Strike The Spike!

Strategies for Combatting After-Meal Highs

Gary Scheiner MS, CDE

Overview
Definitions Risks Detection Management

After-Meal Peaks Defined

The net rise that occurs from before eating to the highest point after eating.
300 + 140 250 200 150 100

ADA Goal:
<180 mg/dl 1-2 hrs after start of meal

DCCT Goals:
<180 mg/dl 2 hrs after meal

European Diabetes Policy Grp:

<165 (to prevent complications)

After-Meal Goals for Children

Under 5 Years:
<250 @ 1 hr. post-meal (<120 pt. Rise)

5-11 Years:
<225 @ 1 hr. post-meal (<100 pt. Rise)

12 Years +
< 200 @ 1 hr. post-meal (<80 pt. Rise)

After-Meal Peaks: Reality for children

300 250 200 150 100
Goal Breakfast Lunch Dinner

293

291

280

<200

Source: Boland et al, Diabetes Care 24: 1858, 2001

After-Meal Peaks: Reality in Children

<180 10% 180-240 18%

>300 46%

241-300 26%

Source: Boland et al, Diabetes Care 24: 1858, 2001

 Tiredness

After-Meal Highs: Immediate Problems

Difficulty Concentrating

Impaired Athletic Performance

Decreased desire to move Mood Shifts Enhanced Hunger

Long-Term Problems
Relative Influence on HbA1c
Post-Meal Fasting
80% 70% 60% 50% 40% 30% 20% 10% 0%
3 <7. -8 7.3 .4 -9 8.5 .2 0.2 1 9.3 >10 .2

Source: Monnier et al, Diabetes Care, 26, 3/03, 881-885

Long-Term Problems (contd)

52 Type 1s, similar BP between groups

Post-prandial glucose

Range

Time to onset of proteinuria

Persistent <200 Intermittent >200

Persistent > 200

110-198 118-228
201 +

23 yrs 19 yrs 14 yrs

Source: Kidney Intl. 1987; 32 (supp 22): S53-S56

Long-Term Problems (contd)

22-yr CVD Mortality Risk by Baseline post-challenge glucose
1.5

ppg <160 ppg 160-200 ppg > 200

0.5

0
adjusted for age adjusted for age, education, smoking, BMI, chol, BP, ECG

Source: Chicago Heart Study, Lowe et al, Diabetes Care, 1997; 20: 163-170.

Long-Term Problems (contd)

% Progression of Diabetic Retinopathy in Type-2 Diabetes (independent of HbA1c)

70% 60% 50% 40% 30% 20% 10% 0%

ppi < 108 ppi 108-210 ppi > 210

ppg >275 ppg 210-275 ppg <210

Source: Osaka Univ. School of Medicine. Diabetes Care (28): 11, 2806.

Long-Term Problems (contd)

Proposed Mechanism of Damage

Coagulation Abnormality DNA Damage from NO Endothelial Dysfunction

?!
Source: Antonio Ceriello, Univ. of Udine, Italy. Diabetes 54: 1-7, 2005

Measurement of After-Meal Peaks

SMBG Capillary (finger) test After completion of meal Check BG 1 Hr PP (or) every 15, 20 or 30 min until 2 consecutive BG drops occur No addl. Food/insulin until test is completed

Meter Test Example

Breakfast Pre 1h Post 117 281 90 302 151 264 Interpretation: Excessive after-meal peak following breakfast; not after lunch or dinner Lunch Pre 1h Post 157 166 58 247 77 152 Dinner Pre 1h Post 191 204 89 147 235 222

Meter Test Example

Time pp Premeal :20 :40 1:00 1:20 1:40 2:00 BG Value 135 155 168 214 222 175 141 Interpretation:
Peak occurred at 1hr, 20min pp; rise from premeal to peak was approx. 90 mg/dl

Measurement of After-Meal Peaks

CGMS (Medtronic)
Worn for 72 hrs (or more), then data is downloaded Meals should be entered as events while wearing Calculates 1 & 3-hr post-meal averages

Measurement of After-Meal Peaks

Real-Time Continuous Glucose Monitors
Allow tracking of postmeal trends Produce BG estimates every 5 minutes

CGMS Case Study

37 year old man

CGMS Case Study

8 year old girl

CGMS Case Studies

12 year old boy

After-Meal Spike Reduction

Lifestyle Approaches Medicinal Approaches

Glycemic Index
All carbs (except fiber) convert to blood glucose eventually G.I. Reflects the magnitude of blood glucose rise for the first 2 hours following ingestion

G.I. Number is % or rise relative to pure glucose (100% of glucose is in bloodstream within 2 hours)

Glycemic Index (contd.)

