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The rebound debate...

Discussion in 'Parents of Children with Type 1' started by MelissaC, Mar 22, 2009.

  1. wilf

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    I agree that normally rebounds protect our kids, but ultimately it all depends on how much insulin was involved..

    If it is a bad overdose of insulin (eg. a double dose, or a bolus insulin mistakenly given in place of a basal, etc.) then the surplus insulin can overwhelm the body's ability to fight the low and you get into the more dire situation of seizures (which again have the effect of raising BG)..
     
  2. Heather(CA)

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    Very true:(
     
  3. amieelynne

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    I definitely think it has to do with the child, and how tightly you attempt to control D, in relation to how often rebounds happen---for my son they are fairly common if we don't catch a low fast enough. he doesn't treat unless he is under 80 and corrects for anything over 125 or so...also corrects at 1 hour postprandial if over 175. they also seem to take more insulin to bring them down vs. simply a high bg. for a higher number I'll increase his correction by 25% or more--but with a rebound I double the correction and he's usually back down in range within 2-3 hours.

    I had so many arguments with his endo because she kept insisting that rebounds didn't happen, that his highs must be from food or a need for more insulin. I would back off on basals a couple hours before I was seeing some super highs and the highs went away. once he started on the dexcom I was able to show her the print outs that showed alex bottoming out then spiking...once he was on the dexcom his TDD went down by a few units a day rather than up...it really is a YMMV disease

     
  4. Heather(CA)

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    Next time, try adding up all the insulin you would normally give her, then subtract 1 unit. It brings it down like a charm because it allows a little wiggle room for the body to take the glucose back:cwds:
     
    Last edited: Mar 24, 2009
  5. Ali

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    I wrote about the fast drops and rebounds. I did not mean that the rebound would not happen but that the bodies reaction to the low (glucose release, insulin resistance)would not be quick enough to prevent a severe low or you might not have enough glucose in reserve to prevent the drop or bring it back up before you are in very very bad shape. This is what I believe Wilf was talking about with the relationship of IOB to the drop and the bodies glucose and insulin resistance response to a low. I also believe there is some evidence that the longer you have had type one and the more lows you have had that the bodies response to lows is diminished. I know they believe that the external clues are less apparent but I thought I read that the actual internal responses can get hindered over time also.Ali
     
  6. Darryl

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    I understand now... it's just that I've never seen anything like it so far!

    The quick rise to 300+ sounds as scary to me as the low. Rapid changes in BG like that
    can't be good for the body, not to mention the follow-on work required to safely get the
    300+ back down.
     
  7. Mama2H

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    In over 2 years we caught 1 rebound on the cgms. Hailey was alarming and laying one her pump therefore I didn't hear the alarms (pre radio shack system) I posted the graph on here of what it looked like but it would take me FOREVER to find it now because I don't even remember what month it happened in. If anyone is bored they can search my old posts for it :eek: The next 2 or 3 days Hailey's bgs were all over the place, it was really scary for a couple of days.

    I don't care whether rebounds are "real or not" I am doing all I can to prevent ANY AND EVERY low so that the "if she kicks out glucose" worry is a non issue. Tight control is not worth brain damage from a severe and sustained low....
     
  8. Mama2H

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  9. Heather(CA)

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    I hope you didn't get the impression I was argueing, I just wasn't sure about a fast drop, but now that you and Wilf cleared it up, I TOTALLY agree:cwds:
     
  10. Nightowl

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    No Scientific Proof of Rebound

    I just noticed this thread and wanted to post a few relevant studies that are right on point. I posted these same comments on another similar thread. I think many people think their child is experiencing a "rebound" when they are actually experiencing a high glucose reading due to a lack of insulin and/or a carb spike. I think this information is important because some parents may mistakenly believe they have a buffer in the so called "rebound effect" that may provide protection for their children in the event of nocturnal hypoglycemia. There does not appear to be a rebound effect and parents should not assume that there is, regardless of what their doctors have told them and what is printed in books. There is no scientific basis for the so called "rebound theory" or Somogyi Phenomenon. This whole concept was never more than a theory or hypothesis. Dr. Somogyi based his hypothesis on his own observations that a few of his patients seemed to experience increased glycosuria after experiencing hypoglycemia. While diabetics can and do experience hyperglycemia following nocturnal hypoglycemia, this appears to occur for different reasons based on different circumstances. Importantly, there is no proof that a counter regulatory or "rebound" process is ever involved. In fact, several studies have been conducted with the specific aim of proving or disproving the rebound effect. These studies have arrived at the same conclusion - there is no scientific support for the existence of the Somogyi Phenomenon or "rebound effect."

