1. Strategies for Combatting After-Meal Highs Gary Scheiner MS, CDE
Strike The Spike!
Strategies for Combatting
After-Meal Highs
Gary Scheiner MS, CDE

2. Overview
Definitions
Risks
Detection
Management

3. After-Meal Peaks Defined
The net rise that occurs from before eating to the highest point after eating.
ADA Goal:
<10 mmol 1-2 hrs after start of meal
AACE Target:
<7.8 mmol at peak
European Diabetes Policy Group:
<9 mmol (to prevent complications)
International Diabetes Federation:
< 7.8 mmol 2 hrs after meal

4. After-Meal Goals for Children
Under 5 Years:
1 hr. post-meal
(<6.7 mmol Rise)
5-11 Years:
1 hr. post-meal
(<5.5 mmol Rise)
12 Years +
< 1 hr. post-meal
(<4.4 mmol Rise)

5. After-Meal Peaks: Reality for children
Source: Boland et al, Diabetes Care 24: 1858, 2001

6. After-Meal Peaks: Reality in Children
Source: Boland et al, Diabetes Care 24: 1858, 2001

7. After-Meal Highs: Immediate Problems
Tiredness
Difficulty Concentrating
Impaired Athletic Performance
Decreased desire to move
Mood Shifts
Enhanced Hunger

8. After-Meal Highs: Immediate Problems
Australian Study of Children w/Type 1. Parents & children reported BG > 15 had negative impact on:
Thinking (68%)
Mood/Emotions (75%)
Coordination (53%)
J Pediatr Endocrinol Metab Jul;19(7);

9. Long-Term Problems Relative Influence on HbA1c
Source: Monnier et al, Diabetes Care, 26, 3/03,

10. Long-Term Problems (contd)
52 Type 1’s, similar BP between groups
Post-prandial glucose
Range
Time to onset of proteinuria
Persistent <11
23 yrs
Intermittent >11
19 yrs
Persistent > 11
>11
14 yrs
Source: Kidney Intl. 1987; 32 (supp 22): S53-S56

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:

12. Long-Term Problems (contd)
Rates of eye and kidney disease based on glucose variability (using CGM) in Type-2 Diabetes
Source: Liu et al, American Diabetes Association 71st Scientific Sessions 2011, Abstract 2205-PO.

14. Measurement of After-Meal Peaks
SMBG
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

15. Meter Test Example Brea kfast Lun ch Din ner Pre 1h Post 6.1 15.2 5.5
9.2
10.7
11.2
5.0
16.1
2.9
13.1
5.4
7.9
7.5
14.7
4.0
8.8
13.3
Interpretation:
Excessive after-meal peak following breakfast; not after lunch or dinner

16. Meter Test Example Time pp BG Value Interpretation: Premeal 6.8: : 1: 1: 1: 2:
Interpretation:
Peak occurred at 1hr, 20min pp; rise from premeal to peak was approx. 5 mmol

17. Measurement of After-Meal Peaks
iPro CGM (Medtronic)
Worn for 72 hrs, then data is downloaded for analysis

18. Measurement of After-Meal Peaks
Real-Time Continuous Glucose Monitors
Allow tracking of post-meal trends
Produce BG estimates every 1-5 minutes

19. CGMS Case Study
37 year old man

20. CGMS Case Study
8 year old girl

21. CGMS Case Studies
12 year old boy

22. 1,5 – anhydroglucitol “GlycoMark”
Spike Measurement
1,5 – anhydroglucitol “GlycoMark”
Laboratory Blood Test
Measures Duration & Magnitude of High BG Excursions for past days
“Normal” is >14 g/ml

23. After-Meal Spike Reduction
Lifestyle Approaches
Medicinal Approaches

24. Glycemic Index
All carbs (except fiber) convert to blood glucose eventually
G.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)

25. Glycemic Index (contd.)
Example:
Spaghetti
GI = 37
Only 37% of spaghetti’s carbs turn into blood glucose in the first 2 hours.
The rest will convert to blood glucose over the next several hours.

