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Strike The Spike!

Strike The Spike!

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Strike The Spike!

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  1. Strike The Spike! Strategies for Combatting After-Meal Highs Gary Scheiner MS, CDE

  2. Overview • Definitions • Risks • Detection • Management

  3. After-Meal Peaks Defined • ADA Goal: <10 mmol 1-2 hrs after start of meal • AACE Target: <7.8 mmol at peak • European Diabetes Policy Group: <9 mmol (to prevent complications) • International Diabetes Federation: < 7.8 mmol 2 hrs after meal The net rise that occurs from before eating to the highest point after eating.

  4. After-Meal Goals for Children • Under 5 Years: <14 @ 1 hr. post-meal (<6.7 mmol Rise) • 5-11 Years: <12.5 @ 1 hr. post-meal (<5.5 mmol Rise) • 12 Years + < 11 @ 1 hr. post-meal (<4.4 mmol Rise)

  5. After-Meal Peaks: Reality for children Source: Boland et al, Diabetes Care 24: 1858, 2001

  6. After-Meal Peaks: Reality in Children Source: Boland et al, Diabetes Care 24: 1858, 2001

  7. After-Meal Highs:Immediate Problems • Tiredness • Difficulty Concentrating • Impaired Athletic Performance • Decreased desire to move • Mood Shifts • Enhanced Hunger

  8. After-Meal Highs:Immediate Problems Australian Study of Children w/Type 1. Parents & children reported BG > 15 had negative impact on: • Thinking (68%) • Mood/Emotions (75%) • Coordination (53%) J Pediatr Endocrinol Metab. 2006 Jul;19(7); 927-36

  9. Long-Term Problems Relative Influence on HbA1c Source: Monnier et al, Diabetes Care, 26, 3/03, 881-885

  10. Long-Term Problems (contd) 52 Type 1’s, similar BP between groups Source: Kidney Intl. 1987; 32 (supp 22): S53-S56

  11. 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.

  12. 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

  13. Meter Test Example Interpretation: Excessive after-meal peak following breakfast; not after lunch or dinner

  14. Meter Test Example Time ppBG Value Premeal 6.8 :20 6.9 :40 8.2 1:00 11.3 1:20 11.7 1:40 10.4 2:00 9.9 Interpretation: Peak occurred at 1hr, 20min pp; rise from premeal to peak was approx. 5 mmol

  15. Measurement of After-Meal Peaks • iPro CGM (Medtronic) • Worn for 72 hrs, then data is downloaded for analysis

  16. Measurement of After-Meal Peaks • Real-Time Continuous Glucose Monitors • Allow tracking of post-meal trends • Produce BG estimates every 1-5 minutes

  17. CGMS Case Study 37 year old man

  18. CGMS Case Study 8 year old girl

  19. CGMS Case Studies 12 year old boy

  20. After-Meal Spike Reduction • Lifestyle Approaches • Medicinal Approaches

  21. 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)

  22. Glycemic Index (contd.) Example: Spaghetti GI = 37 • Only 37% of spaghetti’s carbs turn into blood glucose in the first 2 hours. • The rest will convert to blood glucose over the next several hours.

  23. Glycemic Index (contd)

  24. 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

  25. Glycemic Index (contd.)

  26.   Examples: Use of GI

  27. Adding Acidity to the Meal • ↓ 1-Hour BG rise by 55% • Vinegar/dressing • Tomatoes • Sourdough (Journal of the American Dietetic Association, 07/12/2005)

  28. Split The Meal  Part at the usual mealtime  Part 60-90 minutes later

  29. Choice of Bolus Insulin

  30. Timing of Bolus Insulin

  31. Timing of Bolus Insulin (humalog/novolog)

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

  33. Does Timing Matter? • Bolus w/meal • Bolus pre-meal

  34. Choice of Insulin Program

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

  36. 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???

  37. Insulin + Placebo Insulin + Pramlintide Effect of Pramlintide on Gastric Emptying in Type 1 Diabetes Breakfast 4 * ~1-h delay * 3 MeanHalf-Emptying Time (h) 2 1 0 Placebo 30 µg 60 µg Single SC pramlintide doses: n = 11, crossover; *P<0.004; 99m Tc labelled pancake; solid component measuredData from Kong MF, et al. Diabetologia 1998; 41:577-583

  38. Placebo or 100 µg/h pramlintide infusion 0 1 2 3 4 5 Pramlintide Reduces Postprandial Glucagon Type 2 Diabetes, Late Stage Type 1 Diabetes Placebo Pramlintide • Insulin • Insulin • Sustacal® 30 • Sustacal® 60 20 50 10 Plasma Glucagon (pg/mL)  Plasma Glucagon (pg/mL) 0 40 -10 Placebo or 25 µg/h pramlintide infusion 30 -20 0 1 2 3 4 5 Time (h) Time (h) Type 2 diabetes, n = 12; AUC1-4 h: P = 0.005 Type 1 diabetes, n = 9; AUC1-5 h: P<0.001; Data from: Fineman M, et al. Metabolism 2002; 51:636-641; Fineman M, et al. Horm Metab Res 2002; 34:504-508

  39. Pramlintide Reduces Caloric Intake in Type 2 Diabetes 1250 -202 kcal (-23%) P <0.01 Placebo Pramlintide 1000 750 CHO Ad-Libitum Caloric Intake (kcal) CHO 500 Fat Fat 250 Protein Protein 0 n = 11; subjects given buffet meal Pramlintide (single SC injection, 120 g)Data from Chapman I, et al. Diabetologia 2005; 48:838-848

  40. Pre-Meal Hypoglycemia “Sieve Effect” Accelerates gastric emptying of liquids and solids Produces more rapid BG rise after meal J Clin Endo Metab 2005; 90: 4489-95 A v o i d P r e – M e a l L o w s !

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

  42. Walking Pets Household Chores Planned Exercise Yard Work Gym Class??? Shooting Hoops Dancing Bowling Mini Golf Skating Examples: After-Meal/Snack Activity

  43. Examples: After-Meal/Snack Activity “Free Time With Siblings”

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

  45. 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