    http://www.springerlink.com/content/...6/fulltext.pdf

    Thus the existence of the Somogyi phenomenon is
    rejected by our data, which show that mean morning blood
    glucose concentrations after hypoglycaemic nights are
    more than 5 mmol/l lower than after nights without hypoglycaemia,
    and that the risk of nocturnal hypoglycaemia
    increases progressively as morning blood glucose values
    decrease. This finding was obtained by continuous glucose
    monitoring, which enables comprehensive assessment of
    nocturnal glycaemia without interfering with daily activities
    including sleep. As such, our finding extends results
    from inpatient studies to the daily life situation. These
    earlier studies, using conventional glucose measurements
    ranging from once each night to once every hour during the
    night, reported that nocturnal hypoglycaemia was not
    followed by hyperglycaemia the following morning [2, 4]
    and, furthermore, that a high glucose value after a nocturnal
    hypoglycaemic episode was due to lack of insulin rather
    than to hormonal counterregulation [2, 4].

    http://www.ncbi.nlm.nih.gov/pubmed/6370162

    Marked hyperglycemia (greater than 220 mg/dL) after hypoglycemia results from a large meal to relieve the symptoms of hypoglycemia. Posthypoglycemic hyperglycemia correlates with falling plasma insulin levels, rather than increasing concentrations of counterregulatory hormones, whose secretion may be defective. Asymptomatic nocturnal hypoglycemia is common but subsequent fasting hyperglycemia is not necessarily the result of "rebound." More likely, fasting hyperglycemia is due to a falling predawn insulin level. Nocturnal hypoglycemia is dealt with by a readjustment in the timing and dose of insulin. The failure of the Somogyi phenomenon to occur puts insulin-dependent diabetic patients at increased risk to potential lethal consequences of nocturnal hypoglycemia.

    More recently, the non existence of the rebound theory was proven and reported in Diabetes and Metabolism in November of 2007.



    http://www.ncbi.nlm.nih.gov/pubmed/17652003

    The researchers in this study state "we did not observe the Somogyi phenomenon, but quite the opposite.
     
  11. Darryl

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    I think there may be a chicken-and-egg scenario with rebounds. The third study confirms the obvious,
    namely that if you reduce hypoglycemia using a CGMS, then you won't encounter rebounds.

    While I have never encountered a rebound with my daughter (nor any BG over 279 since starting the
    CGM 2 years ago), I can buy the concept that if BG drops so low as to create a potentially life-threatening
    situation, the body may have some response (such as a seizure, whether visible or not) that may trigger a
    glucose release from the liver.

    Regardless, we do know for certain that normal alpha-cell (glucagon) regulation is non-existent in T1D,
    and there is no 2nd line of defense until things get to a point where the body is in severe distress. Whether
    or not rebounds are "real", it sounds like they should be avoided as much as possible.
     
  12. Mama2H

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    I honestly don't care if they are real or not, my goal is to avoid bgs ever going that low. Worry less, be safer, and feel better :eek: IMHO Hailey's cgms graph shows something happening on that one night and we are lucky that her body compensated, I won't take the chance that it may not compensate the next time.
     
  13. wilf

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    Well, that's a pretty strongly worded post. This part in particular:
    "I think this information is important because some parents may mistakenly believe they have a buffer in the so called "rebound effect" that may provide protection for their children in the event of nocturnal hypoglycemia. There does not appear to be a rebound effect and parents should not assume that there is, regardless of what their doctors have told them and what is printed in books. There is no scientific basis for the so called "rebound theory" or Somogyi Phenomenon. This whole concept was never more than a theory or hypothesis."

    I think you're vastly overstating your case, based on a selective interpretation of what you've read. Here is my response to the references you've cited:


    1) Your first quote is from a reference with a bad link. All I will say is I have observed differently, and learned differently from many sources.


    2) Your second quote/link only took me to an abstract, but even the abstract concedes:
    "Posthypoglycemic hyperglycemia (Somogyi phenomenon) occurs infrequently in insulin-treated diabetic patients. When it occurs it is often in children and adolescents.."

    In case you haven't noticed, this is a part of the site dealing with children with diabetes.. :rolleyes:

    Also I'm wondering why you neglected to quote this part of the second link - perhaps because it didn't support the point you're trying so hard to make? :confused:


    3) Your third link also just went to an abstract. Again, I will say I have observed differently and learned differently from many sources.

