Transcript of Strike The Spike! Strategies for Combatting After-Meal Highs Gary Scheiner MS, CDE.
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- Strike The Spike! Strategies for Combatting After-Meal Highs
Gary Scheiner MS, CDE
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- Overview DefinitionsDefinitions RisksRisks DetectionDetection
ManagementManagement
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- After-Meal Peaks Defined ADA Goal:ADA Goal:
- Long-Term Problems (contd) Post-prandial glucose Range Time to
onset of proteinuria Persistent 116.6-12.7 19 yrs Persistent >
11>11 14 yrs 52 Type 1s, similar BP between groups 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 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
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- Meter Test Example Interpretation: Excessive after-meal peak
following breakfast; not after lunch or dinner BreakfastLunchDinner
Pre1h PostPre1h PostPre1h Post 6.115.25.59.210.711.2
5.016.12.913.15.47.9 7.514.74.08.813.313.1
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- Meter Test Example TimeppBG Value Premeal6.8 :206.9 :408.2
1:0011.3 1:2011.7 1:4010.4 2:009.9 Interpretation: Peak occurred at
1hr, 20min pp; rise from premeal to peak was approx. 5 mmol
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- Measurement of After-Meal Peaks iPro CGM (Medtronic)iPro CGM
(Medtronic) Worn for 72 hrs, then data is downloaded for
analysis
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- Measurement of After-Meal Peaks Real-Time Continuous Glucose
MonitorsReal-Time Continuous Glucose Monitors Allow tracking of
post- meal trends Produce BG estimates every 1-5 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 ApproachesLifestyle
Approaches Medicinal ApproachesMedicinal Approaches
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- Glycemic Index All carbs (except fiber) convert to blood
glucose eventuallyAll carbs (except fiber) convert to blood glucose
eventually G.I. Reflects the magnitude of blood glucose rise for
the first 2 hours following ingestionG.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)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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- 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
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- Glycemic Index (contd.) Slow StuffAverage StuffFast 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 MealHigh-GI OptionsLow-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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- Adding Acidity to the Meal 1-Hour BG rise by 55%
Vinegar/dressing Tomatoes Sourdough (Journal of the American
Dietetic Association, 07/12/2005)
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- Split The Meal Part at the usual mealtime Part at the usual
mealtime Part 60-90 minutes later Part 60-90 minutes later
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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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- (humalog/novolog) High GIModerate GILow GI BG Above Target
Range30-40 min. prior15-20 min. prior0-5 min. prior BG Within
Target Range15-20 min. prior0-5 min. prior15-20 min. after BG Below
Target Range0-5 min. prior15-20 min. after30-40 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; 26:1492-7.
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- Does Timing Matter? Bolus w/mealBolus w/meal Bolus
pre-mealBolus 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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- Effect of Pramlintide on Gastric Emptying in Type 1 Diabetes
Mean Half-Emptying Time (h) 0 1 2 3 4 ~1-h delay * 60 g * 30
gPlacebo Insulin + Placebo Insulin + Pramlintide Breakfast Single
SC pramlintide doses: n = 11, crossover; *P