26. Glycemic Index (contd)
Parillo M et al. Effects of meals with different glycaemic index on postprandial blood glucose response in patients with Type 1 diabetes treated with continuous subcutaneous insulin infusion. Diabet Med; 2011 Feb;28(2):227-9

27. Dietary Intervention Use 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

28. Glycemic Index (contd.)
Slow Stuff
Average Stuff
Fast Stuff
Pasta
Legumes
Salad Veggies
Dairy
Chocolate
Fruit
Juice
Pizza
Soup
Cake
Breads/Crackers
Salty Snacks
Potatoes
Rice
Cereals
Sugary Candies

29. Examples: Use of GI   Meal High-GI Options Low-GI Options Breakfast
 
Examples: Use of GI
Meal
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

30. Add Some Acidity 60-min glucose response 55%*
Tomatoes
Sourdough
Vinegar (Salad Dressing/Condiments)
*Journal of the American Dietetic Association, 2005: v7 no12.

31. Split The Meal
 Part at the usual mealtime
 Part minutes later

32.    Meal Sequences Eat veggies before starch when having mixed meals
  
Eat veggies before starch when having mixed meals
Make lunch the “higher carb” meal (less at breakast & dinner)
Presented at the American Diabetes Associaion Scientific Sessions, 2012, symposium on minimizing glucose variability.

33. Choice of Bolus Insulin
Humalog
Novorapid or
Apidra
Vs.
Regular Insulin
1-hr. peak
3-4 hr. effective duration
2-3 hr. peak
4-6 hr. effective duration

34. Timing of Bolus Insulin

35. Timing 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. after
BG Below Target Range
30-40 min. after

36. Does Timing Matter? Note: Carbs estimated w/pre-meal insulin.
Carbs known with post-meal insulin.
Source: Clinical Therapeutics 2004; 26:

37. Does Timing Matter?
Bolus w/meal
Bolus pre-meal

38. Does Timing Matter?
 Insulin taken with meal  Insulin taken min Pre-Meal (if >150)
A1c
Duran-Valdez, et al (U of New Mexico). Insulin Timing—A Beneficial Addition to Intensive Insulin Therapy in Type-1 Diabetes. Presented at the American Diabetes Association Scientific Sessions 2012, poster 964-P.

39. Insulin Delivery Method
Jet Injection
Vs.
Needle Injection
31 Minutes to Peak
Peak conc. 108 mU/L
Same total absorption
Same total action
105 Minutes to Peak
Peak conc. 79 mU/L
Engwerda et al, Diabetes Care, 2011

40. Warming The Injection/Infusion Site
“Insupatch” (experimental)
Heating element in pump infusion site
Warms site to 38-40C
30-40 minute earlier insulin peak

41. Warming The Injection/Infusion Site

42. Choice of Insulin Program
Lantus & MDI
Vs.
Daytime isophane
Meal/snack boluses
Prolonged peak covers
midday meals/snacks

43. Injectible Symlin (Amylin Pharmaceuticals)
Acts on CNS
 Appetite
Slows gastric emptying
Inhibits glucagon secretion
Really flattens postprandial BGs

44. 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???

45. Effect of Pramlintide on Gastric Emptying in Type 1 Diabetes
Breakfast
Insulin + Placebo
Insulin + Pramlintide 4 * *
~1-h delay 3
DISCUSSION POINTS:
Pramlintide slows gastric emptying of the solid portion of a standard meal in subjects with type 1 diabetes.
Gastric emptying is the rate-limiting step that regulates glucose delivery from the GI tract into the bloodstream.
The effects of pramlintide, seen at the first meal, were no longer present at a subsequent meal.
SLIDE BACKGROUND:
Double-blind, randomized, crossover study (n = 11 males with type 1 diabetes).
Participants self-injected their usual dose of insulin and 15 min later, self-injected either placebo, 30 µg pramlintide, or 60 µg pramlintide prior to the first of 2 meals issued.
Study participants then ate a standard meal (a radio-labeled pancake and milkshake). Radio images of the stomach were obtained for the next 8 h.
Data presented are mean  SEM.
Mean Half-Emptying Time (h) 2 1
Placebo
30 µg
60 µg
Single SC pramlintide doses: n = 11, crossover; *P<0.004;
99m Tc labelled pancake; solid component measured Data from Kong MF, et al. Diabetologia 1998; 41:

