- advertisement -

Does this look like Somogyi?

Discussion in 'Parents of Children with Type 1' started by Theo's dad Joe, Jan 21, 2016.

  1. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802

    I don't have time for this. One of the fundamental disfunctions of T1D is that alpha cells release excessive glucagon in response to eating, largely due to reflexes in intestinal cells that usually stimulate insulin and glucagon in balance in non T1Ds, but it T1Ds there is no insulin to match.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2453684/

    A major reason people take synthetic amylin is that it blocks the disfunctional glucagon release that develops in T1Ds over the first 4-5 years. Also T1Ds alpha cells start to lose their ability to release glucagon to alleviate hypoglycemia.


    There have been studies showing that eating large volumes of lettuce can trigger a reflexive release of glucagon that raises blood sugar significantly (up to 100 points) despite fewer than 10 grams of carbs.
     
    Last edited: Jan 21, 2016
  2. forHisglory

    forHisglory Approved members

    Joined:
    Jan 26, 2015
    Messages:
    382
    The hour after he goes to bed...that same exact thing happens to us. In fact, we started giving carbs for it, then he would go high 2 hours later and we were in a vicious cycle.

    None of my children can eat 4 hours before bed and last. They eat at 5:30, small snack again with protein at 8:00 and then wake at 7:00. It would be so much easier to feed them earlier but they wouldn't make it. My children are all 7 and under though. And actually, what you mention about a high carb dinner holds true. A high carb dinner usually leads to higher numbers upon waking (pancakes or pasta). The pancreas can't seem to keep up with a high carb insult as much.

    I'm not sure how you can definitively describe clearing a late dinner bump as endogenous insulin production though. If it helps you make sense of things, great. But there's really no way to know if the pancreas is helping at that exact moment or if it's x,y,z.
     
  3. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802
    Yes they are almost always zero. He is not eating a very low carb ketogenic diet. That is around 10% carbs and also low protein. Even protein will block ketosis as it is turned into glucose. Again these are all subjects I studied "in the field."
     
    Last edited: Jan 21, 2016
  4. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802
    I was saying that maybe the bump is clearing because the body's supply of gh, cortisol and glucagon get used up and so you just become more sensitive to basal after the bump because the counter regulatories have been depleted for a time.
     
  5. forHisglory

    forHisglory Approved members

    Joined:
    Jan 26, 2015
    Messages:
    382
    I have to agree. This is correct. Amylin is a peptide hormone that is cosecreted with insulin from the pancreatic beta-cell and is thus deficient in diabetic people. It inhibits glucagon secretion, delays gastric emptying, and acts as a satiety agent.

    Honestly none of us have time for this. But it spurs one to learn and dig. At least while waiting for the snowpocalypse to hit.
     
  6. mmgirls

    mmgirls Approved members

    Joined:
    Nov 28, 2008
    Messages:
    6,030
    well then you are in one fantastic honeymoon. I would expect (and saw ketones in my dd over 2 years in advance and myself when not eating) it IS a normal fasting experience. I bid you goodwill and am checking out of this thread as I can not help.
     
  7. rgcainmd

    rgcainmd Approved members

    Joined:
    Feb 6, 2014
    Messages:
    1,374
    This is exactly what "basal testing" is all about! It's a rather complicated and time-consuming process and a bit of a pain in the butt, but the purpose of basal testing is to check whether your particular basal rate during a pre-determined span of time (the span of time during which you are utilizing that particular basal rate) is maintaining a steady BG level.

    http://mysugr.com/basal-rate-testing/

    Gary Scheiner also covers basal testing quite well in Think Like a Pancreas.

    You're missing the point. The definition of a "correct" basal rate (whether provided by a long-acting insulin injected once or twice daily or by a fast-acting insulin "trickled" in gradually via an insulin pump) is one that maintains a steady BG level when the BG level is between about 80 and 180. The purpose of basal insulin is not to correct high or low BG levels (unless you are pumping and you utilize a higher temp basal rate to "help out" a correction), but to maintain a steady BG level once a desired BG level is achieved after a correction (or "correction bolus" as many refer to them) is given to correct a high BG or after carbs are consumed to correct a low BG. Considering you are neither an endocrinologist nor a CDE, I find your questioning Gary Scheiner arrogant and presumptuous.
     
