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