Late afternoon rise - with no food taken

[Supratad]

Hi, I've just joined but rather than post in the Newbies section, I've dived straight in with the reason I've joined to pose this poser.

Here's a tricky one. Obviously, I've been talking to my doctor and clinic for a while about this having switched to Libre, while still using Aviva Expert, and as such have been through various changes in long acting insulins, but I have this problem where about now ... i.e. getting on for 4 o clock ish every afternoon, my blood glucose shoots up. As a typical day, my blood might rise a bit after breakfast, and be normal around lunch and for 2-3 hours post lunch, then shoot up, enough to get a vertical arrow on the Libre Freestyle meter.

Background. T1 for nigh on 40 years now. Quite overweight though and also taking Metformin for long term insulin resistance. I was on Tresiba for many years and this phenomena was happening then, but I used to have a mid afternoon snack, so attributed the rise to mis-managing that, but since being furloughed, and now unemployed, and the change to the Libre Freestyle meter system, I can see my bloods in much greater detail. I stopped the snacks when I stopped working in an actual office, but still it goes up, 3 hours after lunch, despite no intake of any sort.

Now that's after the bolus insulin (Novorapid) should have reached its peak. My Doctor felt I was one of those few people for whom Tresiba doesn't last as long as it should. Its supposed to be 24-30 hours, but I was taking it at 10:00pm, (50 units) and my late afternoon rise was indicating that it had stopped working after 18 hours.
So, against all medical advice, I split the Tresiba to a twice daily dose (25units each) and it really made no difference.

I had allergic reactions to Levemir on a twice daily regime and had to stop that, so I'm now on Lantus twice daily, 30u and 26u, 12 hours apart 9:00am and 9-10:00pm. However with no carb intake after say, 1:30pm, my BG is shooting up by 4:00pm. Yesterday it was 16.6 and rising. Correction dose of 12u was been issued but it was still 14 by the time I had my evening meal.
Today, my bloods have been 6.4 before lunch at 12:30, then 4.8→, 4.7→ then 20 mins ago 7.3↑ . So I've taken a risky 10u to try and chase the rise in good time.

What IS causing this?

I usually have the same thing for lunch, and I did think maybe the cheese was causing the fat to delay carb absorbtion till much later, but if that were the case, then I'd be going hypo immediately post-lunch. Having a low fat, low carb lunch has no effect either. It goes up no matter what lunch I have.
Sometimes, quite often, being an overweight, 51 year old man, I'll have a 15min "power-nap" after lunch (No, its not a "nanna-nap" its a power-nap) I thought maybe, the sleeping action was forcing some sort of digestive dormancy but again, if I don't nap, it still goes up, as it has today.

Some form of liver-dump? Does anyone have any ideas?

 

[trophywench]

Yes - one very good suggestion - ask to have an insulin pump! A pump delivers your basal dose, split up into different amounts hour by hour, and you are not thereby lumbered with once or twice a day - you might eg have the same amount every hour for X number of hours then a few hours or only one hour at less of more, then something different for the next couple or whatever your body actually pretty precisely needs. There's a lot of test test testing to begin with - but OMG it pays off !! Which reminds me - must increase mine around lunchtime - granddaughter arrived to cut both our hair whilst we were still eating lunch and slipped my mind.

You don't get an hour's worth all at once though even - pumps drip it in according to how much it actually is - mine can drip every 3 minutes if that hourly rate is big enough - or it might only split it into 2 drips or whatever. The only time you have a dose of 1u or more is when bolusing for a meal! - cos they are done the same as on pens.

How do you fancy continuing to use the Accu-Chek Expert meter (but a new one enabled to do the necessary) and a matching pump, which communicate directly with each other via Bluetooth? Cos that's what I had a brand spanking new one of, last Thursday!

 

[everydayupsanddowns]

Goodness that is a weird one @Supratad!

Sounds like you are tackling it in an analytical way, and that you are aware of many of the little quirks that T1D has up its sleeve.

Have you tried a fasting basal check over lunch-afternoon? Where you don’t eat lunch and must observe what your body does on basal insulin alone.

Sounds like your individual doses are quite high in T1 terms. have you tried splitting them into smaller subdoses taken at the same time? Just in case the single larger doses are not absorbing effectively?

Hope you manage to get it solved at some point, but it sounds like you have been chipping away at it for years.

Other than that your levels look great!

