# Lingering highs



## Simbul (Apr 2, 2016)

This is one of those ideas I've formed from anecdotal evidence so I'm curious to hear what you think about it.

The theory (or what my consultant said last time) is that correcting a high (with a bolus wizard in my case) should bring BG down to the target value in about 4 hours.
However, I've seen time and again that my high readings tend to linger. For example, I'll eat out and end up with a 15 or 16. Despite correcting, my BG will stay in the 10-12 range for far longer than 4 hours; sometimes even half a day.

Has anyone experienced something similar?


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## Pumper_Sue (Apr 2, 2016)

Simbul said:


> Has anyone experienced something similar?


What are you eating to get numbers like that? If the food is of high fat or protein content then perhaps consider splitting your bolus or doing an extended bolus.
Do you also remember to add an extra percentage for bloods over 12 as insulin resistance tends to kick in with high blood sugars.


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## Simbul (Apr 3, 2016)

I think its mostly high-fat food. Any restaurant tends to be higher in fat than what I eat at home, but let's say Indian as an example. That tends to wreak havoc on my BG pretty regularly 

Can you elaborate on insulin resistance above 12? Do you mean my insulin sensitivity ratio should be lower the higher my BG is?
Won't that put me at risk of dropping too low once BG gets under 12 and my insulin resistance is back to normal?


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## Pumper_Sue (Apr 3, 2016)

If over 12 most people find they need higher correction levels to combat the higher numbers, so you need to experiment to see how much extra you need, obviously the higher you are the higher the resistance. No it wont put you at risk of dropping lower.




Simbul said:


> Any restaurant tends to be higher in fat than what I eat at home, but let's say Indian as an example. That tends to wreak havoc on my BG pretty regularly


Hate to tell you this but that's just basic insulin mismanagement if you are going high and staying high after high fat meals. So you need to look into splitting and or extending your bolus for those meals, then you wont have such a problem.
Perhaps look in your pump manual for guidance or invest in the book pumping insulin


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## Robin (Apr 3, 2016)

Pumper_Sue said:


> If over 12 most people find they need higher correction levels to combat the higher numbers, so you need to experiment to see how much extra you need, obviously the higher you are the higher the resistance. No it wont put you at risk of dropping lower


Problem is, Sue, we are all different. I need to adjust my correction ratio downwards, not upwards, if I'm very high, because I need less insulin to sort it. I think this is because my kidneys swing into action and remove some of the glucose for me, like they do before diagnosis.


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## SB2015 (Apr 3, 2016)

Simbul said:


> higher in fat than what I eat at home, but let's say Indian as an example. That tends to wreak havoc on my BG pretty regularly



Hi Simbul, you are not alone in finding that restaurant meals play havoc with BGs. Indian meal is the worst culprit for me, so I limit myself to grills and sneak a tiny bit of my husband's yummy stuff. 

As others have said, if you are eating food that is high in fat, you may find that you need to use the extended bolus for that.  When on injections I used to try to split my injection but then regularly forgot the second part, so it was just worse.  However now on a pump there is the facility for the multiwave and extended bolus.  A Robin said we are all different, so the only way of working out how long you need to extend the delivery is from your own experience.  



Simbul said:


> Can you elaborate on insulin resistance above 12? Do you mean my insulin sensitivity ratio should be lower the higher my BG is?
> Won't that put me at risk of dropping too low once BG gets under 12 and my insulin resistance is back to normal?



I am not sure which pump you are using, but on my Combo I have a 'health'  setting which I can use to increase or decrease a specific bolus.  I have one set at each of +20%, +50%, -20% and -50%.  If my BG is above 12 I use the +20% setting to increase the bolus. This seems to work and does not result in a hypo later.
 I have only come to these figures from trial and improvement.


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## Simbul (Apr 3, 2016)

That's very interesting. I'm using a MiniMed 640G and I can configure insulin sensitivity based on time of day but not based on BG levels. I'll play around with that a bit by increasing my correction manually and see what happens. Given my values seem to be staying high it's more likely that I'm under-correcting rather than the opposite, but I'll keep your warning in mind @Robin.

As for extending my bolus, I'm usually doing that, though I may not be doing enough of it. I've managed to get my BG under control about 2-4 hours after a meal, but then I get these spikes hours and hours after I've stopped eating (6 to 8 or even 10 hours, if at night). Has anyone else experienced something of that sort?


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## SB2015 (Apr 3, 2016)

Simbul said:


> As for extending my bolus, I'm usually doing that, though I may not be doing enough of it. I've managed to get my BG under control about 2-4 hours after a meal, but then I get these spikes hours and hours after I've stopped eating (6 to 8 or even 10 hours, if at night). Has anyone else experienced something of that sort?



