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
Slide 11
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.
Slide 12
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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
Slide 15
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
Slide 16
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
Slide 17
Measurement of After-Meal Peaks iPro CGM (Medtronic)iPro CGM
(Medtronic) Worn for 72 hrs, then data is downloaded for
analysis
Slide 18
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
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)
Slide 24
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.
Slide 25
Glycemic Index (contd)
Slide 26
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
Slide 27
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
Slide 28
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
Slide 29
Adding Acidity to the Meal 1-Hour BG rise by 55%
Vinegar/dressing Tomatoes Sourdough (Journal of the American
Dietetic Association, 07/12/2005)
Slide 30
Split The Meal Part at the usual mealtime Part at the usual
mealtime Part 60-90 minutes later Part 60-90 minutes later
Slide 31
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
Slide 32
Timing of Bolus Insulin
Slide 33
(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
Slide 34
Does Timing Matter? Note: Carbs estimated w/pre-meal insulin.
Carbs known with post-meal insulin. Source: Clinical Therapeutics
2004; 26:1492-7.
Slide 35
Does Timing Matter? Bolus w/mealBolus w/meal Bolus
pre-mealBolus pre-meal
Slide 36
Choice of Insulin Program Lantus & MDI Vs. Daytime
NPH/Lente Meal/snack boluses Prolonged peak covers midday
meals/snacks
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???
Slide 39
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