little trial of spikes

[ky333]

My daughter has just got her first dexcom a couple of weks ago. Its brilliant and we love it. As I have posted before we have had trouble with very large spikes at breakfast time so using the dexcom readings we did a little trial.

Breakfast with normal carbs she likes to eat ( cereal, approx 40g carbs ) Very high spikes 18+

Breakfast with same cereal but leaving longer and longer between insulin and eating.... no difference to spikes

Breakfast with no carbs just protein... absolutely no spike at all. Which is obviously what we were expecting but my query is...
....with the high carb breakfast she never spiked at lunchtime whilst at school. She stayed constant at around 5-7. Always in range till teatime.

With the protein breakfast she always spiked at instead at lunchtime ( same packed lunch) and stayed high till teatime. Its as if the spike has just moved from breakfast to lunch. Does anyone have any idea why?

 

[Lanny]

It takes longer to convert protein & the delay & the rise is different for everyone. With me if I’m in range, 5-7mmol, I don’t need any bolus as my blood sugars only rise a little bit about 4 hours later: I’d go hypo if I bolused; if I’m higher than 7mmol I’d add a wee bit of bolus or test about 4 hours later to see if I need 2 units depending on how much higher I am. You could try a mix of some carbs & some protein for breakfast instead & see what that does?

 

[Lanny]

Oh forgot to say, being type 2 with insulin resistance that type 1’s don’t usually have 2 units is a tiny amount compared to what I usually need, about 10 times more, but, I know that type 1’s use much less!

 

[ky333]

It takes longer to convert protein & the delay & the rise is different for everyone. With me if I’m in range, 5-7mmol, I don’t need any bolus as my blood sugars only rise a little bit about 4 hours later: I’d go hypo if I bolused; if I’m higher than 7mmol I’d add a wee bit of bolus or test about 4 hours later to see if I need 2 units depending on how much higher I am. You could try a mix of some carbs & some protein for breakfast instead & see what that does?

I see, so you think she maybe rising later in the day ( lunchtime) cause of the protein she ate at breakfast? I hadnt considered that.
We did try nuts and cereal at breakfast - spiked as though she she'd just had the cereal.
Just when we think we have things covered it all changes again!

 

[rebrascora]

When you say you left it longer and longer between the insulin and eating breakfast but the spike was still the same, did you wait until you could see the insulin kicking in before she ate breakfast? I find with NovoRapid it can take an hour or more on a morning and with Fiasp about 45-50 mins for me... longer if my levels are high to start.... it was 1hr 20mins this morning. I am not recommending these time scales but what I do is inject my bolus insulin as soon as I get out of bed. Make my breakfast so it is ready to eat as soon as my levels start to drop. Get washed and dressed and have a cup of coffee and say hello on the forum here, all the while, scanning my Libre every few minutes until I see that the insulin is starting to bring levels down and then I start to eat. I imagine this will be much more difficult with a child but once you figure out the sweet spot for the timing you can set an alarm/timer and unless levels are already low on waking, that will usually be about right.

As regards the protein breakfast, yes it will usually start to break down into glucose 2 hours after eating it but can last for 6-8 hours, so you get a raised plateau rather than a spike. You might have to look at perhaps an increased temp basal rate to cover it or a correction dose of bolus later to bring it down. Approx 40% of protein will break down into glucose. An egg contains about 7g protein, so 2 eggs would be about 14g so the equivalent of 6g carbs from 2 eggs (Obviously meat is different and you would have to calculate it) but you won't see it for 2-6 hours down the line and it will be more of a steady rise than you would get from carbs.
It is all quite complicated when you are used to just dealing with carbs and if she is happier eating her carb rich breakfast then finding the optimum timing for eating after bolus might be best or just accepting that at breakfast time she spikes and try not to worry too much about it or play around with portion size to limit the carbs to an amount that you can keep the spike pretty much within range. For me I can manage about 30g carbs but any more will send me out of range even with the best timing... ie even if I catch it right as I am touching the bottom end of my range at 3.9 it will spike above 10. I don't like it doing that so I keep to 30g carbs or lower. It may be a different amount for your daughter so experiment with portion size and maybe bulk it out with nuts and seeds and full fat natural Greek yoghurt (or cream) which should slow the release of glucose down a bit and allow the insulin to keep pace with it better.

 

[Inka]

If I don’t pre-bolus far enough in advance, I shoot up after breakfast. With a bolus enough in advance, I don’t. You really do have to experiment with moving it 5 mins at a time. For me, my blood sugar will be 11 or 12 or even higher with a bolus at the wrong time compared to below 7 with a bolus at the right time.

Protein is a pain without carbs so I always make sure to have some carbs with it. Protein alone causes a delayed rise and is harder to get that down. Carbs are more predictable.

 

[ky333]

Thanks everyone, you are all really experienced!

We moved the insulin back every 5 min until we got to 40 min. Couldnt move it back anymore. She was injected as soon as she woke up, still half asleep in bed. Couldnt wait any longer as she would be late for school.

She much prefers to have cereal for breakfast but also hates to inject so soon after waking so she cant win either way. Thats why we were trying the protein only

If she continues to have just protein for breakfast, for instance eggs x2 and meat with cheese, how many units should I work out she would then have extra at lunchtime to counteract the protein she had at breakfast?

 

[rebrascora]

I normally find that I need twice the correction dose I would normally need.... so if 1 correction unit of insulin would normally bring me down 3mmols, it will usually just bring me down 1-1.5mmols. I always correct conservatively with an eye to safety and do another correction later if need be. Because I follow a low carb way of eating, it suits my purpose to increase my basal insulin and allow it to mostly take care of my protein and I just top up with the odd carb snack like a dried apricot here and there through the day if I need it or of course a jelly baby etc, just to keep me in range.

