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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