If you BG is rising well after the meals it sounds as if it may be your basal rates that need adjusting. Have you done a fasting basal rate test recently.  Once you have your basal rates sorted you can start to adjust your ratios. I will try to find TrophyWench's post with a link about basal rate testing made easy and flag it up for you.


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## SB2015 (Apr 3, 2016)

Here's a link for basal testing, which will hopefully clear up the myths for anyone starting on their pump journey 
http://diatribe.org/issues/13/learning-curve
Plus this might help as well.
http://diatribe.org/issues/26/thinking-like-a-pancreas

This was not TW but from pumper sue, and is pinned to the top of the pumping thread.


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## Simbul (Apr 3, 2016)

Thanks @SB2015. My BG is usually fine after my usual meals. It's restaurant food that wreaks havoc on it, which makes me think there's something wrong with the bolus rather than the basal.

However, it has been a while since my last fasting test, so taking your advice will to me good. The links you posted are going to be helpful: thanks 


I also found this little tidbit in the first article:


You may not take in any calories for at least 4 hours preceding the basal test.

The meal/snack preceding the basal test should be low in fat (no restaurant food or take-out; these tend to take much longer to finish digesting).
Back to my original question, I think we can infer from the above that restaurant food is supposed to take longer than 4 hours to digest.


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## SB2015 (Apr 3, 2016)

Their 4 hour period is to ensure that the last dose of insulin given for carbs is cleared. The low fat meal is to ensure that the carbs from the food you ate four hours earlier has completely cleared the system.  So when you start the fasting test you have no active insulin and no carbs mucking up the readings.  

I treated myself to if push cakes and chips last time I went out for lunch!!! Not a good idea as I went up to 16.
If I am being sensible I just have a salad which has identifiable bits in for which I can count the carbs, and no greasy fatty sauces.  However I am not always sensible.


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## Simbul (Apr 3, 2016)

SB2015 said:


> The low fat meal is to ensure that the carbs from the food you ate four hours earlier has completely cleared the system. So when you start the fasting test you have no active insulin and no carbs mucking up the readings.



True. In addition, you can infer from those statements that high-fat food can still raise your BG after more than 4 hours, which I wasn't aware of.

As people were pointing out in another thread, we can't really be sensible all the time. Sure it would be nice to never waver, but we're all human after all and sometimes we have to have our fishcakes and chips and our Indian food


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## Pumper_Sue (Apr 4, 2016)

Simbul said:


> True. In addition, you can infer from those statements that high-fat food can still raise your BG after more than 4 hours, which I wasn't aware of.



If on the rare occasion I have gluten free fish and chips at 5.30 pm, my bloods start to rise at about 4 AM the following morning so I learnt a long time ago if I do have f&c  then I change my basal to +30% for 4 hours for that night to start at 2 AM. Thus problem solved.


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## everydayupsanddowns (Apr 4, 2016)

The ghee in Indian food usually massively delays the carbs for me - much more than for other high-fat meals. I would generally do a combo/dual wave bolus over several hours to cover the evening and in addition set a square wave bolus for several hours overnight based on my experience of how much my levels usually rise after going to sleep.

I also have to over-estimate the insulin:carbs by quite some way (say dose for 80-100g CHO but only aim to eat around 60-70) which is possibly just my own estimation-errors of food on plate/carb values of the stuff we normally eat. If I think I'm eating 'correctly' for the dose I almost always end up above range.

I just practiced/recorded/kept notes a fair few times until I worked out a system that generally worked for me and Indian takeaways. Some 'scientific research' is easier to struggle through than others


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## Simbul (Apr 4, 2016)

Good to know it's a common issue. So far I've used dual wave + an increased basal to cover the night, but I've been very tentative about it and results have not been significant. I'll go at it a bit more forcefully next time I have to wrangle Indian food


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## Sally71 (Apr 4, 2016)

Sometimes you have to be brave! You can always stop boluses/change settings back if you overdo it by mistake.  My daughter's BGs shot up to 13 and wouldn't come down again today, no idea why as she had not eaten or done anything unusual.  Correction dose with her lunch had no noticeable effect.  Perhaps I need to adjust her insulin sensitivity; I shall be watching that over the next few days.  In the end I did an extra correction mid afternoon and stuck her on a +20% temp basal for a couple of hours and that did the job!

It might just be that it's school holidays, I find it almost impossible to keep her stable then as no two days are the same


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## SB2015 (Apr 4, 2016)

Pumper_Sue said:


> If on the rare occasion I have gluten free fish and chips at 5.30 pm, my bloods start to rise at about 4 AM the following morning so I learnt a long time ago if I do have f&c  then I change my basal to +30% for 4 hours for that night to start at 2 AM. Thus problem solved.