    You're statement regarding the Abstract yet again overstates things:
    "More recently, the non existence of the rebound theory was proven and reported in Diabetes and Metabolism in November of 2007."

    This isn't how science works. A couple of studies are not enough to prove that a hypothesis is incorrect. All they do is set up a competing hypothesis.

    *****

    So where does that leave us? Numerous references describe and discuss the rebound effect, and describe the hormonal response which causes it. It is widely known and understood to occur, including by many doctors and endocrinologists. Lots of us on here have also observed rebounds, including myself (I'm a scientist by training and am well aware of how to test a hypothesis). So we have one hypothesis, namely that there is such a thing as a rebound effect which can be observed in at least some children including our own..

    Now along come you, with a lot of arm waving and 3 references (one of which didn't come up, and one of which did not support your absolutism on the topic) to advance a different hypothesis - namely that there is no such thing as a rebound effect.

    I guess we'll just have to recognize that we disagree on this issue. I will always choose to believe a hypothesis which I've observed and tested for myself, and I would advice others to do so as well..
     
  14. Darryl

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    Wilf,

    I am not taking a position one way or the other on whether rebounds happen, however
    the studies quoted by Nightowl were published in the Archives of Internal Medicine and
    Diabetes & Metabolism, and appear to be properly conducted scientific studies on multiple
    T1D individuals (81 T1D individuals in the latter study), whereas Hanas presents data on
    a single 9-year old girl, without any data on carbs or insulin relating to the observed
    "rebound".

    Can you post any scientific studies documenting the rebound effect? Hanas page 50 is not
    a scientific study, and it is interesting that he would choose such a poorly framed data point
    to make his case. Obviously the BG did go from 40 to 350, but it is not clear how much of
    that was due to carbs.
     
  15. kiwikid

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    My case study is one child only.When Rachel was dx'd I was not taught about the 'rebound' effect. I learned later on from CWD what might have happened.
    Rachel was very small - 13 or 14 months old. She had a late night up with friends staying over. I can still visualise her playing on my bed in the morning and then just sort of collapsing. I didn't get what was happening and she seemed to come around okay. 10 or so minutes later she was 'HI'. I even came to CWD (my first visit) to ask if peanuts could have caused the 'HI' :rolleyes:

    I do believe in that case it was a rebound, and I haven't seen anything since that was the same and that couldn't be attributed to overcarbing or low/missed basal etc :cwds:
     
  16. Nightowl

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    Wilf... Researchers set out to prove or disprove the very question posed by the original poster. I'm sure many people reading the thread are interested in the only research that has been conducted on this point. The research speaks for itself. I wish I could post all of the studies in full, but due to the restrictions of my access I am not allowed to. The critical point is that when researchers have sought to prove that rebound exists they could not, and they published their findings in peer reviewed journals.
     
  17. Nightowl

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  18. Heather(CA)

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    I said it once, and I will say it again...I frankly don't care what ANY study does or does not say...My son has had D for almost 6 years, he DEFIANTELY has had rebounds. No one is saying every high is a rebound, not even close, there are LOTS of reasons our kids can, and do, go high. Rebounds IS one of them. Nightowl, you never cease to amaze me...
     
  19. Heather(CA)

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    Um, did you read in that study that the mean age was 46:eek:And that most of them were women? No offence, I'm getting there myself, but I don't know too many 46 year old females that have two hour soccer practices mixed with adreneline and hormones. I wouldn't think someone of that age would have much need for rebounds. Unless they OD them then did nothing just to see what would happen? I doubt it:rolleyes: They were told to live as normal a life as poss....It's not normal that causes rebounds, and after the average 21 years of D, I would think they could count a carb :rolleyes: So no misjudgement was likely to ooccur.
    Who ever did that study knows nothing about the circumstaces in which rebounds are most likely to happen :rolleyes:
    It's not worth the paper it's written on!
     
    Last edited: Mar 26, 2009
  20. Sportsrep

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    ?the non existence of the rebound theory was proven and reported?

    Of course, you can?t actually prove a negative. All you can say is that the results of this particular study did not support the existence of the rebound theory. That is not the same as saying it does not exist.

    FWIW, I think Heather is right, based on my own experiences. I was diagnosed 17 years ago and don?t recall ever experiencing a rebound other than one caused by my stuffing my face after a bad hypo :)

    My children, however, most certainly do have rebounds, most frequently following a bout of exercise in the late afternoon, early evening.
     

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