Have you considered something like a low carb "grab and go" type breakfast. Nature Valley protein bars are tasty and are pretty much 10g carbs per bar, so maybe a bowl of yoghurt with berries and seeds and one of those for breakfast would still be less than her current cereal and be somewhere in between the protein and the high carb foods so might work better and they taste really nice. They do a peanut and chocolate or a salted caramel, which really yummy and I think there is a coconut one but you don't often see it in the shops.

 

[Inka]

I just looked back to remind myself how old your daughter is - she’s 8yrs? I know you said she likes Weetabix. That’s something I eat for breakfast. What I often do though is mix it with another cereal eg I have one WB and some All Bran (I appreciate you might need to try a different mix for an 8 yr old). I find that mix of different GIs works well. I think I mentioned the milk type already on a previous thread, but keeping to minimal milk helps and only having one WB is far less absorbent than two as they seem to soak the milk up. Experimenting with other cereals and mixes might help too. There are a large number of not-too-sweet options to try.

There’s also another possible option which is to pre-pre-bolus (that’s not it’s real name but I’ve forgotten the technical term). That is, you split the bolus and have a little earlier to get working.

I hope you manage to sort it out. It’s frustrating when a meal needs attention. One thing I forgot to ask is are you sure her ratio is right? Not just her breakfast ratio, but her ratio for cereal? I find a few foods need just a little bit extra insulin. 18 is a high spike and you’ve tried moving her bolus, so if it was me I’d consider increasing the insulin.

 

[ky333]

We did increase her breakfast insulin ratio but she hypo'd everytime before lunch.

Funny today though... she had just protein for breakfast, no spike. Just protein for lunch, no spike.

In fact she stayed between 5-6mmols all day till 1900 teatime. No protein rise at all. It seems she has to have a carb to make a protein rise occur or at least thats how it worked out today

(Its not something that she would obviously do normally, have no carbs, it just worked out that way with an English breakfast first thing and cheese with meats for lunch.)

 

[rebrascora]

Good to hear she had a nice stable day of readings. Could it be she was more active today or even yesterday as that will bring my levels down from protein, because it is a slower increase than the spike you get from carbs, so if you have been burning energy it counteracts it at the same sort of rate. At least that's what I find on a low carb diet but will be interested to read how your experiments continue.

 

[Inka]

We did increase her breakfast insulin ratio but she hypo'd everytime before lunch.

Funny today though... she had just protein for breakfast, no spike. Just protein for lunch, no spike.

In fact she stayed between 5-6mmols all day till 1900 teatime. No protein rise at all. It seems she has to have a carb to make a protein rise occur or at least thats how it worked out today

(Its not something that she would obviously do normally, have no carbs, it just worked out that way with an English breakfast first thing and cheese with meats for lunch.)

Ah, I remember now - apologies for forgetting and/or repeating myself. In that situation, I’d have a mid/late morning snack. I did that pretty consistently through the whole honeymoon period, and still do sometimes now.

 

[trophywench]

And - exercise can affect BG for approx 48 hours not just on the day you do it.

 

[everydayupsanddowns]

Sorry to hear about your daughter’s cereal woes @ky333

I confess I decided that cereal and me really didn’t get on when I started post-meal checking.

Have you tried different varieties to see if there might be one or other that work better for her? Sometimes diabetes just doesn’t make sense (eg frosties generally slower for people than cornflakes).

Which cereal(s) has she tried so far?

Could you try one of those layered bowls with full fat greek yoghurt, berries, and a sprinkle of cereal/granola for texture?

 

[ky333]

Thanks everyone. We have tried a few different cereals, adding protein after eating, using different milks.All seems to be the same. Spikes for long periods.

Only change was when she only ate protein... no spike till she ate carbs again later in the day. When she ate protein only for breakfast and lunch... no spike till evening meal.

 

[helli]

I find with NovoRapid it can take an hour or more on a morning and with Fiasp about 45-50 mins for me... longer if my levels are high to start.... it was 1hr 20mins this morning. I am not recommending these time scales but what I do is inject my bolus insulin as soon as I get out of bed. Make my breakfast so it is ready to eat as soon as my levels start to drop. Get washed and dressed and have a cup of coffee and say hello on the forum here, all the while, scanning my Libre every few minutes until I see that the insulin is starting to bring levels down and then I start to eat.

Do you take into consideration the 15 minute delay with the Libre?
If you are thinking your Fiasp start working when you see your BG drop on your Libre, it has actually been dropping for 15 minutes already. Depending what your starting BG is, this could be concerning.

 

[rebrascora]

Yes, I take the Libre delay into consideration. I am becoming pretty adept at timing it so that I just skim the bottom end of my range as the food starts to kick in and then hopefully I can keep in range or not go too far above. As with anything it takes practice and there are occasions when I make a slight miscalculation but Fiasp really doesn't work that fast for me, so generally it is only if I get distracted that I get it slightly wrong. It may help that my digestive system is very fast and efficient so even on low carb foods the glucose hits my blood stream remarkably quickly.... obviously I wouldn't bolus up front if I was just eating protein as that clocks in about 2 hours later, but for a small amount of carbs like yoghurt with berries and seeds and a sprinkle of low carb granola, it works well.
This morning I was 4.3 on waking.... had a late night and a late start today. Up to 4.7 a few minutes later (9.18am) when I injected 3 units of Fiasp and my Levemir. By 9.57am my reading was 4.2 but still an horizontal arrow so I started eating my breakfast (20g carbs in the above described concoction) and didn't go into the red. Now at 7.4 and still rising. So just 39mins this morning because I was low to start with.