    Last edited: Jan 22, 2016
  8. forHisglory

    forHisglory Approved members

    Joined:
    Jan 26, 2015
    Messages:
    382
    Our ENDO has said from Day 1 that our son is "very sensitive" to insulin. We were not discussing his ISF. He made a blanket statement about his overall response to insulin, which is that micro corrections affect him more than the typical patients he has seen. So, even by endos the term sensitive is used in conjunction to a response and the meaning is that he has very little resistance to insulin and responds promptly to doses overall. Those are great specific definitions when making treatment decisions and outcomes, but it's not the only way sensitivity is described in the T1D world.
     
  9. Nancy in VA

    Nancy in VA Approved members

    Joined:
    Jul 16, 2007
    Messages:
    7,308
    I haven't read the entire thread, so I apologize if this is a repeat.

    Understand that for some people, Lantus just doesn't work. It's a "flat" insulin, meaning it supposedly works to keep a diabetic flat if they ate nothing.
    But people's body chemistry's aren't flat.

    We struggled with Lantus for 6 months after Emma was diagnosed. We worked with a really smart CDE and I'm a statistician and a numbers person who is great at identifying numbers trends and the reality was just that EMMA NEEDED A VARIABLE BASAL AND LANTUS COULDN'T DO THAT!

    She actually threw up her hands and said we could try Levemir and work with overlapping, or just get her on a pump faster.

    We seriously have had some times of day in her basal profile where she gets 10x more than other times of day. Yes, that means we have a time of day where she gets 1.0 of basal during an hour and other times she get .1 units. No way Lantus can do that!
     
  10. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802

    I know that the purpose of basal according to modern pumping practice is to keep you flat. My question is whether this is basically a practical guideline or whether the body will actually tend to stay flat with a certain basal insulin whether blood sugar is at 80 or 180. Regarding Gary Scheiner, I know he is describing flat basal and basal testing properly, but where did those concepts arise from? I am not questioning his description at all. I have talked to two researchers at different diabetes research clinics who think that flat basal was created for practical purposes for pumping, but that in reality a basal that keeps you flat at 100 may lead to a slow rise trend in a blood sugar of 70 and a slow drop trend (4+ hours) in someone at 180 because other mechanisms are involved in regulation like the rate that the liver removes insulin and also the fact that there are simply more glucose molecules to remove from the blood at 170 than 70 and so more glucose to remove (as long as resistance doesn't occur). I am asking why the concept originated that a certain level of insulin will actually keep you flat whether you are at 70 or 170.
     
  11. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802
    Your body burns fat mostly by beta oxidation and then puts it into the same cycle that it used to get energy from carbs. Beta oxidation IN MUSCLES doesn't yield ketones and the body gets better and better at it when fat content rises (to a point).

    When the liver needs to do beta oxidation (when insulin levels are very low) then ketones are the by product. You can get starvation ketones produced by the liver but since muscles burn 85%+ fat on a 30% carb diet, they are not robbing blood glucose that is needed by the brain and so the liver will usually have enough glycogen to get through the night.

    You have about 1 gram of liver glycogen per pound of bodyweight and the brain and glucose dependent tissues use about 3-5 grams an hour, so part of the key is that muscles burn more and more fat and store it "on site" rather than having to bring it in from adipose cells when the carb content of the diet goes down below about 35%.
     
    Last edited: Jan 22, 2016
  12. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802
    Also by the way, after dx my son could not consistently eat enough carbs to gain weight. They made him feel bad because they had made him feel sick for quite some time prior to dx. I was trying to get him to force down about 160 grams a day and it was only adding up to about 1200 calories which is below what he needed.

    I HAD to up the fat content, and it got him to about 1600 cals with 100-130 grams of carbs and he went UP on the growth chart for the first time in his life, and actually made about 2 years of growth this year.