What pump are you on Sue.  I am not aware on the Combo of a way of delaying the TBR for a period of time.


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## Pumper_Sue (Apr 5, 2016)

SB2015 said:


> What pump are you on Sue.  I am not aware on the Combo of a way of delaying the TBR for a period of time.


I have the Animas vibe and all you do is change the basal percentage before you go to bed and change it back in the morning. As they say there are ways and means


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## SB2015 (Apr 5, 2016)

Pumper_Sue said:


> I have the Animas vibe and all you do is change the basal percentage before you go to bed and change it back in the morning. As they say there are ways and means



I can set the TBR to go through the whole night, but have no way of delaying its start.


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## everydayupsanddowns (Apr 5, 2016)

SB2015 said:


> I can set the TBR to go through the whole night, but have no way of delaying its start.


Yes I've often thought that would be handy too.


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## Pumper_Sue (Apr 5, 2016)

SB2015 said:


> I can set the TBR to go through the whole night, but have no way of delaying its start.


As I stated above all I do is change the basal rate. You can do this on any pump as you do it when basal testing and adjusting basals so it's the same principle. You know that eating fatty foods raises your blood sugar at x hour after eating so increase the basal 2 hours before that and experiment with the length of time it's needed for as obviously everyone is different.

Just remember to change the basal back in the morning.


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## Annette (Apr 5, 2016)

Pumper_Sue said:


> As I stated above all I do is change the basal rate. You can do this on any pump as you do it when basal testing and adjusting basals so it's the same principle. You know that eating fatty foods raises your blood sugar at x hour after eating so increase the basal 2 hours before that and experiment with the length of time it's needed for as obviously everyone is different.
> 
> Just remember to change the basal back in the morning.


The point is that, if you go high say 6 hours after a certain meal, you need to change your basal 4 hours after, but you go to bed 3 hours after, so you have to set an alarm to wake up and change your basal.
Fine if you dont go to bed before the 4 hours are up, but otherwise, delayed start tbrs would be useful! (All numbers taken at random btw)


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## Pumper_Sue (Apr 5, 2016)

Annette Anderson said:


> The point is that, if you go high say 6 hours after a certain meal, you need to change your basal 4 hours after, but you go to bed 3 hours after, so you have to set an alarm to wake up and change your basal.
> Fine if you dont go to bed before the 4 hours are up, but otherwise, delayed start tbrs would be useful! (All numbers taken at random btw)



No you don't.
When you go to bed just change the basal setting on your pump so instead of say a basal of 0.70 @ 2am just change it over to 0.91 (example)
It's called using your pump and brain to the best advantage 
You don't wake up every hour to change or set your basals through the night do you, so why is eating fatty food an exception? Just change the setting before you go to bed. Problem solved.


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## everydayupsanddowns (Apr 5, 2016)

TBH I just start a square wave bolus when I go to bed for those particularly difficult meals where I expect a reasonably predictable 'x' mmol/L rise overnight. I find that much easier to estimate than basal rate increases or having a specific basal pattern for an occasional takeaway (mostly because my basal seems to change up/down/shape about once a fortnight so I'd always be setting up the overnight pattern from scratch which is a bit too much faff). This is fine for me because the rises tend to happen more or less constantly through the night. If I continued to dip/was level for a few hours overnight and *then* began to rise I guess I'd just make the ad-hoc basal pattern tweak. But I am pretty sure I'd forget to set it back again some days and get myself in trouble the following night. 

That's the main reason I prefer temporary apporaches to temporary situations. Changing my actual basal pattern for a one-off event just doesn't fit so well with a meal-specific event in my head


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## Pumper_Sue (Apr 5, 2016)

everydayupsanddowns said:


> That's the main reason I prefer temporary apporaches to temporary situations. Changing my actual basal pattern for a one-off event just doesn't fit so well with a meal-specific event in my head


I just leave a note on top of my clothes to remind me to change it back. So much simpler and more accurate the way I do it.


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## Annette (Apr 5, 2016)

everydayupsanddowns said:


> That's the main reason I prefer temporary apporaches to temporary situations. Changing my actual basal pattern for a one-off event just doesn't fit so well with a meal-specific event in my head


Exactly my feelings. I hadnt even considered making a 'permanent ' change to my basal then remembering to reverse that change next day (chance of remembering : slim) perhaps because it introduces a level of risk to the situation that Im not happy with (ie, forgetting and having a major hypo next night). But thats me.


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## Annette (Apr 5, 2016)

Pumper_Sue said:


> I just leave a note on top of my clothes to remind me to change it back. So much simpler and more accurate the way I do it.


Notes go misteriously missing in my household I'm afraid. And I would actually say its not simpler your way (if using a combo)-far more button presses!
Each to their own.


