WLS hypo advice for Type 1

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Ricketty Girl

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Hi everyone

I’m due to be having gastric bypass surgery soon (I’m down for a Roux-en-Y), but I’m really anxious about managing hypos and I wondered if any other Type 1’s have experience or advice they could share? My main concerns are:

1. On the pre-op liver diet, is there a way to stabilise a hypo without breaking the diet? (long acting carbs after sugar tablets??)
2. Post-op, how do you stabilise a hypo if your stomach capacity is the size of an egg and you can’t have carbs (esp in the first few weeks of liquids only)?
3. Dumping syndrome sounds horrible and I’ll be doing my best to avoid it, but does it make you hypo too? Should I need to be thinking of a different type of WLS?

I’ve asked my diabetes team about this stuff but they’d nothing to offer other than telling me to reduce my insulin by 40-50% and that “it’ll be fine”... It’s a scary enough procedure without worrying about hypos too, and I’ll be glad of any help, please!
 
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Ricketty Girl said:
Hi everyone

I’m due to be having gastric bypass surgery soon (I’m down for a Roux-en-Y), but I’m really anxious about managing hypos and I wondered if any other Type 1’s have experience or advice they could share? My main concerns are:

1. On the pre-op liver diet, is there a way to stabilise a hypo without breaking the diet? (long acting carbs after sugar tablets??)
2. Post-op, how do you stabilise a hypo if your stomach capacity is the size of an egg and you can’t have carbs (esp in the first few weeks of liquids only)?
3. Dumping syndrome sounds horrible and I’ll be doing my best to avoid it, but does it make you hypo too? Should I need to be thinking of a different type of WLS?

I’ve asked my diabetes team about this stuff but they’d nothing to offer other than telling me to reduce my insulin by 40-50% and that “it’ll be fine”... It’s a scary enough procedure without worrying about hypos too, and I’ll be glad of any help, please!
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Welcome to the forum, I can't help but it sounds as if your diabetic team aren't all that supportive, Is that because they are not in favour of your proposed surgery.
What insulin do you take and do you have a Libre or similar.. I expect there will need to be a lot of adjustment and it will be a learning process.
I think there may be someone here who has had that surgery but I think they may be Type 2, I will rack my brains to see if I can find who they are.
@Sarahp had surgery quite a while ago but is Type 2 but may be able to help with general queries.
 
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Thank you for your message, and you’re right about my diabetes team- it’s not because they’ve got an opinion about the surgery tbh, they’re just pretty useless.

I use levemir 12 units twice daily, and novorapid pre-meal, usually 20-24 units depending on what I’m eating. I’ve got a libre and my control’s usually pretty good but with insulin resistance due to my weight it’s not always easy... also, I live alone, so there won’t be anyone close by to keep an eye on me, which is adding to my anxiety (recently separated and now I realise that none of my family or friends are local enough to support me- I’ll be re-locating back to the other end of the country once this is done!)

I’ve just found Sarahp’s thread now (this is all new to me), so thanks again lovely Dragonfly!
 
These sound like questions for the medical team you’ve been working with to agree on the surgery. I assume there’s a tier 4 team that you’ve had preparation appointments with and will have follow up with after?

Would glucose gels or fruit juice work for bringing glucose levels up? Maybe milk for slow carbs when only on liquids? You’re unlikely to be bolusing too much if you’re not having any carbs though, so reducing your basal further to stop the hypos would seem the best action?
 
It does sound like a tricky balancing act @Ricketty Girl

One thing you’d really want to do is make sure your basal is set right. And then keep re-adjusting it as your weight reduces. That should mean any dips in BG levels are easier to treat, and may not need follow-up carbs?

Dextro tabs might be a good option for treatment too - not a lot of extra ‘padding’ just the glucose you need.

BG levels sometimes run high during illness, or recovery from surgery, so with reduced doses you may find your indidence of hypos is reduced anyway?
 
Thanks for getting back to me Lucy- if by tier 4 you mean the hospital team then yes, and this is the same team that was so useless I gave up on them years ago to return to my GP diabetes team. All I’ve had is a quick call and when I asked the doctor about managing hypos, he only told me to reduce my insulin as a prevention and that I’d be fine. I understand that prevention is better than cure, but we all know how unpredictable our sugars can be, especially at times of stress and lifestyle change.

I’ve always got glucose tablets to hand, it’s the long acting carbs to stabilise me afterwards that I’m worried about, as I don’t want to break my diet before surgery, and I’m worried that just an egg cup full of milk won’t be enough post-op either... I’ve read that diabetics have a fairly high post-op readmission rate with hypos, and I live alone so there’s no one to keep an eye out for me (I manage this fine normally, it’s just the surgery...)

You’ve made a good point about minimising the boluses, thanks, and maybe I just need to live with running my numbers a bit higher at times rather than putting myself at risk... anyway, thanks again for posting, much appreciated!
 
I never need follow up carbs and usually just one or two JBs treat a hypo for me but I adjust my Levemir quire regularly to ensure that it is keeping me level, so I think that is something to give attention to before the surgery although I would expect your basal needs to rise during and after the surgery due to stress and inflammation, so I think it unlikely that you will have too many problems with hypos.