    Also, he tells me that he likes his meals and doesn't want to try any changes.

    Also Joslin DC has been actively promoting a 30% carb diet for type 1 diabetes control for the last 3-4 years. Also it is the way I have eaten for the last 4-5 years and improved my health.

    The body burns at least 70% fat (often 80-90%) during normal daily activity even if you eat 70% carbs, so what are the implications of that? Now people will burn carbs faster if they eat a higher percentage, but with T1D that just makes them use up their muscle glycogen faster during activity. They will store more muscle glycogen, but because glycogen is bound to water, muscles can store 10x more energy from a volume of fat than from a volume of glycogen, and that is what happens. At about 30% carbs, 50%+ fat, muscles start to store more fat inside and around them rather than simply having the body put it into adipose cells (using insulin) and holding it there (with more basal insulin) and then NOT begin able to access it during activity because injected insulin blocks fat mobilization from adipose cells during times of high activity. When the fat is stored in the muscle insulin does not block the muscle from accessing it.

    ANYWAY, I really didn't want this to be a nutrition thread, but just one about how to manage insulin.
     
    Last edited: Jan 22, 2016
  13. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802
    I think that makes sense. I have talked with T1Ds who tell me for example that they have to go to bed at 65 so they don't wake up over 180, or they have to be over 150 or take x amount of carbs 4 hours after dinner or they will be in the 50s when they are most sensitive in their case around midnight.

    The strategy at my son's clinic is ideally to give enough night time Lantus that the drop is between 0-60 points over night, and then compensate for daytime issues with adjusted carb ratios and corrections, and sometimes corrections after dinner when it is wearing off.

    Another problem we have is that my son's Lantus needs are fluctuating as the honeymoon is passing.
     
  14. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802
    I wanted to add that my Son's endo also believes that the liver learns to dispose of insulin faster or slower at different times of the day depending on insulin needs, so she feels that it takes at least 3 days for a Lantus change to smooth out and for the liver to learn the new pattern. She mentioned that some people will overeact to a low or high, say they will be low with a 12:1 carb ratio one day so they will go to 14:1, then they will be high because the liver remembers that blood sugar was lower yesterday at that time and so it disposes of insulin faster. (basically she doesn't recommend changing carb ratios on a day to day basis, OK OK I get it but her explanation was interesting).
     
  15. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802
    I did some looking into this. My son's clinic recommends that he gets his dinner bolus at least 3 hours before bed, and then a check and snack at that point if under 130. The recommended amount of sleep for child his age (6-13) is 9-11 hours. If I achieve both of those, he would have dinner 12 to 14+ hours before breakfast (if he ate the second he was out of bed).

    I also wanted to add this continuing bizarre dinner trend. Here he bolused at 12:1 at 4:15 pm and waited 15 minutes to eat. It wasn't anything odd, a hot dog (no bun) but a piece of toast, ice cream bar, about 3 ounces of berries, green peppers and tomatoes, and reduced carb milk. 48 grams with 4.0 units.

    He started at 129, and stayed under 129 (but over 75) for almost 3 hours, not even starting to rise until an hour after eating. Then at the 4 hour point he had slowly drifted up to 140. If I reduce even half a unit he ends up 40 points higher at the 4 hour mark, though he is still below pre prandial numbers at the 1 hour mark. He also is dropping below pre prandial with no prebolus for breakfast and lunch (though fingerstick had him over 70 with dexcom rising), but if I reduce the dose he ends up 150-180 at the 3 hour mark and stays there. Then a half unit correction has him back at 100 in 90 minutes or less!

    I included some other dinners where he went up out of range late with less insulin (14 to 1). Edit I checked and all three of those were pizza, but only 1 or 2 slices.
     