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## Simbul (Apr 10, 2016)

Hi all.
I have a bit of a mystery on my hands and seeing as it has to do with the original subject of this discussion, I thought I'd post it to ask for your opinion 

Here's the timeline:

At _16:45_ my BG was *4.2* and I was feeling the low particularly strongly. I corrected with the usual glucose tablets, but unfortunately I went a bit overboard and also had a 45g nut bar (13.5g of carbs, about half of those sugars). I was ready for some weird BG later on, but I couldn't imagine what would actually happen
At _17:30_ I realised I overcorrected (and I was feeling fine), so I set up a *0.6u* square wave for 1h
At _18:45_ I changed my infusion set
At _19:30_ I tested my BG again. Guess what, it was now *13.8*. I had a correction bolus of *1.5u*: since my insulin sensitivity is 3.5, it should have brought me down to 8.5 or thereabouts

At _20:45_ I had dinner: usual stuff, tried and true carb counting, with a bolus of *4.8u*
At _23:00_, to my dismay, my BG was still *12.8*. This is the main mystery: almost 4 hours after the correction bolus, why had it not gone down? I had a minimal bolus correction of *0.2u* at this point, as most of the dinner insulin was still around
I woke up suddenly at _6:30_ the next morning with a BG of *4.3*
So my BG went down, then shot up, then down again. I can see how it would have followed that pattern given my sugary overload in the afternoon, but I can't quite explain why the swing was so pronounced. And the nighttime low is also a bit unclear.
It's almost as if my bolus correction at 19:30 had decided to take effect 8 to 12 hours later.

Any ideas?


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## SB2015 (Apr 10, 2016)

Although you knew the carbs for your meal, I wonder whether the content was slow release, or if there was a higher fat content to the meal which would again slow the release of the glucose from the food that you ate.  

3. Did you remember to prime the cannula when you changed your infusion set?  I have forgotten to do that before now (too often)

4. You may need more insulin when You are high than the normal correction.  If I am above 12 then I add in an extra correction over and above the suggested amount.  The higher I am the more I add in.  I have these set up on my combo as Stress (+20%) and illness (+50%).  I have worked these out for me by trial and improvement.  You would need to work out if this applies to you and how much you would need.

6. Your correction would not have completed its job when you ate your meal.  You mention that your carbs were correct, but it wonder what the glycaemic index was .  If it was low GI it would release the carbs slowly, as it would if there was a high fat content.  So that could account for the high later in the evening.

I hope that that lot makes some sense.  Do you have easy access to a DSN?  It would be worth getting them to look at your readings with you.  They sometimes spot patterns that we don't see ourselves.  apart from that just keep asking.


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## Annette (Apr 11, 2016)

SB2015 said:


> Your correction would not have completed its job when you ate your meal.


Just to add to this point - it may be (it is for me), if you add carbs to an already high bg, as in this case, your insulin resistance could be temporarily higher (which is why you need more correction dose for higher bgs than slightly high bgs, as in point 4), so your carb ratio may have been correct for a normal situation, but not for an abnormal one (as this was).


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## Simbul (Apr 12, 2016)

Those are some interesting points.
I'm pretty sure the cannula was primed correctly and my dinner was not especially high-fat or low-GI.

I've definitely not accounted for the extra insulin needed in my correction. I remember we talked about it in another thread but it'll take me a while to get used to doing it: my bolus wizard has definitely spoiled me from that point of view 
I also think you may be onto something with insulin resistance: I've noticed before that eating when my BG is high tends to perpetuate the high even though carb counting would suggest otherwise.

One doubt I have is to do with the low in the night / morning: if I had had a bigger correction or a bigger bolus for dinner, wouldn't that have made my BG even lower in the morning?


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## SB2015 (Apr 12, 2016)

Simbul said:


> One doubt I have is to do with the low in the night / morning: if I had had a bigger correction or a bigger bolus for dinner, wouldn't that have made my BG even lower in the morning?


If your resistance is higher with the higher BG the insulin will get 'used up' doing its job at those higher BGs.  (Not exactly a medical description but I hope that it makes sense).  

Could you delay your meal when you are high.  Go for a bit of a premeal walk to get things down before you start eating. If you test about half an hour before your meal you could then delay the readiness of the food. And start to look at delivering your insulin before your meal.  The higher I am the earlier I deliver my I insulin

With regard to the overnight lows, could you eat earlier, say at least four hours before you go to bed, so that the insulin has done its job before you go to bed.  If you are particularly worried you could set an alarm to test during the night.


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## Simbul (Apr 12, 2016)

Yeah, waiting before eating is a good point: I'll have to start doing that more. Thanks


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