 

[Supratad]

trophywench - My nurse has floated the pump idea, but for now as levels are OK except this blip, in the Covid situation she's happier to leave me to try and predict, counter and correct the mystery rise rather than come into clinic and start a whole new pump regime. As you say, it would be a whole process to get it set right.
I was quite averse to pumps until a few months back, Last time it was discussed would have been about 6 years at least, when my previous diabetic, Diabetic nurse showed me hers (easy now). That was a bluetooth linked Accu-Chek and pump, but the whole wearing a pouch and having tubes thing put me off.
Having looked at the very latest ones though, just like a big Libre sensor, I'd be OK with it.

everydayupsanddowns - I never have lunches on a weekend and for the most part, this afternoon rise doesn't happen then. That makes me believe it must be due to food and digestive release, somehow. Something is being released into my bloodstream that the basal insulin can't cover. As said, even when splitting Tresiba to 30u in the morning and 20+ at night, it was still going up. I mean 30u of Tresiba cannot run out of steam in under 7 hours. Doctor wasn't happy with me doing that though, but you know, I've been diabetic longer than he's been alive. (that's terribly arrogant)
I certainly do inject a lot of insulin and do spilt the dose across sites if a bolus is getting to 40u and above.

I can fully recommend the Libre system to those that can get it on prescription. My old money HBA1c was always around 8 for years until now. The predicted level is 7-7.5 and about 80% in range.

Thanks to both of you for your answers.

 

[everydayupsanddowns]

That makes me believe it must be due to food and digestive release, somehow. Something is being released into my bloodstream that the basal insulin can't cover.

Very odd that no lunch no rise, but no-carb lunch provokes as strong a reaction as a carby one.

What are you having for your no-carb or low-carb lunches? Eggs have been a weird one for some folks in the past and needed bolus. Any chance there might be some sneaky carbs hidden in there?

Could it be a lunch ratio thing and/or needing to bolus for proteins (or illogical need to bolus for no apparent reason).

It just feels like it can’t be basal, because basal isn’t supposed to be involved with foods, and this seems to be triggered by eating lunch (even if low carb).

 

[Supratad]

Here's yesterdays graph, and today's is much the same. I've posted again because I've shifted my Basal times to midday and midnight, yet it has no effect. Lunch was pitta bread, hummus and olives, with a muffin after, so around the 100 carbs area.



Blood glucose rising at about the 2 hour mark, just when the Novorapid should be working its hardest. Insulin resistivity? but why not at all other times of day when I inject?
So odd.

 

[trophywench]

Well with that lunch yes it was high carb - but it wasn't low fat, hence the fat is very likely to have slowed down the carb 'spike'. Even without that fat component, might you be better off splitting your lunch bolus? or just having a different insulin to carb ratio for lunch?

 

[stillgoing]

Hi, Just a thought. How about reducing the amount of carb you are eating. Personally I only eat 110 units in the whole day including snacks but then I am not very active. If you think of a pendulum it swings back and forth like you BG. If you give the pendulum a slight tap at the correct time you can increase the swing to the point it goes out of control. A small tap can stop it in it tracks but it then swings back the other way even further.

By reducing your carb intake you will reduce the force you are hitting the pendulum with and hopefully bring the swings into a better limited position.

Hope you get it sorted.

 

[Inka]

When I eat a higher carb meal I often split my bolus. I find that helps a lot. It takes a little experimentation but works well if you can get it right.

 

[trophywench]

My husband is over 10 years older than you, and would quite happily consume that for lunch AND be looking for cake with his afternoon cuppa. The OP is that much younger than yourself and no idea what he does for a living - OH had manual jobs throughout his working life and at one time he walked the streets or across huge tracts of farms for his wages, reading meters.

Struck me that lunch could quite easily be inside a plastic box packed up and brought from home really conveniently,

It's his lunch, not yours or mine - I hate olives!

 

[Supratad]

Well with that lunch yes it was high carb - but it wasn't low fat, hence the fat is very likely to have slowed down the carb 'spike'. Even without that fat component, might you be better off splitting your lunch bolus? or just having a different insulin to carb ratio for lunch?

These are my misperceptions and probably why I’m 144kg. I think of that lunch as a healthy one, because olives, but of course the olives are drizzled in olive oil, the hummus is fatty and the pitta is about 50g of carb. The muffin cakething after doesn’t help.
My other usual lunch would be a cheese and pickle sandwich, though sometimes just one slice of wholemeal, but still marg, cheese sweet pickle and a packet of crisps.
When increasing my lunch carb ratio though, I’ve found my bg dropping right after lunch.