    Attached Files:

    Last edited: Jan 23, 2016
  16. rgcainmd

    rgcainmd Approved members

    Joined:
    Feb 6, 2014
    Messages:
    1,374
    My daughter's clinic (and sites on the internet, books, diabetes "gurus", etc.) recommend a whole lot of things that if I followed would lead my daughter, and I suspect a whole lot of other children with Type 1, to do one (or more) of the following:

    1. Run too high
    2. Run too low
    3. Have no energy
    4. Feel sick
    5. Be miserable
    6. Resent diabetes even more
    7. Rebel against to the detriment of their health
    8. Have an A1c over 7.5

    I fervently believe that it's best to just listen, and then decide to do what works best for ones own child, regardless of what the "experts" say you should do.
     
  17. Michelle'sMom

    Michelle'sMom Approved members

    Joined:
    Aug 21, 2009
    Messages:
    1,432
    I wholeheartedly agree with this. Management is definitely more art than science.
     
  18. Theo's dad Joe

    Theo's dad Joe Approved members

    Joined:
    Jun 7, 2015
    Messages:
    802
    I don't disagree with this. My son eat breakfast between 7:00 and 8:00 and usually lunch between 11:00 and 12:00 and usually dinner between 4:30 and 5:00 and he basically chose that, and has declined snacks in the evening because he is not hungry. I am just saying that there is no reason to push dinner into the later pm closer to bedtime if he is fine with it earlier-that standard practice does not say that there is anything medically or nutritionally wrong with a 9 year old eating a slow digesting dinner early and sleeping for 9+ hours at night. It is medically/healthfully appropriate. If it didn't work for him or when it stops working we'll do it differently.

    But once again I am asking for practical advice here. Looking at my son's post dinner blood sugar curve, is there a way to manage it? If he ate dinner at 7:00 and went to bed at 9:00 he'd be 75, but not even having had his blood sugar rise yet from dinner. Does anyone have any way to explain the kind of dinner time pattern I am seeing regardless of the makeup of the meal? It is pre-pubescent hormones at 7:30 and I am over bolusing him for dinner, but seeing the hormone bump at part of the meal?
     
    Last edited: Jan 23, 2016
  19. mmgirls

    mmgirls Approved members

    Joined:
    Nov 28, 2008
    Messages:
    6,030
    Are you actually giving a snack if under 130?

    Most things I have read about figuring out if it is a basal or bolus issue tells me a rise after 3 hours is a basal issue, yet you continue to mess with bolus regarding the a rise at 4 hours. You are doing so much work trying to figure out this but your son's body is too, all on its own. I commend you for trying to see the trees in the forest, but I wonder what toll it is taking on enjoying life food n family? it seems to me that you are using advanced tools yet are living a very regimented life around when the last bolus was and when the next meal is. But maybe your family was already structured like that and I am reading too much into it.
     
  20. rgcainmd

    rgcainmd Approved members

    Joined:
    Feb 6, 2014
    Messages:
    1,374
    The point that so many have tried to make is that you are managing your son's post-dinner blood sugar curve. What exactly are you hoping for or expecting? Something considerably better than what you already have? Because if you are, your expectations are not realistic in light of the fact that your son is likely having irregular and unpredictable releases of endogenous insulin. And because, despite how you'd like it to be, T1D does not play by the rules and, frequently and unfortunately, there is no logical scientific explanation for the spikes and drops and things that go bump in the diabetes night. Once again, if your tracings generally look like what you post, your expectations for "better" are not reasonable. You are trying to fix something that just ain't broke. And I pity what you will be like once the honeymoon is completely over and you no longer have even the sputterings of a handful of dying islet cells to use as an explanation for things that don't follow the rules. Additionally, your question has been answered multiple times. For example, mmgirls has pointed out that it looks like a basal insulin issue (which I tend to agree with). But you keep asking the same question ad infinitum because no one's answers fit your rigid "pure science" paradigm.

    What I find annoying is that, at least in my opinion, you repeatedly post what I consider to be "non-problems", ask for advice, then disagree with most of what people have to offer, and then use their responses as a platform for spouting how much you think you know. If you clearly know so very much and disagree with most everything everyone has to say, then why continue asking questions here?
     

Share This Page

- advertisement -

  1. This site uses cookies to help personalise content, tailor your experience and to keep you logged in if you register.
    By continuing to use this site, you are consenting to our use of cookies.
    Dismiss Notice