Example:

Spaghetti
GI = 37 Only 37% of spaghettis carbs turn into blood glucose in the first 2 hours. The rest will convert to blood glucose over the next several hours.

Glycemic Index (contd)

High GI Med GI Low GI

0 hrs

1 hr

2 hrs

3 hrs

4 hrs

Glycemic Index (contd)

Use of Glycemic Index
Lower GI foods digest & convert to glucose more slowly High-fiber slower than low Hi-fat slower than low Solids slower than liquids Cold foods slower than hot Slowest Type of sugar/starch affects GI
Fastest
Glucose Dextrose Starch (branched-chain) Sucrose/Corn Syrup Fructose Starch (straight-chain) Lactose Galactose Sugar Alcohols

Glycemic Index (contd.)

Slow Stuff Average Stuff Fast Stuff

Pasta Legumes Salad Veggies Dairy Chocolate

Fruit Juice Pizza Soup Cake

Breads/Crackers Salty Snacks Potatoes Rice Cereals Sugary Candies

Examples: Use of GI
Meal Breakfast High-GI Options
Cereal, Bagel, Waffle, Pancakes, Muffins White Bread, Fries, Tortillas, Cupcake Pretzels, Chips, Crackers, Doughnuts

Low-GI Options
Oatmeal, Milk, Whole Fruit Sourdough/Pumpernickel, Yogurt, Corn, Carrots Fruit, Popcorn, Nuts, Ice Cream, Chocolate

Lunch
Snacks

Dinner

Rice, Mashed or Baked Potatoes, Rolls

Pasta, Peas, Beans, Sweet Potato, Salad Veggies

Choice of Bolus Insulin

Humalog Novolog or Apidra
1-hr. peak 3-4 hr. effective duration

Vs. Regular Insulin

2-3 hr. peak 4-6 hr. effective duration

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

Timing of Bolus Insulin

Low BG OK High BG Low G.I. Mod High G.I. -30 -15 0 Minutes from meal 15 30

Timing of Bolus Insulin

(humalog/novolog)
High GI
BG Above Target Range BG Within Target Range BG Below Target Range

Moderate GI

Low GI

30-40 min. prior

15-20 min. prior

0-5 min. prior

15-20 min. prior

0-5 min. prior

15-20 min. after

0-5 min. prior

15-20 min. after

30-40 min. after

Does Timing Matter?

200 150 Pre-Meal Insulin Post-Meal Insulin

100

50

2-hrs

Note: Carbs estimated w/pre-meal insulin. Carbs known with post-meal insulin.
Source: Clinical Therapeutics 2004; 26:1492-7.

3-hrs

4 hrs

1-hr

Does Timing Matter?

Bolus w/meal

Bolus pre-meal

Choice of Insulin Program

Lantus & MDI
Meal/snack boluses

Vs. Daytime NPH/Lente

Prolonged peak covers midday meals/snacks

D in n e r

Lunc h

D in n er

B k fs t

L u n ch

B k fs t

Bed

B ed

Injectible Symlin
(Amylin Pharmaceuticals)
Acts on CNS
Appetite Slows gastric emptying Inhibits glucagon secretion Really flattens postprandial BGs

Injectible Symlin
(Amylin Pharmaceuticals)
Issues
Nausea
Must be injected*, cannot mix w/insulin Insulin doses must be adjusted, delayed Not yet FDA approved for children * pumped???

Physical Activity Intervention

Muscle Use Soon After Eating

Accelerated Insulin Absorption

Delayed Digestion

Glucose Uptake/ Utilization

Improved After-Meal Control

Examples: After-Meal/Snack Activity

Walking Pets Household Chores Planned Exercise Yard Work Gym Class??? Shooting Hoops Dancing Bowling Mini Golf Skating

Examples: After-Meal/Snack Activity

Free Time With Siblings

Summary
After-Meal Blood Sugar Levels Are:
Important to Control
Measurable Manageable

For More Information:

Gary Scheiner MS, CDE Integrated Diabetes Services 877-735-3648 (877-SELF-MGT) Website: www.integrateddiabetes.com E-mail: gary@integrateddiabetes.com