strike the spike! strategies for combatting after-meal highs gary scheiner ms, cde
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Strike The Spike!Strike The Spike!
Strategies for Combatting Strategies for Combatting
After-Meal HighsAfter-Meal Highs
Gary Scheiner MS, CDEGary Scheiner MS, CDE
OverviewOverview
• DefinitionsDefinitions
• RisksRisks
• DetectionDetection
• ManagementManagement
After-Meal Peaks DefinedAfter-Meal Peaks Defined
The net rise that occurs The net rise that occurs from before eating to from before eating to the highest point after the highest point after eating.eating.
• ADA Goal:ADA Goal:– <180 mg/dl 1-2 hrs after start
of meal
• DCCT Goals:DCCT Goals:
– <180 mg/dl 2 hrs after meal
300 + 140
250 200 150 100
After-Meal Goals for ChildrenAfter-Meal Goals for Children• Under 5 Years:Under 5 Years:
<250 @ 1 hr. post-meal<250 @ 1 hr. post-meal(<120 pt. Rise)(<120 pt. Rise)
• 5-11 Years:5-11 Years:<225 @ 1 hr. post-meal<225 @ 1 hr. post-meal(<100 pt. Rise)(<100 pt. Rise)
• 12 Years +12 Years +< 200 @ 1 hr. post-meal< 200 @ 1 hr. post-meal(<80 pt. Rise)(<80 pt. Rise)
After-Meal Peaks: After-Meal Peaks: Reality for childrenReality for children
280291293
<200
100
150
200
250
300
Goal Breakfast Lunch Dinner
Source: Boland et al, Diabetes Care 24: 1858, 2001
After-Meal Peaks: After-Meal Peaks: Reality in ChildrenReality in Children
>30046%
241-30026%
180-24018%
<18010%
Source: Boland et al, Diabetes Care 24: 1858, 2001
After-Meal Highs:After-Meal Highs:Immediate ProblemsImmediate Problems
• TirednessTiredness
• Difficulty ConcentratingDifficulty Concentrating
• Impaired Athletic Impaired Athletic PerformancePerformance
• Decreased desire to Decreased desire to movemove
• Mood ShiftsMood Shifts
• Enhanced HungerEnhanced Hunger
Long-Term ProblemsLong-Term Problems
0%
20%
40%
60%
80%
100%
>10.29.3-10.2
8.5-9.27.3-8.4 <7.3
Post-Meal Fasting
Percent Contribution to HbA1cPercent Contribution to HbA1c
Source: Monnier et al, Diabetes Care, 26, 3/03, 881-885
Long-Term Problems (contd)Long-Term Problems (contd)
Post-prandial glucose
RangeTime to onset of
proteinuria
Persistent <200 110-198 23 yrs
Intermittent >200 118-228 19 yrs
Persistent > 200 201 + 14 yrs
52 Type 1’s, similar BP between groups
Source: Kidney Intl. 1987; 32 (supp 22): S53-S56
Long-Term Problems (contd)Long-Term Problems (contd)
0
0.5
1
1.5
adjusted for age adjusted for age, education, smoking,BMI, chol, BP, ECG
ppg <160
ppg 160-200
ppg > 200
22-yr CVD Mortality Risk by Baseline post-challenge glucose
Source: Chicago Heart Study, Lowe et al, Diabetes Care, 1997; 20: 163-170.
LongLong--Term Problems (Term Problems (contdcontd))
0%10%20%30%40%50%60%70%
ppi < 108 ppi 108-210 ppi > 210
ppg <210
ppg 210-275
ppg >275
% Progression of Diabetic Retinopathy in Type-2 Diabetes (independent of HbA1c)
Source: Osaka Univ. School of Medicine. Diabetes Care (28): 11, 2806.
LongLong--Term Problems (Term Problems (contdcontd))Proposed Mechanism of Damage
Source: Antonio Ceriello, Univ. of Udine, Italy. Diabetes 54: 1-7, 2005
Coagulation Abnormality
DNA Damage from NO
Endothelial Dysfunction
?!
