Wanting to know more about the 'rebound' phenomenon

[sololite]

I am juggling a lot of factors that are affecting my diabetes at the moment and really trying to focus on my control.

I am interested to know what the body is doing when BS rebounds.

I have experienced rebounding from hypo territory when I've over compensated by having too many jelly babies or some fruit but am I right in thinking that BS can also go high some hours after a meal because I take too much rapid insulin with my meal? If so, is there anyway for a layman to understand why by reading up on the subject?

Regards,

Chris

 

[Peely66]

What reading have you done so far about this effect?
The only thing I can recall reading and hearing about (had to do a quick search to refresh my memory) is the somogyi effect. I think this is when your BS goes low over night and triggers the body's hormones that release glucose (or is it glycogen?) leading to morning highs. Something else to think about. Endless isn't it?

 

[sololite]

Thanks for the pointer @Peely66 . I have done no reading except distill posts on this forum that talk about rebounds. I get so little quality time with my DSN and even less with the head honcho at my diabetes unit, I'm scrabbling around for any factors that could be causing my elevated levels some hours after my lunch or dinner. I used to try and understand by reading my copy of Think Like a Pancreas, but now it's been removed I haven't revisited it. At least I have removed one factor - alcohol , its dry January in our house 🙂
Regards,
Chris

 

[Tdm]

Are you thinking of the pizza affect...where a high fat, high carb meal digests slowly and is still raising bs when the bolus insulin has run out? The answer to that is a delayed bolus or maybe a split bolus

 

[Amity Island]

I am juggling a lot of factors that are affecting my diabetes at the moment and really trying to focus on my control.

I am interested to know what the body is doing when BS rebounds.

I have experienced rebounding from hypo territory when I've over compensated by having too many jelly babies or some fruit but am I right in thinking that BS can also go high some hours after a meal because I take too much rapid insulin with my meal? If so, is there anyway for a layman to understand why by reading up on the subject?

Regards,

Chris

There is something known as gluconeogenesis. Where fats and amino acids are converted into glucose. Some people seem to do this better than others and is problematic for diabetics.

 

[sololite]

Are you thinking of the pizza affect...where a high fat, high carb meal digests slowly and is still raising bs when the bolus insulin has run out? The answer to that is a delayed bolus or maybe a split bolus

Thanks. I certainly am on high fat. I was experimenting with split bolus a month ago but then had my annual review with the head honcho in December who didn't like the idea and said I shouldn't - doh!

 

[Tdm]

Did they give a reason?

 

[rebrascora]

Are you following a low carb way of eating? If so, then yes you will see a rise starting about 2 hours after your meal as the proteins and fats are broken down for glucose. About 40% of protein and about 10% of fat will be broken down into glucose if you don't eat enough carbs. It isn't a rebound, it is just protein (and fat) release. I have to inject a correction about 2 hours after my low carb meals to deal with this. I now just keep an eye on my Libre and inject when my levels start to drift upwards anywhere above 8, fo me and I usually need a couple of units to deal with it.

I too would be interested to know what reason the consultant gave for not splitting doses? At the end of the day, if it works for you (as it works for many people) and you are not having hypos as a result, then it is up to you to manage your diabetes to the best of your ability and if it involves splitting doses then you are entitled to do that. The important thing is not to forget that that second dose is likely still partially active when you come to your next meal and therefore not make add a correction based on your reading without factoring in that "active insulin on board".....

So if you ate a low carb breakfast (say an omelette) at 8am and jabbed a couple of units before the meal and then another couple of units at 10am for protein release, but at 12.30pm just before lunch your levels are say 8.2 then some of those 2 units you injected at 10am will still be active because it is only 2.5 hours later and most meal time insulins act over 4-5 hours so you would not give yourself a correction because you were above target before lunch, because that insulin may well still bring you down. Hope that makes sense.
Obviously if we are talking about a split dose for an evening meal then you don't have to worry about your levels at the next meal because that insulin will be long spent by breakfast. However you do have to remember that you may be going to bed with active bolus insulin in your system which if you have miscalculated, could cause a nocturnal hypo and that may be a reason for the consultant to discourage you from splitting the dose on an evening especially if you suffer from nocturnal hypos.

 

[Inka]

@sololite I’ve never heard of this particular rebound. Rebounds after hypos, yes, but if you take too much bolus for your meal, you’ll go too low, then have to have some carbs and might go a bit high later. It’s not a rebound as such.

The only other thing I’ve thought of is either injecting where the insulin is absorbed too fast, so you go low, eat, then the insulin wears off early (because it absorbed too fast) so you go high.

I also agree with @rebrascora about a no/very low carb meal and rising blood sugar a few hours later (because, in the absence of enough carbs,your body will turn the protein into glucose).