I think there’s definitely a delayed digestion thing going on. Right now, my bg is 4 as I have no lunches on a weekend and have been more active today. The afternoon rise must be explicitly linked to my lunchtime food.

 

[Supratad]

Hi, Just a thought. How about reducing the amount of carb you are eating. Personally I only eat 110 units in the whole day including snacks but then I am not very active. If you think of a pendulum it swings back and forth like you BG. If you give the pendulum a slight tap at the correct time you can increase the swing to the point it goes out of control. A small tap can stop it in it tracks but it then swings back the other way even further.

By reducing your carb intake you will reduce the force you are hitting the pendulum with and hopefully bring the swings into a better limited position.

Hope you get it sorted.

Yeah, I’m probably eating three times that amount and not very active. All this weather means I’m not even getting a weekly bike ride in now.

 

[Supratad]

When I eat a higher carb meal I often split my bolus. I find that helps a lot. It takes a little experimentation but works well if you can get it right.

I certainly do that for meals like pasta, or curries with rotisserie and poppadoms etc.

 

[Deleted member 25429]

I have whole meal bread with lots of seeds in it with full fat cheese for breakfast and I have to split the dose . I then don’t see any rise helps that I walk for an hour with our dogs about an hour after eating it

 

[Supratad]

Thread resurrection.
Having split my morning Lantus of 33 to 18 and 15, 9:00am and 12:00pm, I've found absolutely no change in the late afternoon BG spike. It still rockets up at around 4 ish, despite having no food at all. That's when the Lantus spike should be having an effect.
Even yesterday, I went out for a hour and half bike ride up the NY Moors, 1100ft of climbing and my blood stayed good, around 6 which felt a bit edgy as it can drop quickly when I exercise. But when I got back to the car, it suddenly went to 9.2.
This is all very weird.

 

[mikeyB]

It all rather depends on what you ate on this expedition, if anything. Any snacks? Energy bars?

 

[Supratad]

No nothing, but water.

 

[Supratad]

2 year resurrection.
I might have made some progress with this over the last three weeks.
I think the culprit is chocolate. Years ago I gave up desserts, which has no absolutely no effect on my weight, and started ending lunch and dinner with a little bit of chocolate instead. Usually, a piece of very dark choc like 85% or even 100% and then a few Cadbury's buttons or twirl bites. Probably too many than I should have.

However, as of the last few weeks I've completly cut out dark and milk choclates and have found for the most part, my blood does not suddenly rise about 4pm. Sometimes it goes low due to the amounts of insulin I'm injecting and I end up with high BG anyway through hypo-overcorrect. But it does seem to be working, I mean, right now its 4:20pm and my blood is 6.2 and its been below 8.5 since 11.00am.

I recall my previous nurse talking about why you should not use chocolate (on its own) when in hypo as the choc forms a barrier to the sugars getting into the blood quickly. Wine gums or Jelly Babies preferred. I suppose a Mars Bar is much more caramel goop than chocolate.

Anyone else found issues with chocolate?

 

[everydayupsanddowns]

I recall my previous nurse talking about why you should not use chocolate (on its own) when in hypo as the choc forms a barrier to the sugars getting into the blood quickly. Wine gums or Jelly Babies preferred. I suppose a Mars Bar is much more caramel goop than chocolate.

Anyone else found issues with chocolate?

Yep! Chocolate can definitely have a BG sting in the tail for me, hours after I’ve eaten it.

And for years (even know I knew it was hopeless for it) I used fun-sized bars to treat hypos. I shudder at the thought of how many extra hours of sub-4 BGs I must surely have caused myself over the years. Mars bars no different speed-wise to less caramel-goopy versions tbh.

These days I generally reserve chocolate for when I want a slow-and-steady glucose release over several hours. Eg when exercising at low intensity, like a long leisurely walk.

Bit even then it can come back and bite me on the bum hours later!

 

[SB2015]

I also had a time when I eliminated chocolate apart from after meals. However I am not very good at limiting my intake when I do eat it, so I stick to things that come in bite size bits, a plain chocolate Brazil, a wrapped mini bar of chocolate.

Then like @everydayupsanddowns I have the treat of chocolate when out for a full day of walking where I need the fat content to slow the release of glucose over a period of time.