Low in the middle of dinner (too big a meal? Bolus too early?)

[Skater P]

So I just over 4 weeks in to this whole T1D thing, I'm doing basic carb counting (or just reading labels) on basal and bolus for meals.
About half way through my fist CGM sensor too.
...anyway having a lovely dinner of salad, then fish pie and celariac then pudding (all up about 90 grams of carbs) and bolused for that at my usual ratio for dinner. Just after I'd finished my main course I got a low alarm that a finger prick confirmed.

So I have questions (or more conformation from older hands of where I went wrong)

1. I assume I was way too early between the bolus and the carbs kicking in, between plating up and eating a salad it might have been half an hour before the main, I'm thinking this is the main leason here.
2. Can too big a meal send you low before it goes up? I think my dietition may have mentioned that.
3. What is the usual protocol for a low in the middle of a meal? I went for half a juice box (so about 10g of carbs) that seemed to do the trick if a little slower than usual as I had a full stomach.

Everyday is a school day it seems

 

[Inka]

1- Yes. If you’re having a non-carby starter, delay your bolus.
2 - Yes, in theory, although your meal doesn’t sound super-big. If you split your fish pie and pudding bolus into two separate boluses, that would help, as might other splits such as some bolus before the meal, some after.
3 - Depends how low you go but if you were in the 3s and felt antsy, I’d have a Dextro or two and carry on eating @Skater P

 

[Inka]

As an added comment, you might not need to bolus too far in advance for your evening meal anyway as it’s usually the time we’re most sensitive to insulin. I can bolus right before eating in the evening.

 

[Skater P]

1- Yes. If you’re having a non-carby starter, delay your bolus.
2 - Yes, in theory, although your meal doesn’t sound super-big. If you split your fish pie and pudding bolus into two separate boluses, that would help, as might other splits such as some bolus before the meal, some after.
3 - Depends how low you go but if you were in the 3s and felt antsy, I’d have a Dextro or two and carry on eating @Skater P

Thanks Inka
2. Given I like a big and long duration meal sometimes (though less than the before times) a split bolus sounds like a good plan for me.
3. Yeap, even though I felt a little full I was able to force down my planned pudding 🙂

 

[Skater P]

oh, and of course my meter is now telling me I'm too high, gaaahhh. <considers hurling phone into the front garden> 🙂

 

[SB2015]

oh, and of course my meter is now telling me I'm too high, gaaahhh. <considers hurling phone into the front garden> 🙂

Well done on getting your head round things so quickly and dealing effectively with the mid meal low. Very frustrating at times as you don’t necessarily want a juice in the middle of a lovely meal. Glad you continued to pud too.

The post hypo high is a common pattern, and more so if it is mid meal. With hypos at other times I find that using the info from the sensor, including the arrows, I can decide how many jelly babies to go for. I still find the wait for 15 minutes can feel interminable.

As you are only a few weeks into T1 I suspect that you have some beta cells left that are being ‘helpful’ and responding to the food you are eating, alongside the bolus that you have given. You may have heard of the Honeymoon Period. Splitting the bolus sounds a good plan. I found that I needed to do this for specific types of meals, such as high fat content, and also had to adapt for larger meals.

Glad that you hung on to your phone. That temptation is there at intervals for many of us.

Keep the questions coming.

 

[everydayupsanddowns]

Great to see you thinking things through like this so early on @Skater P

I suspect you are right and that the salad starter artificially lengthened your prebolus time.

Another thing perhaps to bear in mind, and keep an eye on in the future, is that I generally find larger meals absorb more slowly for me. So I often need to take the bigger bolus dose in 2 sections. One up front, and then an additional ‘top up’ later as the bigger meal continues to digest. This spreads the insulin action, and reduces the risk of an early dip followed by a much later rise-and-rise-and-rise.

 

[SimonP]

2. Can too big a meal send you low before it goes up? I think my dietition may have mentioned that.

I must say I don't like the statement as it's not the big meal that might send you low, it's the big bolus which is not well matched to the meal (in terms of insulin absorption/activity vs carbs absorption).

Lots of other valid points above re insulin sensitivity, splitting bolus (which I always do to limit any single bolus injection) and the fact that large meals might be even more slowly absorbed than their pure carb content indicates (carbs are absorbed at a reasonably fixed rate) due to their composition (fat and oil further slow digestion), but I just wanted to say I'm not keen on the dietician's way of stating point 2. above (but then I'm not keen on dieticians in general 🙂)

 

[Skater P]

One up front, and then an additional ‘top up’ later as the bigger meal continues to digest. This spreads the insulin action, and reduces the risk of an early dip followed by a much later rise-and-rise-and-rise.

I tried that yesterday where I had my first meal "out" (a three course lunch at Miller and Carter who have a very useful menu/pdf on thier site with all the carb values, even if it takes a bit of thought to use)

Tried jabbing for each course as it arrived but left the last one (pudding and an unplanned extra) for an hour or so later as my line hadn't moved at all throughout lunch so had the last 2 units when I climbed at about 3pm (later carbs going up meeting the first bolus tailing off)
As the rise didn't fully plateau after an hour and a half I went for a bike ride which sorted it right out, if not looking like it might go the other way (backing off the effort when I passed 5mmol/L stopped the crash before I needing a gel)

So jabbing as you go, a lovely lunch and a bonus bike ride on a lovely evening I will take as a win.