but the timing of your bolus is also very relevant.

The third thing I would say is that if this hypo is happening whilst your meal is still digesting ie within 2 hours of eating your meal, then the carbs in the meal will act as the follow up carbs, so in that case I would just take the fast acting carbs and then test again (finger prick) in 15 mins to ensure you have come back up and if not have somemore fast acting carbs, but if you are back up then the digesting food will stop you going low again.

I think combination of when you inject for your evening meal, the composition of the meal and exercise increasing your sensitivity is leading to hypo and over treating the hypo is leading to the subsequent high.

Levemir gives you greater flexibility because you can vary your daytime and night time doses to match what your body actually needs much more closely than with a once a day basal insulin. For me, my daytime needs mostly stay pretty constant and I need much more insulin through the day and less at night particularly if I have been very active throughout the day. I currently take 24 units on a morning and just 3 units at night so not even close to a 50/50 split. If I do a lot of exercise then I reduce my evening dose that night and increase it when I have more sedentary days. My Libre will usually give me an idea at bedtime if it is trending upward or downward if I need an increase or decrease taking into account my day's activity and when I ate and what I ate.
As others have said, fatty or fibrous meals involving beans/lentils etc or high protein, will release glucose over a longer period and will need a smaller upfront bolus and then a correction afterwards to balance it, otherwise the insulin hits your blood stream before most of the glucose from the meal and takes you down too low, even though the dose might be right, then carbs to treat the hypo mean that you end up with not enough insulin left for the carbs that are still digesting.

It's a fine balancing act and experimenting is absolutely key to finding how your body works and the best strategy to deal with it. It might be that injecting your bolus after your evening meal works better for you, so that is something else to try.

 

[Jennyninja]

I would agree. You mention prebolusing 30 mins before breakfast, but when do you pre bolus for your evening meal? I need 45 mins before breakfast but much less at lunchtime and evening.

Exercise before the meal will certainly make you more sensitive to the insulin so you may need to change your carb ratio for your evening meal, but the timing of your bolus is also very relevant.

The third thing I would say is that if this hypo is happening whilst your meal is still digesting ie within 2 hours of eating your meal, then the carbs in the meal will act as the follow up carbs, so in that case I would just take the fast acting carbs and then test again (finger prick) in 15 mins to ensure you have come back up and if not have somemore fast acting carbs, but if you are back up then the digesting food will stop you going low again.

I think combination of when you inject for your evening meal, the composition of the meal and exercise increasing your sensitivity is leading to hypo and over treating the hypo is leading to the subsequent high.

Levemir gives you greater flexibility because you can vary your daytime and night time doses to match what your body actually needs much more closely than with a once a day basal insulin. For me, my daytime needs mostly stay pretty constant and I need much more insulin through the day and less at night particularly if I have been very active throughout the day. I currently take 24 units on a morning and just 3 units at night so not even close to a 50/50 split. If I do a lot of exercise then I reduce my evening dose that night and increase it when I have more sedentary days. My Libre will usually give me an idea at bedtime if it is trending upward or downward if I need an increase or decrease taking into account my day's activity and when I ate and what I ate.
As others have said, fatty or fibrous meals involving beans/lentils etc or high protein, will release glucose over a longer period and will need a smaller upfront bolus and then a correction afterwards to balance it, otherwise the insulin hits your blood stream before most of the glucose from the meal and takes you down too low, even though the dose might be right, then carbs to treat the hypo mean that you end up with not enough insulin left for the carbs that are still digesting.

It's a fine balancing act and experimenting is absolutely key to finding how your body works and the best strategy to deal with it. It might be that injecting your bolus after your evening meal works better for you, so that is something else to try.

Thanks so much @rebrascora . You've given me a lot to think about. I hadn't thought about the currently digesting food being the slow carbs after the fast acting for the hypo. Without the half a piece of bread or crackers I might not have ended up with the hyper later. Also several references have been made to split bolus. Makes sense to me but I've just never tried it. I guess that's down to being inexperienced. Also with an evening meal there is no risk of a delayed previous meal insulin bumping into the next meal's dose if you know what I mean. Goodness me. I never thought I'd become a walking science experiment

 

[rebrascora]

There is a lot to think about and you are still very early in your journey with diabetes.
It is like trying to do "advanced maths" when you have only just got the hang of long division, so by all means experiment when you have a bit of time and it is safe to play about with adjusting these things but it is absolutely fine just to manage things as best you can and muddle along for the time being and once the basic stuff becomes second nature, then look at refining it a bit here and there. You are probably on the steepest bit of the learning curve and it is a very long curve so you can't expect to get it right all the time. The important thing to accept is that perfection is not possible and these things will still happen 10 or 20 years down the road, but by then you will have developed a range of strategies to try to deal with them.
If nothing else, "impersonating a pancreas" keeps your mind sharp and active.

 

[Inka]

And just to add that sometimes we all muddle along a bit however long we’ve been diagnosed because Life gets in the way. You need to find a way to deal with the D without letting it take-over your life and take up all your time. Sometimes it’s ok to ‘muddle along’. I know I do sometimes even after decades of Type 1. It’s a mental battle as well as a physical one.

 

[Jennyninja]

There is a lot to think about and you are still very early in your journey with diabetes.
It is like trying to do "advanced maths" when you have only just got the hang of long division, so by all means experiment when you have a bit of time and it is safe to play about with adjusting these things but it is absolutely fine just to manage things as best you can and muddle along for the time being and once the basic stuff becomes second nature, then look at refining it a bit here and there. You are probably on the steepest bit of the learning curve and it is a very long curve so you can't expect to get it right all the time. The important thing to accept is that perfection is not possible and these things will still happen 10 or 20 years down the road, but by then you will have developed a range of strategies to try to deal with them.
If nothing else, "impersonating a pancreas" keeps your mind sharp and active.

Thank you. I'm grateful for all the support and realistic advice through experience from you and others. You're right ref keeping your mind sharp. I used to struggle with remembering the formula for converting values from 100% to actual percentage or weight. Now I find myself doing mental arithmetic all the time. I scraped through with a C in maths O level just as 1st generation calculators were coming in

 

[Jennyninja]

Progress update and so far so good. X2 experiments using some of your advice above: night before last I had an evening meal that replicated lunch ie a sandwich. BGs didn't drop, thus supporting the suggestion that my usual proteiny, high fibre evening meal could be absorbing more slowly than the insulin that I am more sensitive to in the evening after a day's worth of physical activity. Yesterday pm I had a slightly more proteiny /high fibre dinner. BGs started to go down fairly rapidly. Once they hit 5, I took x1dextrose tab. Continued to go down so i took another. Held my nerve and watched my BGs level out and start to go up. Continued to go up but not into double numbers. So suggestion ref no need to take slow release carbs because I'm still digesting the meal was really helpful. Next I'm going to try the split dose with a more complex high fibre /protein meal that I prefer to have in the evening and see where that goes. Thank goodness for Libre. Otherwise I wouldn't have been able to monitor this so closely. Libre is not perfect but using it along side some finger pricking at the extremes has been a real bonus. I wish I'd applied this level of logic and perseverance in Science at school. I might have gone further in the subject ! Thanks again everyone !