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

2. Overview DefinitionsDefinitions RisksRisks DetectionDetection ManagementManagement

3. After-Meal Peaks Defined ADA Goal:ADA Goal: <180 mg/dl 1-2 hrs after start of meal AACE Target:AACE Target: <140 at peak European Diabetes Policy Group:European Diabetes Policy Group: <165 (to prevent complications) International Diabetes Federation:International Diabetes Federation: < 140 mg/dl 2 hrs after meal The net rise that occurs from before eating to the highest point after eating.

4. After-Meal Goals for Children Under 5 Years:Under 5 Years: <250 @ 1 hr. post-meal (<120 pt. Rise) 5-11 Years:5-11 Years: <225 @ 1 hr. post-meal (<100 pt. Rise) 12 Years +12 Years + < 200 @ 1 hr. post-meal (<80 pt. 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 TirednessTiredness Difficulty ConcentratingDifficulty Concentrating Impaired Athletic PerformanceImpaired Athletic Performance Decreased desire to moveDecreased desire to move Mood ShiftsMood Shifts Enhanced HungerEnhanced Hunger

8. After-Meal Highs: Immediate Problems Australian Study of Children w/Type 1. Parents & children reported BG > 270 had negative impact on: –Thinking (68%) –Mood/Emotions (75%) –Coordination (53%) J Pediatr Endocrinol Metab. 2006 Jul;19(7); 927-36

9. Long-Term Problems Relative Influence on HbA1c Source: Monnier et al, Diabetes Care, 26, 3/03, 881-885

10. Long-Term Problems (contd) Post-prandial glucose Range Time to onset of proteinuria Persistent <200110-198 23 yrs Intermittent >200118-228 19 yrs Persistent > 200201 + 14 yrs 52 Type 1s, similar BP between groups 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: 163-170.

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 71 st Scientific Sessions 2011, Abstract 2205-PO.

14. 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

15. Meter Test Example Interpretation: Excessive after-meal peak following breakfast; not after lunch or dinner BreakfastLunchDinner Pre1h PostPre1h PostPre1h Post 117281157166191204 903025824789147 15126477152235222

16. Meter Test Example TimeppBG Value Premeal135 :20155 :40168 1:00214 1:20222 1:40175 2:00141 Interpretation: Peak occurred at 1hr, 20min pp; rise from premeal to peak was approx. 90 mg/dl

17. Measurement of After-Meal Peaks iPro (Medtronic)iPro (Medtronic) –Worn for 72 hrs, then data is downloaded –BG data every 5 minutes –Analysis software shows post-meal patterns

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 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. After-Meal Spike Reduction Lifestyle ApproachesLifestyle Approaches Medicinal ApproachesMedicinal Approaches

23. 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)

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.

25. Glycemic Index (contd)

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

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

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

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

30. Split The Meal Part at the usual mealtime Part at the usual mealtime Part 60-90 minutes later Part 60-90 minutes later

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

32. Timing of Bolus Insulin

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

34. Does Timing Matter? Note: Carbs estimated w/pre-meal insulin. Carbs known with post-meal insulin. Source: Clinical Therapeutics 2004; 26:1492-7.

35. Does Timing Matter? Bolus w/mealBolus w/meal Bolus pre-mealBolus pre-meal

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

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

38. Injectible Symlin ( Pharmaceuticals) Well-tolerated in adolescents 4-week A1c decrease of.84 Slight weight decrease (<1 lb) No observed DKA or severe hypoglycemia (w/careful dose titration) Chase, et al, and Burdick, et al. Diabetes, June 2008, V57 suppl. 1, 1802-P and 1803-P.

39. 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???

40. Effect of Pramlintide on Gastric Emptying in Type 1 Diabetes Mean Half-Emptying Time (h) 0 1 2 3 4 ~1-h delay * 60 µg * 30 µgPlacebo Insulin + Placebo Insulin + Pramlintide Breakfast 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; 41:577-583

41. Pramlintide Reduces Postprandial Glucagon Type 1 Diabetes Time (h) Placebo Pramlintide Placebo or 25 µg/h pramlintide infusion -20 0 10 20 30 -10 Insulin Sustacal ® 023451 Type 2 Diabetes, Late Stage Time (h) Plasma Glucagon (pg/mL) Insulin Sustacal ® 60 40 30 50 Placebo or 100 µg/h pramlintide infusion 0 12345 Plasma Glucagon (pg/mL) Type 2 diabetes, n = 12; AUC 1-4 h : P = 0.005 Type 1 diabetes, n = 9; AUC 1-5 h : P<0.001; Data from: Fineman M, et al. Metabolism 2002; 51:636-641; Fineman M, et al. Horm Metab Res 2002; 34:504-508

42. Pramlintide Reduces Caloric Intake in Type 2 Diabetes 0 250 500 750 1000 1250 Protein CHO Fat CHO Fat Protein -202 kcal (-23%) P <0.01 Ad-Libitum Caloric Intake (kcal) Placebo Pramlintide n = 11; subjects given buffet meal Pramlintide (single SC injection, 120 g) Data from Chapman I, et al. Diabetologia 2005; 48:838-848

43. 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: 4489-95 A v o i d P r e – M e a l L o w s !

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

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

46. Examples: After-Meal/Snack Activity Free Time With Siblings

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

48. For More Information: Gary Scheiner MS, CDE Integrated Diabetes Services 877-735-3648 (877-SELF-MGT) Website: www.integrateddiabetes.comwww.integrateddiabetes.com E-mail: gary@integrateddiabetes.com