 

[sololite]

Did they give a reason?

Not really other than there should be no need. They are very stretched. The annual review is very brief, it's not their fault. I have a meeting with the dsn coming up soon. I can explore further

 

[sololite]

Are you following a low carb way of eating? If so, then yes you will see a rise starting about 2 hours after your meal as the proteins and fats are broken down for glucose. About 40% of protein and about 10% of fat will be broken down into glucose if you don't eat enough carbs. It isn't a rebound, it is just protein (and fat) release. I have to inject a correction about 2 hours after my low carb meals to deal with this. I now just keep an eye on my Libre and inject when my levels start to drift upwards anywhere above 8, fo me and I usually need a couple of units to deal with it.

I too would be interested to know what reason the consultant gave for not splitting doses? At the end of the day, if it works for you (as it works for many people) and you are not having hypos as a result, then it is up to you to manage your diabetes to the best of your ability and if it involves splitting doses then you are entitled to do that. The important thing is not to forget that that second dose is likely still partially active when you come to your next meal and therefore not make add a correction based on your reading without factoring in that "active insulin on board".....

So if you ate a low carb breakfast (say an omelette) at 8am and jabbed a couple of units before the meal and then another couple of units at 10am for protein release, but at 12.30pm just before lunch your levels are say 8.2 then some of those 2 units you injected at 10am will still be active because it is only 2.5 hours later and most meal time insulins act over 4-5 hours so you would not give yourself a correction because you were above target before lunch, because that insulin may well still bring you down. Hope that makes sense.
Obviously if we are talking about a split dose for an evening meal then you don't have to worry about your levels at the next meal because that insulin will be long spent by breakfast. However you do have to remember that you may be going to bed with active bolus insulin in your system which if you have miscalculated, could cause a nocturnal hypo and that may be a reason for the consultant to discourage you from splitting the dose on an evening especially if you suffer from nocturnal hypos.

Thanks Barbara. That sounds sensible. I never go near hypo territory so am relaxed about taking another dose before bed. If I go high during the day I can manage it with exercise. Its that night time one that worries me. Do you think if I kept my dinner to low carb that the body would still try to convert the fat and protein into glucose during the night?

 

[sololite]

@sololite I’ve never heard of this particular rebound. Rebounds after hypos, yes, but if you take too much bolus for your meal, you’ll go too low, then have to have some carbs and might go a bit high later. It’s not a rebound as such.

The only other thing I’ve thought of is either injecting where the insulin is absorbed too fast, so you go low, eat, then the insulin wears off early (because it absorbed too fast) so you go high.

I also agree with @rebrascora about a no/very low carb meal and rising blood sugar a few hours later (because, in the absence of enough carbs,your body will turn the protein into glucose).

Thanks @Inka I never get to this level of understanding with my diabetes team. I did DAFNE and things got better but I was eating very little. Since my op it's a hard time keeping weight on but of course the more I eat the more I am high. And round and round I go

 

[everydayupsanddowns]

Not really other than there should be no need. They are very stretched. The annual review is very brief, it's not their fault. I have a meeting with the dsn coming up soon. I can explore further

Well that’s a bit frustrating isn’t it!

Reminds me of the Tommy Cooper joke,
I went to my doctor and said, “It hurts when I do this” (rapidly raises one arm above his head)
He said, well don’t do it then!

It’s hardly helpful for your consultant to dismiss a strategy you are using to reduce unwanted high levels, because you “shouldn’t need to”. Because that doesn’t help with the levels you were trying to address! If splitting doses was a such terrible idea, why would be an option on all the insulin pumps!?

There are lots of factors that can cause changes in blood glucose. Too much insulin would result in low levels (so that seems unlikely to be the cause).

Low glucose (hypos) can make the liver a bit twitchy, and it might ‘help’ by dumping some of its emergency stored glucose, but the signalling can be a bit erratic and unreliable in T1, so it may be hard to spot when this is happening.

Rebound highs from overtreating hypos should be the easiest to fix (well… in theory anyway). Just by being more disciplined with things like the 10 or 15 rule (eg 15g of fast acting carbs and recheck after 15 minutes). But these days it’s prudent to recheck with fingerstick rather than sensor glucose, because sometimes the lag in sensor / interstitial glucose values can encourage you to double-treat when fingerstick levels are already recovering.

Getting the dose timing (and split) right for fatty meals (and also meals which are bigger and carbier than usual) is a bit of a long game, as it seems necessary to develop various approaches and strategies and then tweak / rethink those on an ongoing basis.

Good luck with it!

