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 The net rise that occurs from before eating to the highest point after 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 European Diabetes Policy Grp:European Diabetes Policy Grp: <165 (to prevent complications)

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

9. 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

10. 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.

13. 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

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

15. 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

16. Measurement 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 1 & 3-hr post-meal averages

17. 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

18. CGMS Case Study 37 year old man

19. CGMS Case Study 8 year old girl

20. CGMS Case Studies 12 year old boy

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

22. 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)

23. 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.

24. Glycemic Index (contd)

25. 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

26. 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

27. 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

28. 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

29. Timing of Bolus Insulin

30. (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

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

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

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

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

35. 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???

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

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

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

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

40. 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