It might be helpful and perhaps reassuring to know that the glucose from fast acting carbs absorb quickest through the cells inside your mouth so if you use a liquid hypo treatment, swill it around inside your mouth well before swallowing it and if you use solid hypo treatment like jelly Babies or glucose tablets, then chew them thoroughly.

Wishing you lots of luck with your surgery.
 
Thanks @everydayupsanddowns, I’m thinking that the basals might be the key- I’ve never tried managing a hypo without follow up carbs but you’re right, maybe the drops won’t be significant enough to need them... well, watch this space, I can only try!
 
Thanks rebrascora/ Barbara (Is this the same person? I’m so digitally illiterate, apologies!) You’re a very friendly bunch! 🙂
 
Interesting that you are on 12 units of Levemir am and pm. Have you done any basal testing to confirm that you need the same amount during the day and night. Many of us need less at night although I am sure there are some people who need the same and some no doubt who need more at night and less during the day. .My day/night requirement are quite extreme in that I need 22 units in the morning as soon as I wake up (and before I get out of bed) but only 0-5 units on a night depending upon how active I have been during the day and the previous days. If I have been pretty active for 3 days on the trot I am down to 0 but if I have a couple of more sedentary days it needs to go back up. I am very prone to nocturnal hypos even sometimes with no evening Levemir, so being able to adjust it on a day by day basis is really important to me. I love my Levemir for how flexible it is and how easily you can adjust it for your own body's needs.

I too mostly live alone, so I can sympathise with concerns about hypos but generally I a very confident dealing with them and they are usually pretty minor only requiring 5-10g carbs total probably because I adjust my basal doses to counteract exercise etc.
 
Ricketty Girl said:
I’ve read that diabetics have a fairly high post-op readmission rate with hypos, and I live alone so there’s no one to keep an eye out for me (I manage this fine normally, it’s just the surgery...)
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Yeah I’ve read diabetics have high admission rates after weight loss surgery with either DKA from the low carb intake combined with recovery from surgery, or with severe hypos. So I would really keep on at the hospital bariatric surgery team to give you a plan for treating things whilst also being on top of your basal yourself.
 
Do your threads want combining so you can keep track of replies better?
 
Lucyr said:
Do your threads want combining so you can keep track of replies better?
Click to expand...
I’ve never ‘posted’ before except through a letterbox Lucy, so I’ve got no idea how to do it! I went on 2 threads because my questions are pretty specific and I didn’t think I’d get such a good response- if it’s simple enough and you can tell me how, I might give it a go?
 
rebrascora said:
Interesting that you are on 12 units of Levemir am and pm. Have you done any basal testing to confirm that you need the same amount during the day and night. Many of us need less at night although I am sure there are some people who need the same and some no doubt who need more at night and less during the day. .My day/night requirement are quite extreme in that I need 22 units in the morning as soon as I wake up (and before I get out of bed) but only 0-5 units on a night depending upon how active I have been during the day and the previous days. If I have been pretty active for 3 days on the trot I am down to 0 but if I have a couple of more sedentary days it needs to go back up. I am very prone to nocturnal hypos even sometimes with no evening Levemir, so being able to adjust it on a day by day basis is really important to me. I love my Levemir for how flexible it is and how easily you can adjust it for your own body's needs.

I too mostly live alone, so I can sympathise with concerns about hypos but generally I a very confident dealing with them and they are usually pretty minor only requiring 5-10g carbs total probably because I adjust my basal doses to counteract exercise etc.
Click to expand...
Sounds like you’ve got it pretty sussed, I’m impressed! Yep, I’m happy with my levemir too, I halved my daily dose and switched to twice daily because I was getting dose failure before 24hrs was up... it’s usually the boluses that bring on the hypos for me, carb counting is unreliable because of insulin resistance from my weight, and I’m pretty sensitive to any variation in activity, heat, stress etc... I’ve always been heavy but till arthritis got the better of me I was running up to 10k (albeit with tortoises passing me by!)- now I get breathless just walking slowly from my car to the office (no stairs), and I seem to hypo pretty easily when I’m out and about, maybe shopping or visiting somewhere - with stage 3 renal failure and retinopathy, I’m really hoping that this surgery makes a difference to my control and I can get my life back!
 
Lucyr said:
Yeah I’ve read diabetics have high admission rates after weight loss surgery with either DKA from the low carb intake combined with recovery from surgery, or with severe hypos. So I would really keep on at the hospital bariatric surgery team to give you a plan for treating things whilst also being on top of your basal yourself.
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Thanks Lucy, will do! 🙂
 
Ricketty Girl said:
I’ve never ‘posted’ before except through a letterbox Lucy, so I’ve got no idea how to do it! I went on 2 threads because my questions are pretty specific and I didn’t think I’d get such a good response- if it’s simple enough and you can tell me how, I might give it a go?
Click to expand...

