Optimising postprandial glycaemia Caroline Adamson
Why target Postprandial Blood Sugars <ul><li>Improving post prandial BSL’s may improve HBA1C </li></ul><ul><li>Glucose Flu...
Blood sugars aren’t in target <ul><li>CHO ratio, is it correct </li></ul><ul><li>Other Dietary influences on post prandial...
Basal Testing <ul><li>Examining the basal rate whilst eliminating/minimising the effect of food </li></ul><ul><li>Can be d...
Potential Dietary Influences <ul><li>Carbohydrate </li></ul><ul><ul><li>Glycaemic Index (GI), sugar alcohols (nutritive sw...
Glycaemic Index <ul><li>Low GI  - 55 or less  </li></ul><ul><li>Medium GI  - between 56 and 69  </li></ul><ul><li>High GI ...
Glycaemic index <ul><li>Low GI may lower postprandial hyperglycaemia </li></ul><ul><li>Meta analysis Low GI diet lowered A...
Dual wave/ Combo Bolus <ul><li>Dual wave/Combo bolus in low GI meals may optimise postprandial BSL’s </li></ul><ul><li>50:...
0  1  2  3  4 0  1  2  3  4 0  1  2  3  4 0  1  2  3  4 Normal Bolus Extended or Square wave Bolus Combination or dual wav...
Low GI meal (34) High GI meal (76) Optimising postprandial glycaemia in pediatric patients with type 1 diabetes using insu...
Summary <ul><li>Check CHO ratio’s </li></ul><ul><li>Lower GI </li></ul><ul><li>Alternative bolus options </li></ul>
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Optimising postprandial glycaemia parents evening 2011

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  • Postprandial glucose is a major determinant of A1C that to specifically improve PPG have the ability to improve A1C. Activating oxidative stress
  • Blood sugars are affected at any given moment by -basal insulin -Food -Boluses and corrections -activity -Stress and illness Carbohydrate amount is considered the most important dietary determinant of postprandial glucose control: ADA position paper 2006
  • Glycaemic index for meal planning has not been endorsed by the ADA. However base on experience, people can develop their own “personal glycaemic index”. Whilst some evidence that following a lower Gi meal can have a small but clinically sig effect on glycaemic contro Fat delays peak glycaemic response Sugar alcohols: (average 2 cals per gram) recommended if &gt;10g per serve, divide by 2 and count it. Sorbitol, Xylitol, Mannitol, Maltitol Study showed that addition of extra protein showed a greater glucose response and insulin req Peters AL, Davidson MB. Protein and fat effects on glucose responses and insulin requirements in subjects with insulin-dependant diabetes mellitus. American Journal of Clinical Nutrition 58:555-60, 1993.
  • Testing using 50g CHO Glycaemic load – validated in glycaemic response and insulin demand in healthy adults, whether it can be employed as a predictor of exogenous insulin req, not examined. Low GL may not necessarily offer the glycaemic benefits of a low GI diet
  • Carbohydrate amount is considered the most important dietary determinant of postprandial glucose control: ADA position paper 2006 Second meal effect of GI Meta analysis low Gi 0.5% than those produced by high GI diets, small but clinically useful second article: PPGE lower with low GI and pre-prandial insulin better than post Low GI diet JADA had more fibre les fat and no diff in energy (education and food lists given), sig lower mean BSL on day they consumed low GI Adolescents with diabetes consume fewer calories from CHO and more from fat (esp boys, more sat fat) than those without diabetes: Diabetes Care 2006
  • Pizza Study 50:50 over 8 hours Cross-sectional study 499 records Lowest HBA1C’s were found in the group using 1 or more alternate boluses per day
  • Meals had equal macronutrient ( CHO ~60g) calories and fibre, only GI varied, n=20 Randomised to either standard or Dual wave 50:50 2 hours Consumed either low or high 2 consecutive days CGMS used to monitor A DW bolus before low GI meal decreased PPG are under curve by 47% and lowered risk for hypoglycaemia for the same premeal glucose compared to std bolus. High GI meals resulted in SIG upward trend regardless of bolus type 11 hypos’ seen in low GI group (7 with std bolus, 4 with dual wave bolus). Those with lower pre-meal BSL’s more likely to go low using a std bolus than a dual wave
  • Optimising postprandial glycaemia parents evening 2011

    1. 1. Optimising postprandial glycaemia Caroline Adamson
    2. 2. Why target Postprandial Blood Sugars <ul><li>Improving post prandial BSL’s may improve HBA1C </li></ul><ul><li>Glucose Fluctuations influencing risk of complications </li></ul>
    3. 3. Blood sugars aren’t in target <ul><li>CHO ratio, is it correct </li></ul><ul><li>Other Dietary influences on post prandial blood sugars </li></ul><ul><li>Basal Testing </li></ul>
    4. 4. Basal Testing <ul><li>Examining the basal rate whilst eliminating/minimising the effect of food </li></ul><ul><li>Can be done once >3 hours since last CHO or corrections </li></ul><ul><li>Hourly blood sugars over desired time period </li></ul><ul><li>Discontinue if Hypo occurs or blood sugars require correction </li></ul><ul><li>Ideally without food but for children we recommend no CHO (protein meal/snack) </li></ul>
    5. 5. Potential Dietary Influences <ul><li>Carbohydrate </li></ul><ul><ul><li>Glycaemic Index (GI), sugar alcohols (nutritive sweetener) </li></ul></ul><ul><li>Fat content </li></ul><ul><ul><li>Delayed gastric emptying </li></ul></ul><ul><ul><li>Decreased insulin sensitivity (increased insulin resistance post meal) </li></ul></ul><ul><li>Protein content </li></ul><ul><ul><li>BG effect difficult to predict </li></ul></ul><ul><li>Need to look for individual response! </li></ul>
    6. 6. Glycaemic Index <ul><li>Low GI - 55 or less </li></ul><ul><li>Medium GI - between 56 and 69 </li></ul><ul><li>High GI - 70 or more </li></ul><ul><li>The glycolic effect of foods depends on a number of factors, such as: </li></ul><ul><li>the type of starch (relative amounts of amylose and amylopectin) </li></ul><ul><li>amount and physical structure of the food </li></ul><ul><li>fat content </li></ul><ul><li>protein content </li></ul><ul><li>pH level of the meal. </li></ul>
    7. 7. Glycaemic index <ul><li>Low GI may lower postprandial hyperglycaemia </li></ul><ul><li>Meta analysis Low GI diet lowered A1C ~0.5% </li></ul><ul><li>Concerns that may limit food choice and increase fat intake </li></ul>
    8. 8. Dual wave/ Combo Bolus <ul><li>Dual wave/Combo bolus in low GI meals may optimise postprandial BSL’s </li></ul><ul><li>50:50 split over 2 hours </li></ul><ul><li>Using alternative boluses may improve HBA1C </li></ul>Application of novel dual wave meal bolus and it’s impact on glycated hemoglobin A1C level in children with type 1 diabetes. Pediatric Diabetes 2008
    9. 9. 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 Normal Bolus Extended or Square wave Bolus Combination or dual wave Bolus (50/50)
    10. 10. Low GI meal (34) High GI meal (76) Optimising postprandial glycaemia in pediatric patients with type 1 diabetes using insulin pump therapy, Impact of GI and prandial bolus type. Diabetes Care 31(8);1491-1495 2008
    11. 11. Summary <ul><li>Check CHO ratio’s </li></ul><ul><li>Lower GI </li></ul><ul><li>Alternative bolus options </li></ul>

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