 

[Inka]

Thanks @Inka I never get to this level of understanding with my diabetes team. I did DAFNE and things got better but I was eating very little. Since my op it's a hard time keeping weight on but of course the more I eat the more I am high. And round and round I go

No problem @sololite I find when the diabetes isn’t playing ball, it helps to simplify things for a while. I do this by eating the same meals, or basically the same with variations only in the non-carb items. That way you can work and work on getting g things as right as possible for each meal, you don’t have to think too much, and you’re able to get the calories in more easily.

Before doing that, it might be a good idea to do a basal test to check that’s right. If your basal dose is wrong, it can make it harder to get everything else right and can be quite stressful.

 

[rebrascora]

Thanks Barbara. That sounds sensible. I never go near hypo territory so am relaxed about taking another dose before bed. If I go high during the day I can manage it with exercise. Its that night time one that worries me. Do you think if I kept my dinner to low carb that the body would still try to convert the fat and protein into glucose during the night?

If you are eating enough carbs then generally the body will not break down protein and fats because it can easily access the glucose from the carbs. The protein (and to a lesser extent fat) glucose release is usually only an issue if you don't eat enough carbs, generally 30-40g carbs, although I do wonder if part of the pizza effect issue is that those carbs don't release quickly enough due to the high fat content and therefore the body starts the process of breaking down protein and fat, which then releases later as well as the carbs releasing later resulting in more insulin being needed than you might expect. That is just a guess on my part as I seem to need more insulin than the protein and fat alone would suggest.

I wonder if perhaps your issue is not "a rebound" which by definition, would only happen following a low and you say that you manage to steer well clear of hypos, so your problem may simply be an issue with your basal insulin not holding you steady and therefore your levels rising through the night. Can you post a couple of daily graphs from your CGM which show the issue you are having and is it a regular issue regardless of what you eat or just an issue when you eat a high fat meal?
I agree with @Inka that keeping things similar with meals for a few days and doing some basal testing may help identify the problem more clearly.

 

[sololite]

Well that’s a bit frustrating isn’t it!

Reminds me of the Tommy Cooper joke,
I went to my doctor and said, “It hurts when I do this” (rapidly raises one arm above his head)
He said, well don’t do it then!

It’s hardly helpful for your consultant to dismiss a strategy you are using to reduce unwanted high levels, because you “shouldn’t need to”. Because that doesn’t help with the levels you were trying to address! If splitting doses was a such terrible idea, why would be an option on all the insulin pumps!?

There are lots of factors that can cause changes in blood glucose. Too much insulin would result in low levels (so that seems unlikely to be the cause).

Low glucose (hypos) can make the liver a bit twitchy, and it might ‘help’ by dumping some of its emergency stored glucose, but the signalling can be a bit erratic and unreliable in T1, so it may be hard to spot when this is happening.

Rebound highs from overtreating hypos should be the easiest to fix (well… in theory anyway). Just by being more disciplined with things like the 10 or 15 rule (eg 15g of fast acting carbs and recheck after 15 minutes). But these days it’s prudent to recheck with fingerstick rather than sensor glucose, because sometimes the lag in sensor / interstitial glucose values can encourage you to double-treat when fingerstick levels are already recovering.

Getting the dose timing (and split) right for fatty meals (and also meals which are bigger and carbier than usual) is a bit of a long game, as it seems necessary to develop various approaches and strategies and then tweak / rethink those on an ongoing basis.

Good luck with it!

Thanks Mike. I have been a bit casual with the 15 minute rule in the past but am on it now. No more kidding myself that I could dodge jelly babies by having fruit or naughties either. I am on day 2 of a weigh everything and calculate the carbs regime to see if I can improve matters. Will keep you posted. Regards, Chris

 

[sololite]

If you are eating enough carbs then generally the body will not break down protein and fats because it can easily access the glucose from the carbs. The protein (and to a lesser extent fat) glucose release is usually only an issue if you don't eat enough carbs, generally 30-40g carbs, although I do wonder if part of the pizza effect issue is that those carbs don't release quickly enough due to the high fat content and therefore the body starts the process of breaking down protein and fat, which then releases later as well as the carbs releasing later resulting in more insulin being needed than you might expect. That is just a guess on my part as I seem to need more insulin than the protein and fat alone would suggest.

I wonder if perhaps your issue is not "a rebound" which by definition, would only happen following a low and you say that you manage to steer well clear of hypos, so your problem may simply be an issue with your basal insulin not holding you steady and therefore your levels rising through the night. Can you post a couple of daily graphs from your CGM which show the issue you are having and is it a regular issue regardless of what you eat or just an issue when you eat a high fat meal?
I agree with @Inka that keeping things similar with meals for a few days and doing some basal testing may help identify the problem more clearly.

Thanks for the great advice Barbara. I don't want to sound ungrateful but you have your own diabetes to manage and I don't want you spending precious time on me. Let me follow the guidance posted here for a week and if I can't crack it will post some screenshots if I can find a repeatable pattern. Regards Chris