46. Pramlintide Reduces Postprandial Glucagon
Type 2 Diabetes, Late Stage
Type 1 Diabetes
Placebo
Pramlintide
Insulin
Insulin
Sustacal® 30
Sustacal® 60 20
DISCUSSION POINTS:
Pramlintide reduces postprandial glucagon secretion in insulin-using patients with both type 2 and type 1 diabetes.
This slide demonstrates the effect of intravenous infusion of pramlintide on postprandial glucagon in 2 separate studies involving insulin-using patients with type 2 diabetes (left figure) and type 1 (right figure) diabetes.
SLIDE BACKGROUND:
Left figure: Crossover design study; insulin-treated patients with type 2 diabetes (n = 12) were infused with either pramlintide (100 g/h) or placebo for 5 h during a SUSTACAL® meal challenge test.
Right figure: Crossover study design; patients with type 1 diabetes (n = 9) infused with pramlintide (25 g/h) or placebo for 5 h during a SUSTACAL® meal challenge test.
In both studies, pramlintide or placebo was infused at t = 0 min, regular insulin injected at t = 30 min, and SUSTACAL® meal ingested at t = 60 min. Data presented are mean ( SE) plasma glucagon (pg/mL).
A similar study, conducted in non-insulin-using patients with type 2 diabetes, yielded similar results.
SUSTACAL® is a registered trademark of Mead Johnson. 50 10
Plasma Glucagon (pg/mL)
 Plasma Glucagon (pg/mL) 40
-10 30
Placebo or 100 µg/h pramlintide infusion 1 2 3 4 5
Placebo or 25 µg/h pramlintide infusion
-20 1 2 3 4 5
Time (h)
Time (h)
Type 2 diabetes, n = 12; AUC1-4 h: P = 0.005
Type 1 diabetes, n = 9; AUC1-5 h: P<0.001;
Data from: Fineman M, et al. Metabolism 2002; 51: ; Fineman M, et al. Horm Metab Res 2002; 34:

47. Pramlintide Reduces Caloric Intake in Type 2 Diabetes
1250
-202 kcal
(-23%)
P <0.01
Placebo
Pramlintide
1000
DISCUSSION POINTS:
Pramlintide reduced mean caloric intake and macronutrient intake during a buffet study in subjects with type 2 diabetes.
SLIDE BACKGROUND:
In a randomized, double-blind, placebo (PBO)-controlled, crossover study, subjects underwent a standardized buffet meal test on 2 occasions. After an overnight fast, subjects received a single SC injection of pramlintide (120 g) or PBO, immediately followed by a standardized preload meal. After 1 h, subjects were offered an ad-libitum buffet meal. Total caloric intake (TCI) and meal duration were measured.
750
CHO
Ad-Libitum
Caloric Intake
(kcal)
CHO
500
Fat
Fat
250
Protein
Protein
n = 11; subjects given buffet meal Pramlintide (single SC injection, 120 g) Data from Chapman I, et al. Diabetologia 2005; 48:

48. Pre-Meal Hypoglycemia
“Sieve Effect”
Accelerates gastric emptying of liquids and solids
Produces more rapid BG rise after meal
J Clin Endo Metab 2005; 90:
A v o i d P r e – M e a l L o w s !

49. Physical Activity Intervention
Muscle Use Soon After Eating
Accelerated Delayed Glucose Uptake/
Insulin Absorption Digestion Utilization
Improved After-Meal Control

50. Effects of Post-Meal Walking
30 Minutes of casual stop & go walking after meals
Avg. 30 mg/dl (1.75 mmol/L) BG reduction
Peak post-meal glucose 45% higher when not walking
Kudva, et al. Diabetes Care, published online Aug 8, 2012

51. Examples: After-Meal/Snack Activity
Walking Pets
Household Chores
Planned Exercise
Yard Work
Gym Class???
Shooting Hoops
Dancing
Bowling
Mini Golf
Skating

52. Examples: After-Meal/Snack Activity
“Free Time With Siblings”

53. Summary After-Meal Blood Sugar Levels Are: Important to Control
Measurable
Manageable

54. For More Information: Gary Scheiner MS, CDE
Integrated Diabetes Services
(USA)
(USA) (877-SELF-MGT)
Website: