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Strike the Spike II
Five years ago, I wrote an article for Diabetes Self-Management about the management of after-meal blood glucose spikes. It was called “Strike the Spike” and no article I’ve ever written has led to greater reader response. To this day, I still receive calls, letters, and e-mails thanking me for offering practical answers to this perplexing challenge. I’ve even been asked to speak on the topic at some major conferences. So when presented with the opportunity to readdress the issue, I jumped at the chance.
A lot has changed in the past five years: we know more than ever about the harmful effects of after-meal blood glucose spikes, but we also have a number of potent new tools and techniques for preventing them. Now that I know how important this topic is to so many people, I’ll do my absolute best to bring you up to date.
What’s a spike?
The reason blood glucose tends to spike after eating in many people with diabetes is a simple matter of timing. In a person who doesn’t have diabetes, eating foods containing carbohydrate causes two important reactions in the pancreas: the immediate release of insulin into the bloodstream, and the release of a hormone called amylin. The insulin starts working almost immediately (to move glucose out of the bloodstream and into cells) and finishes its job in a matter of minutes. The amylin keeps food from reaching the small intestine too quickly (where the nutrients are absorbed into the bloodstream). As a result, the moment blood glucose starts to rise, insulin is there to sweep the incoming glucose into the body’s cells. In most cases, the after-meal blood glucose rise is barely noticeable.
However, in people with diabetes, the situation is like that of a batter with very slow reflexes facing a pitcher who throws 98-mph fastballs: The timing is all fouled up. Rapid-acting insulin that is injected (or infused by a pump) at mealtimes takes approximately 15 minutes to start working, 60–90 minutes to “peak,” or reach maximum effectiveness, and 4 hours or more to finish working. Meanwhile, amylin is either produced in insufficient amounts or not at all, so the movement of food from the stomach to the intestines is not slowed the way it should be. As a result, food digests even faster than usual. This combination of slower insulin and faster food can cause the blood glucose level to rise quite high soon after eating. Once the mealtime insulin finally kicks in, the high is followed by a sharp drop.
Why are spikes a problem?
Your A1C test result reflects your average blood glucose level for all times of day (before and after meals) over the past two to three months, with the more recent weeks influencing the result more than earlier weeks. So if your pre-meal blood glucose average is 130 mg/dl for a given three-month period, and your post-meal average is 240 mg/dl, your A1C will probably reflect an overall average somewhere in the middle of these two numbers.
Interestingly, research has shown that for people with an A1C below 7.5%, post-meal blood glucose readings have a greater influence on A1C than pre-meal readings. In other words, lowering your pre-meal readings will only get you so far. If you want your A1C level to be as close to normal as possible, you need to pay attention to your after-meal numbers as well.
The long-term effects of high blood glucose levels after meals have been studied extensively. For people with Type 1 diabetes, significant after-meal rises have been shown to produce earlier onset of kidney disease and to accelerate the progression of existing retinopathy, the eye problem most commonly associated with diabetes. In people with Type 2 diabetes, high blood glucose after meals is a risk factor for cardiovascular problems.
But the problems are not limited to long-term complications. Any time blood glucose levels rise particularly high, even temporarily, quality of life suffers. Energy decreases, brain function falters, physical and athletic abilities become diminished, and moods become altered. An Australian study of young people with Type 1 diabetes indicated that short-term high blood glucose negatively affects thinking performance, coordination, and emotions and moods. A study conducted on people with Type 2 diabetes showed that sharp rises in blood glucose level slowed mental performance, lowered attention, reduced energy levels, and led to feelings of sadness and tension.
Additionally, the effects of a bout of post-meal high blood glucose do not go away immediately when blood glucose returns to normal. Each episode of high blood glucose can alter the way certain genes function, resulting in the production of harmful chemicals called free radicals, which cause inflammation and damage to the linings of the blood vessels for hours, if not days. So clearly, post-meal spikes represent a challenge worthy of attention.
When interpreting your numbers, take your pre-meal readings into account. For example, a pre-meal blood glucose of 210 mg/dl followed by a 1-hour post-meal reading of 240 mg/dl shows just a 30-point rise, whereas a 110 mg/dl followed by a 240 mg/dl shows a 130-point rise.
So exactly how high is too high after a meal? There is no universal consensus on this issue. The American Diabetes Association recommends keeping blood glucose below 180 mg/dl one to two hours after the start of a meal. The European Diabetes Policy Group recommends keeping it below 165 mg/dl at the peak, and the American Association of Clinical Endocrinologists and International Diabetes Federation suggest keeping it below 140 mg/dl after eating. However, no specific guidelines are provided by any of these groups for Type 1 versus Type 2 diabetes, insulin users versus non-users, or children versus adults.
Based on my experience, I recommend the following after-meal goals for the following groups. These numbers are generally achievable, lead to a decent A1C level, and do not interfere with daily quality of life:
After-meal readings that are consistently above these levels should be addressed by you and your health-care team (see strategies in the sections below).
Besides monitoring with a conventional blood glucose meter, a few other options exist for detecting post-meal spikes. Continuous glucose monitoring (CGM) systems provide glucose readings every couple of minutes and provide trend graphs that make it easy to see exactly what is happening after meals and at other times of the day. (See an example of a trend graph here.) Medtronic, DexCom, and Abbott Diabetes Care all make CGM devices.
Individuals can purchase a CGM for long-term or ongoing use, or, alternatively, some specialized diabetes centers offer them on a temporary or loaner basis. (Feel free to contact my office for a loaner if your providers do not offer them.) CGM systems include a tiny sensor filament that is inserted just below the skin, a small radio transmitter attached to the sensor, and a handheld receiver that displays your data. The systems are all uploadable to a computer for analysis of the information.
Another way to assess after-meal blood glucose control is with a blood test trade-named GlycoMark. GlycoMark measures the level of a specific type of sugar (1,5-anhydroglucitol, or 1,5-AG) that becomes depleted whenever the kidneys are spilling glucose into the urine; this typically occurs when blood glucose exceeds approximately 180 mg/dl. The test result reflects blood glucose levels over the prior one to two weeks. Ask your diabetes doctor if this test is available near you.
Medical approaches to spike control
Here are some strategies that may work better:
Choose the right insulin (or other medicine). The right insulin or medicine program can make or break your ability to control after-meal spikes. In general, insulins and other medicines that work quickly and for a short time will work better than those that work slowly over a prolonged period.
For instance, rapid-acting insulin analogs (brand names Humalog, NovoLog, and Apidra), which start working 10–15 minutes after injection and peak in about an hour, cover the after-meal blood glucose rises much better than Regular insulin, which takes 30 minutes to begin working and 2–3 hours to peak. If you use a morning injection of NPH insulin to “cover” the carbohydrate eaten in the middle of the day, your blood glucose level after lunch and after any daytime snacks is likely to be very high. This is also the case if you take a premixed insulin (75/25, 70/30, or 50/50) twice daily. For fewer spikes, consider taking a rapid-acting insulin before each meal or snack and using a long-acting “basal” insulin such as Lantus or Levemir for coverage between meals.
If you use oral diabetes medicines, your choice of pill can also affect your after-meal blood glucose control. Sulfonylureas (glyburide, glipizide, and glimepiride) stimulate the pancreas to secrete a little extra insulin throughout the day, without regard to meals. Because these medicines fail to concentrate the insulin secretion at times when it is needed most, after-meal blood glucose levels can run very high. However, there are two other oral medicines, repaglinide (Prandin) and nateglinide (Starlix), which also stimulate the pancreas to release more insulin but do so in a much faster and shorter manner. When taken at mealtimes, these drugs may produce better after-meal control than a sulfonylurea.
Another class of oral diabetes medicines called alpha-glucosidase inhibitors (which includes the drugs Precose and Glyset) lowers after-meal blood glucose levels by partially blocking the transport of sugars across the intestines and into the bloodstream. However, these medicines can sometimes cause gas, bloating, and gastrointestinal upset, so the pros of taking them don’t always outweigh the cons.
Time your bolus insulin properly. For people who take rapid-acting insulin at mealtimes, the timing of the bolus can have a huge impact on after-meal blood glucose levels. Boluses given too late to match the entry of glucose from dietary carbohydrates into the bloodstream can produce significant blood glucose spikes soon after eating. A properly timed bolus, on the other hand, can result in excellent after-meal control.
Unless you have gastroparesis (slowed stomach emptying, usually caused by nerve damage), it is best to give bolus insulin doses before eating. How long before? It depends mainly on what you are eating and on your pre-meal blood glucose level.
Figuring out the pre-meal blood glucose part is fairly straightforward: the higher your blood glucose, the earlier the bolus should be given. If your pre-meal blood glucose is well above your target, it is best to give the bolus and then wait at least 30 minutes before eating. Near your target blood glucose? Wait 15 minutes. Below target? Either take the bolus and eat right away, or take the bolus after eating.
The “what you are eating” part is a bit more complex. Essentially, the higher the glycemic index of the food, the earlier the bolus should be given. The glycemic index is a ranking of how quickly a food is broken down during digestion and raises blood glucose. Foods with a high glycemic index (greater than 70) include most cold breakfast cereals, breads, potatoes, rice, and snack chips. They tend to cause a significant rise in blood glucose about 30–45 minutes after they are eaten. For meals consisting of mainly high-glycemic-index foods, it is best to bolus 15–20 minutes before eating. This will allow the insulin peak to coincide as closely as possible with the blood glucose peak.
Foods with a moderate glycemic index (approximately 45–70) digest a bit slower, resulting in a slightly less pronounced blood glucose peak approximately 45–60 minutes after eating. Examples include ice cream, orange juice, cake, carrots, pizza, and meals that include a variety of foods. It is best to bolus 5–10 minutes before eating foods with a moderate glycemic index.