Don’t worry @Ricketty Girl

I’ve merged your threads together to keep your replies in one place 🙂
 
Leadinglights said:
Welcome to the forum, I can't help but it sounds as if your diabetic team aren't all that supportive, Is that because they are not in favour of your proposed surgery.
What insulin do you take and do you have a Libre or similar.. I expect there will need to be a lot of adjustment and it will be a learning process.
I think there may be someone here who has had that surgery but I think they may be Type 2, I will rack my brains to see if I can find who they are.
@Sarahp had surgery quite a while ago but is Type 2 but may be able to help with general queries.
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Hi @Leadinglights yes am type 2 and surgery was in 2014 but have been on insulin since my operation for a few months due to my GI complications, will try and help where I can! Thank you for the introduction!
 
Ricketty Girl said:
Hi everyone

I’m due to be having gastric bypass surgery soon (I’m down for a Roux-en-Y), but I’m really anxious about managing hypos and I wondered if any other Type 1’s have experience or advice they could share? My main concerns are:

1. On the pre-op liver diet, is there a way to stabilise a hypo without breaking the diet? (long acting carbs after sugar tablets??)
2. Post-op, how do you stabilise a hypo if your stomach capacity is the size of an egg and you can’t have carbs (esp in the first few weeks of liquids only)?
3. Dumping syndrome sounds horrible and I’ll be doing my best to avoid it, but does it make you hypo too? Should I need to be thinking of a different type of WLS?

I’ve asked my diabetes team about this stuff but they’d nothing to offer other than telling me to reduce my insulin by 40-50% and that “it’ll be fine”... It’s a scary enough procedure without worrying about hypos too, and I’ll be glad of any help, please!
Click to expand...
Hi @Ricketty Girl
I will try and help though obviously am type 2 and started insulin after my op .
So 1. Hypo treatments for me are glucose tabs, they do not contain fat, the pre-op diet is about controlling the fat in your liver so carbs are t a issue so long as they aren’t containing fat but you should have a specific plan from your WLS team, have you a date for surgery yet? I went into hypos during my pre-op diet and had to tweak my meds at the time and was allowed extra food but this had to be agreed by the team, it was made clear not to add anything without consulting them.
2. Stabilisation a hypo, I can’t answer this from a point of view of a type 1 but I ate very carefully post op as I was scared of dumping as my type 2 meds did give me hypos so I had small amounts of low fat custard, about a egg cup full was as much as I could manage at first or two to three ice cubs of puréed food once allowed solids (4- 5 weeks) and the custard was week 3-4. Any more and I would bring food back up or not manage my fluids and I started to have kidney pain, I never could have fluid at meals, everything had to be separate. Again a specialist Dietican should be advising you on this.
3. Dumping syndrome , this makes me hypo even now, I dump still when I have glucose tabs, I am ok with OJ but anything with glucose, sweets, fizzy drinks or meds or fat makes me dump, usually within 10-20 mins, it’s the best deterant ever for staying on plan, again a specialist Dietican should be helping you.
If you can’t get access to a Dietican through your diabetes team then ask your WLS link for a referral, your type 1 needs are very specific and different to others going through the surgery in your WLS group.
More than happy to chat and try and support, WLS I believe saved my life but I had complications post op due to other conditions so I am more than happy to support anyone to get answers from their team.
 
Ricketty Girl said:
Thanks for getting back to me Lucy- if by tier 4 you mean the hospital team then yes, and this is the same team that was so useless I gave up on them years ago to return to my GP diabetes team. All I’ve had is a quick call and when I asked the doctor about managing hypos, he only told me to reduce my insulin as a prevention and that I’d be fine. I understand that prevention is better than cure, but we all know how unpredictable our sugars can be, especially at times of stress and lifestyle change.

I’ve always got glucose tablets to hand, it’s the long acting carbs to stabilise me afterwards that I’m worried about, as I don’t want to break my diet before surgery, and I’m worried that just an egg cup full of milk won’t be enough post-op either... I’ve read that diabetics have a fairly high post-op readmission rate with hypos, and I live alone so there’s no one to keep an eye out for me (I manage this fine normally, it’s just the surgery...)

You’ve made a good point about minimising the boluses, thanks, and maybe I just need to live with running my numbers a bit higher at times rather than putting myself at risk... anyway, thanks again for posting, much appreciated!
Click to expand...
Just wanted to add as I had the same procedure that the fluids phase post op is clear fluids and milk or oh would not be recommended post op normally. Can you ask your GP to refer you to a different dietitian?
 
Thank you so much for getting in touch Sarah, your post is really helpful- you know, I’ve been given diet sheets but I’ve not had a 1:1 with a dietitian that I can remember (though I’ve got health related memory issues, so maybe I’m missing something…) - at any rate, there’s a dietitian in the WLS service that might be more helpful than the diabetes team, so I’ll get in touch with them to make a plan. Those dumping hypos sound like a barrel of fun- well done you for getting through all this, and starting on insulin too at the same time, I take my hat off to you… can I ask, how long did it take for you to get into your stride again? Are you seeing results and has your QOL improved enough that make it worthwhile? It’s just such an enormous commitment!
 
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