Measurement of After-Meal PeaksMeasurement of After-Meal Peaks
• SMBGSMBG
– 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 ExampleMeter Test Example
Interpretation:Interpretation:
Excessive after-meal peak following breakfast; not Excessive after-meal peak following breakfast; not after lunch or dinnerafter lunch or dinner
Breakfast Lunch Dinner
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
Meter Test ExampleMeter Test Example
Time pp BG Value
Premeal 135 :20 155 :40 1681:00 2141:20 2221:40 1752:00 141
Interpretation:Interpretation:
Peak occurred at 1hr, 20min pp; rise from premeal to peak was approx. 90 mg/dl
Measurement of After-Meal PeaksMeasurement of After-Meal Peaks
• Glucowatch Glucowatch (Cygnus/Animas)(Cygnus/Animas)– Takes readings every 10
minutes, following 2-hr warmup
– Can download to computer or retrieve readings manually
– May “skip” readings during periods of rapid rise or fall
Measurement of After-Meal PeaksMeasurement of After-Meal Peaks
• CGMS (Medtronic)CGMS (Medtronic)– Worn for 72 hrs (or
more), then data is downloaded
– Meals should be entered as “events” while wearing
– Calculates 3-hr post-meal averages
CGMS Case StudyCGMS Case Study37 year old man
CGMS Case StudyCGMS Case Study
8 year old girl
CGMS Case StudiesCGMS Case Studies
12 year old boy
After-Meal Spike ReductionAfter-Meal Spike Reduction
• Lifestyle Approaches Lifestyle Approaches
• Medicinal ApproachesMedicinal Approaches
Dietary InterventionDietary Intervention• Use of Glycemic IndexUse 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
Fastest Glucose
Dextrose
Starch (branched-chain)
Sucrose/Corn Syrup
Fructose
Starch (straight-chain)
Lactose
Galactose
Slowest Sugar Alcohols
Use of Glycemic Index (contd)Use of Glycemic Index (contd)
0 hrs 1 hr 2 hrs 3 hrs 4 hrs
High GI
Med GI
Low GI
Examples: Use of GIExamples: Use of GIMeal 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
Choice of Bolus InsulinChoice of Bolus Insulin
Humalog Humalog
or Novolog or Novolog
Vs. Regular InsulinRegular Insulin
• 1-hr. peak
• 3-4 hr. effective duration
• 2-3 hr. peak
• 4-6 hr. effective duration
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4
Choice of Bolus InsulinChoice of Bolus Insulin
Timing of Bolus InsulinTiming of Bolus Insulin
-30 -15 0 15 30
Minutes from meal
OK
Low G.I.
Mod
High G.I.
High BG
Low BG
Timing of Bolus InsulinTiming 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
Does Timing Matter?Does Timing Matter?• Bolus w/meal Bolus w/meal
• Bolus pre-mealBolus pre-meal
Choice of Insulin ProgramChoice of Insulin ProgramLantus & MDILantus & MDI Vs. Daytime NPH/LenteDaytime NPH/Lente• Meal/snack boluses • Prolonged peak covers
midday meals/snacks
Bkfst
Lunc
h
Dinne
r
Bed
Bkfst
Lunch
Dinner
Bed
Injectible SymlinInjectible Symlin(Amylin Pharmaceuticals)(Amylin Pharmaceuticals)
Acts on CNS
Appetite
Slows gastric emptying
Inhibits glucagon secretion
Really flattens postprandial BGs
Injectible SymlinInjectible Symlin(Amylin Pharmaceuticals)(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 InterventionPhysical Activity Intervention
Muscle Use Soon After EatingMuscle Use Soon After Eating
Accelerated Delayed Glucose Uptake/ Insulin Absorption Digestion Utilization
Improved After-Meal ControlImproved After-Meal Control
Examples: Examples: After-Meal/Snack ActivityAfter-Meal/Snack Activity
• Walking Pets• Household Chores• Planned Exercise• Yard Work• Gym Class???
• Shooting Hoops• Dancing• Bowling• Mini Golf• Skating
Examples: Examples: After-Meal/Snack ActivityAfter-Meal/Snack Activity
““Free Time With Siblings”Free Time With Siblings”
SummarySummary
After-Meal Blood Sugar Levels Are: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: garyscheiner@prodigy.net
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