Foods with a low glycemic index (below 45) tend to cause a slow, gradual blood glucose rise. The blood glucose “peak” is usually modest and may occur an hour or two after eating. Examples of foods with a low glycemic index include pasta, milk, yogurt, and cooked, dried beans. For these types of foods, bolusing right at the start of the meal, during the meal, or right after the meal usually works best.
Does earlier bolusing make a difference? Absolutely. Research has shown that simply giving mealtime boluses before eating rather than after eating can reduce the post-meal spike by about 50 mg/dl.
Use a “super bolus.” For people who use insulin pumps, one way to have more insulin working right after eating and less working several hours later is to give what John Walsh, coauthor of the Pumping Insulin books, calls a “super bolus.” This is done by substantially reducing the basal rate for 3 hours before eating, then adding the amount of insulin that wasn’t given as basal insulin to the normal pre-meal bolus. For example, if your normal basal rate in the morning is 0.6 units per hour, you could set a temporary basal rate of 10% (90% reduction), for the 3 hours before breakfast, then bolus an extra 1.8 units at breakfast.
Try Byetta or Symlin. Two injectable synthetic hormones, exenatide (Byetta) and pramlintide (Symlin), can substantially lower post-meal blood glucose levels. Both hormones slow stomach emptying, which keeps carbohydrates from raising the blood glucose too quickly after meals. Byetta, which is approved for use only in people with Type 2 diabetes, also blunts appetite and promotes the growth of insulin-producing cells in the pancreas. Symlin, which is approved for use in people with either Type 1 or Type 2 diabetes who take rapid-acting insulin at mealtimes, is a replacement for the hormone amylin. It helps to diminish appetite, and it additionally blunts post-meal glucagon secretion from the pancreas. (Glucagon is a hormone that raises blood glucose level by stimulating the liver to release stored glucose.)
Think lower GI. As mentioned earlier, the glycemic index is a rating of how quickly a food raises the blood glucose level. While all carbohydrates (except for fiber) convert into glucose eventually, some forms do so much faster than others.
Many starchy foods (such as breads, cereals, potatoes, and rice) have a high glycemic index; they digest easily and convert into blood glucose quickly. However, some starchy foods (such as pasta, beans, and peas) have lower glycemic index values. Foods that have dextrose in them — such as glucose tablets and gel and candies such as SweeTarts, Smarties, Spree, Runts, Nerds, and AirHeads — tend to have a very high glycemic index. Table sugar (sucrose) and fructose (fruit sugar) have moderate glycemic index values, while lactose (milk sugar) is slower to raise blood glucose.
A number of books, notably Dr. Jennie Brand-Miller’s Glucose Revolution series, contain extensive information about the glycemic index, along with lists of glycemic index values for hundreds of foods.
As a general rule, switching to lower-glycemic-index foods will help to reduce your after-meal blood glucose spikes. There are a number of characteristics that slow down the rate at which foods are digested and raise blood glucose. Here are some of them:
Another food property that affects the rate of digestion is acidity. This is why sourdough bread has a much lower glycemic index value than regular bread. Research has shown that adding acidity to a meal in the form of vinegar (straight or consumed as part of a salad dressing or other condiment) can reduce the one-hour post-meal blood glucose rise by 50% or more.
Split your meal. The amount you eat has the greatest effect on your blood glucose level after you eat. One way to lower your blood glucose rise after meals, therefore, is to eat less. But you don’t have to starve: instead, save a portion of your meal for a “snack” one or two hours later. That way, you get all the food you need, but it doesn’t raise your blood glucose all at once.
If you use mealtime insulin, you should still give yourself your full mealtime dose before eating any of the meal. For example, if you normally have a bowl of cereal and juice for breakfast, you would take enough insulin to cover both, but then just eat the cereal for breakfast, and postpone the juice until mid-morning.
Get moving. Physical activity after eating can reduce post-meal spikes in a number of ways. If you took insulin before your meal or snack, the enhanced blood flow to the skin surface caused by exercise is likely to make the insulin absorb and act more quickly. Muscle activity also diverts blood flow away from the intestines, resulting in slower absorption of glucose into the bloodstream. In addition, the glucose that does enter the bloodstream is likely to be used by the working muscles, rather than stored for later use.
How much activity is required to experience these benefits? Not much. Ten or 15 minutes (or more) of mild activity will usually get the job done. The key is to avoid sitting for extended periods of time after eating. Instead of reading, watching TV, or working on the computer, go for a walk, shoot some hoops, or do some chores. Try to schedule your active tasks (housework, yardwork, shopping, walking pets) for after meals. Also attempt to schedule your exercise sessions for after meals. On “date nights,” resist the urge to sit and talk for hours or to head straight for a movie. Instead, go out dancing, bowling, or skating.
Prevent hypoglycemia. Low blood glucose is problematic in many ways. One of the body’s typical responses to hypoglycemia is to speed up the rate at which the stomach empties. That means food digests and raises blood glucose even more rapidly than usual. While this is certainly desirable when you’re low, it does contribute to post-meal spikes. Preventing hypoglycemia before meals and snacks, therefore, is yet another effective strategy for controlling post-meal blood glucose levels.
Time to strike!
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