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Strike The Spike!. Strategies for Combatting After-Meal Highs Gary Scheiner MS, CDE. Overview. Definitions Risks Detection Management. 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:

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strike the spike

Strike The Spike!

Strategies for Combatting

After-Meal Highs

Gary Scheiner MS, CDE

overview
Overview
  • Definitions
  • Risks
  • Detection
  • Management
after meal peaks defined
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.

after meal goals for children
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)

after meal peaks reality for children
After-Meal Peaks: Reality for children

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

after meal peaks reality in children
After-Meal Peaks: Reality in Children

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

after meal highs immediate problems
After-Meal Highs:Immediate Problems
  • Tiredness
  • Difficulty Concentrating
  • Impaired Athletic Performance
  • Decreased desire to move
  • Mood Shifts
  • Enhanced Hunger
after meal highs immediate problems8
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

long term problems
Long-Term Problems

Relative Influence on HbA1c

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

long term problems contd
Long-Term Problems (contd)

52 Type 1’s, similar BP between groups

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

long term problems contd11
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.

measurement of after meal peaks
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
Meter Test Example

Interpretation:

Excessive after-meal peak following breakfast; not after lunch or dinner

meter test example16
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

measurement of after meal peaks17
Measurement of After-Meal Peaks
  • iPro CGM (Medtronic)
    • Worn for 72 hrs, then data is downloaded for analysis
measurement of after meal peaks18
Measurement of After-Meal Peaks
  • Real-Time Continuous Glucose Monitors
    • Allow tracking of post-meal trends
    • Produce BG estimates every 1-5 minutes
cgms case study
CGMS Case Study

37 year old man

cgms case study20
CGMS Case Study

8 year old girl

cgms case studies
CGMS Case Studies

12 year old boy

after meal spike reduction
After-Meal Spike Reduction
  • Lifestyle Approaches
  • Medicinal Approaches
glycemic index
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
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.
glycemic index contd26
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
adding acidity to the meal
Adding Acidity to the Meal
  • ↓ 1-Hour BG rise by 55%
    • Vinegar/dressing
    • Tomatoes
    • Sourdough

(Journal of the American Dietetic Association, 07/12/2005)

split the meal
Split The Meal

 Part at the usual mealtime

 Part 60-90 minutes later

timing of bolus insulin33
Timing of Bolus Insulin

(humalog/novolog)

does timing matter
Does Timing Matter?

Note: Carbs estimated w/pre-meal insulin.

Carbs known with post-meal insulin.

Source: Clinical Therapeutics 2004; 26:1492-7.

does timing matter35
Does Timing Matter?
  • Bolus w/meal
  • Bolus pre-meal
injectible symlin amylin pharmaceuticals
Injectible Symlin(Amylin Pharmaceuticals)

Acts on CNS

  •  Appetite
  • Slows gastric emptying
  • Inhibits glucagon secretion

Really flattens postprandial BGs

injectible symlin amylin pharmaceuticals38
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???

effect of pramlintide on gastric emptying in type 1 diabetes

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

pramlintide reduces postprandial glucagon

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

pramlintide reduces caloric intake in type 2 diabetes
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

pre meal hypoglycemia
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 !

physical activity intervention
Physical Activity Intervention

Muscle Use Soon After Eating

Accelerated Delayed Glucose Uptake/

Insulin Absorption Digestion 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
examples after meal snack activity45
Examples: After-Meal/Snack Activity

“Free Time With Siblings”

summary
Summary
  • After-Meal Blood Sugar Levels Are:
          • Important to Control
          • Measurable
          • Manageable
for more information

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