Strike The Spike!

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Strike The Spike!

• Strategies for Combatting
• After-Meal Highs
• Gary Scheiner MS, CDE

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Overview

• Definitions
• Risks
• Detection
• Management

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After-Meal Peaks Defined

• The net rise that occurs from before eating to
  the highest point after eating.
• ADA Goal
• lt180 mg/dl 1-2 hrs after start of meal
• DCCT Goals
• lt180 mg/dl 2 hrs after meal
• European Diabetes Policy Grp
• lt165 (to prevent complications)

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After-Meal Goals for Children

• Under 5 Years
• lt250 _at_ 1 hr. post-meal
• (lt120 pt. Rise)
• 5-11 Years
• lt225 _at_ 1 hr. post-meal
• (lt100 pt. Rise)
• 12 Years
• lt 200 _at_ 1 hr. post-meal
• (lt80 pt. Rise)

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After-Meal Peaks Reality for children
Source Boland et al, Diabetes Care 24 1858,
2001
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After-Meal Peaks Reality in Children
Source Boland et al, Diabetes Care 24 1858,
2001
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After-Meal HighsImmediate Problems

• Tiredness
• Difficulty Concentrating
• Impaired Athletic Performance
• Decreased desire to move
• Mood Shifts
• Enhanced Hunger

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Long-Term Problems
Relative Influence on HbA1c
Source Monnier et al, Diabetes Care, 26, 3/03,
881-885
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Long-Term Problems (contd)
52 Type 1s, similar BP between groups
Post-prandial glucose Range Time to onset of proteinuria
Persistent lt200 110-198 23 yrs
Intermittent gt200 118-228 19 yrs
Persistent gt 200 201 14 yrs
Source Kidney Intl. 1987 32 (supp 22) S53-S56
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Long-Term Problems (contd)
22-yr CVD Mortality Risk by Baseline
post-challenge glucose
Source Chicago Heart Study, Lowe et al,
Diabetes Care, 1997 20 163-170.
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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

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Meter Test Example
Brea kfast Lun ch Din ner
Pre 1h Post Pre 1h Post Pre 1h Post
117 281 157 166 191 204
90 302 58 247 89 147
151 264 77 152 235 222
Interpretation Excessive after-meal peak
following breakfast not after lunch or dinner
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Meter Test Example

• Time pp BG Value
• Premeal 135
• 20 155
• 40 168
• 100 214
• 120 222
• 140 175
• 200 141

Interpretation Peak occurred at 1hr, 20min pp
rise from premeal to peak was approx. 90 mg/dl
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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

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Measurement of After-Meal Peaks

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

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CGMS Case Study
37 year old man
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CGMS Case Study
8 year old girl
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CGMS Case Studies
12 year old boy
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After-Meal Spike Reduction

• Lifestyle Approaches
• Medicinal Approaches

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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)

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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.

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Glycemic Index (contd)
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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
• Type of sugar/starch affects GI

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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
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Examples Use of GI
? ?
Meal High-GI Options Low-GI Options
Breakfast Cereal, Bagel, Waffle, Pancakes, Muffins Oatmeal, Milk, Whole Fruit
Lunch White Bread, Fries, Tortillas, Cupcake Sourdough/Pumpernickel, Yogurt, Corn, Carrots
Snacks Pretzels, Chips, Crackers, Doughnuts Fruit, Popcorn, Nuts, Ice Cream, Chocolate
Dinner Rice, Mashed or Baked Potatoes, Rolls Pasta, Peas, Beans, Sweet Potato, Salad Veggies
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Choice of Bolus Insulin
Humalog Novolog or Apidra Vs. Regular Insulin
1-hr. peak 3-4 hr. effective duration 2-3 hr. peak 4-6 hr. effective duration
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Timing of Bolus Insulin
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Timing of Bolus Insulin
(humalog/novolog)
High GI Moderate GI Low GI
BG Above Target Range 30-40 min. prior 15-20 min. prior 0-5 min. prior
BG Within Target Range 15-20 min. prior 0-5 min. prior 15-20 min. after
BG Below Target Range 0-5 min. prior 15-20 min. after 30-40 min. after
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Does Timing Matter?
Note Carbs estimated w/pre-meal insulin.
Carbs known with post-meal insulin. Source
Clinical Therapeutics 2004 261492-7.
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Does Timing Matter?

• Bolus w/meal
• Bolus pre-meal

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Choice of Insulin Program
Lantus MDI Vs. Daytime NPH/Lente
Meal/snack boluses Prolonged peak covers midday meals/snacks
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Injectible Symlin(Amylin Pharmaceuticals)

• Acts on CNS
• ? Appetite
• Slows gastric emptying
• Inhibits glucagon secretion
• Really flattens postprandial BGs

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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???

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Physical Activity Intervention
Muscle Use Soon After Eating Accelerated
Delayed Glucose Uptake/ Insulin
Absorption Digestion
Utilization Improved After-Meal Control
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Examples After-Meal/Snack Activity

• Walking Pets
• Household Chores
• Planned Exercise
• Yard Work
• Gym Class???

• Shooting Hoops
• Dancing
• Bowling
• Mini Golf
• Skating

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Examples After-Meal/Snack Activity
Free Time With Siblings
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Summary

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

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For More Information

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