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Diabetes Update: Guidelines

Number 45;September 16, 2002

By David Mendosa


My Cat, Hannah
Hannah Mendosa

This newsletter keeps you up-to-date with new articles, columns, and Web pages that I have written. I list and link most of these on my Diabetes Directory at www.mendosa.com/diabetes.htm

From time to time Diabetes Update may also include links to other Web pages of special interest.

My most recent contribution is:

    on September 16, 2002
  • Guidelines on Testing and Everything
    After writing the “Testing After Meals” section below, I realized that I could adapt it to make a good column on the American Diabetes Association's Web site. Using testing as the peg, the column has, however, a different emphasis. It’s on the guidelines where we can find the answers to questions like when to test. It’s on-line now at http://www.diabetes.org/main/community/info_news/web/default.jsp.

    on September 10, 2002

  • “Mendosa Light”
    "I wonder if some newbies might be overwhelmed by the vast resources available on your site," one of my most regular correspondents wrote me a few days ago. "I wonder if it would work to have a “Mendosa light” Web page for newbies, which would list only the most essential information.”

    Since this is a pretty common question for me to get, I had already prepared most of the page anyway. Please see my Advice for Newbies.

    on September 12, 2002

  • “Free Foods”
    The supermarket still wants to charge you for the free foods you eat. But this foods are free in an even more important sense—they will have little or no impact on your blood sugar. That's because they are so low in available carbohydrate.

    I developed this list as reference material for a book that I am writing with two other people. It is essentially an update to my main glycemic index page at http://www.mendosa.com/gi.htm and the list of free foods is on-line at http://www.mendosa.com/freefoods.htm.

Updates

    on September 4, 2002
  • Testing After Meals
    The American Association of Clinical Endocrinologists has new guidelines that say that postprandial glucose should be 140 mg/dl or less. But the guidelines fail to state if the testing should be one or two hours after beginning or finishing a meal.

    I refer to The American Association of Clinical Endocrinologists Medical Guidelines for the Management of Diabetes Mellitus: The AACE System of Intensive Diabetes Self-Management-2002 Update at http://www.aace.com/clin/guidelines/diabetes_2002.pdf

    Since Dr. Richard Hellman is listed first among the members of the Diabetes Medical Guidelines Task Force that wrote the guidelines, I asked him.

    He replied as follows:

    “Thank you for pointing out the lack of detail in our guidelines on this point. In fact, there is a considerable variation in the duration of meals, and it is more precise to measure it from the start of the meal, at the time of the first bite. It is true that there will be variances nonetheless, since the patient may have variable absorption of the carbohydrate due a variety of causes: the composition of the meal, as for example: a higher fat content lowering the rate of carbohydrate absorption, but also variations in the glycemic index will also affect absorption as will pathological concerns, such as malabsorption, or gastroparesis, to name just a few. But in the guidelines, the starting point used was 2 hours after the beginning of the meal.”

    Subsequently, I sniffed around the Internet a bit more. Specifically, I wanted to see if I could find the report on which the AACE Medical Guidelines are based. In a footnote it cites the “ACE (American College of Endocrinology) Consensus Development Conference on Guidelines for Glycemic Control.” Endocr Pract. Suppl., Nov/Dec 2001.

    I found it at http://www.upcmd.com/dot/examples/00005/dccwhitepaper.pdf and it is helpful, saying in part:

    “Independent of complications per se, diabetes control targeting postprandial hyperglycemia proved more effective than use of fasting hyperglycemia in reducing HbA1c levels in pregnant and nonpregnant patients with type 2 diabetes (27,28). Indeed, investigators have suggested that postprandial glycemia may better correlate with HbA1c levels than fasting glycemia (28). In subjects without diabetes, blood glucose levels typically peak approximately 1 hour after the start of a meal and return to preprandial levels within 2 to 3 hours; 2-hour postprandial blood glucose levels rarely exceed 140 mg/dl (39,40). Therefore, the consensus panel recommends a treatment-targeted 2-hour postprandial blood glucose level of <140 mg/dl.”

    The numbers in parentheses are references that the ACE Consensus Development Conference Guidelines used. Number 39 is the American Diabetes Association’s “Consensus Statement on Postprandial Blood Glucose,” Diabetes Care 2001 24:775-778, and it too is online. The URL is http://care.diabetesjournals.org/cgi/content/full/24/4/775 . It says in part:

    “Glucose concentrations begin to rise 10 min after the start of a meal as a result of the absorption of dietary carbohydrates. The PPG profile is determined by carbohydrate absorption, insulin and glucagon secretion, and their coordinated effects on glucose metabolism in the liver and peripheral tissues.

    “The magnitude and time of the peak plasma glucose concentration depend on a variety of factors, including the timing, quantity, and composition of the meal. In nondiabetic individuals, plasma glucose concentrations peak 60 min after the start of a meal, rarely exceed 140 mg/dl, and return to preprandial levels within 2-3 h. Even though glucose concentrations have returned to preprandial levels by 3 h, absorption of the ingested carbohydrate continues for at least 5-6 h after a meal....

    “Because the absorption of food persists for 5-6 h after a meal in both diabetic and nondiabetic individuals, the optimal time to measure postprandial glucose concentration must be determined. Practical considerations limit the number of blood samples that can be obtained. In general, a measurement of plasma glucose 2 h after the start of a meal is practical, generally approximates the peak value in patients with diabetes, and provides a reasonable assessment of postprandial hyperglycemia. Specific clinical conditions, such as gestational diabetes or pregnancy complicated by diabetes, may benefit from testing at 1 h after the meal.”

    To me the key point is one made by ACE Consensus Development Conference Guidelines, that, “In subjects without diabetes, blood glucose levels typically peak approximately 1hour after the start of a meal and return to preprandial levels within 2 to 3 hours; 2-hour postprandial blood glucose levels rarely exceed 140 mg/dl.”

    When I posted much of this on the Diabetes mailing list, it generated considerable discussion. Some people still prefer to test one hour after starting a meal. There's a good rationale for that, because this is when blood glucose is the highest, at least among people who don’t have diabetes.

    Most prefer, however, to follow the guidelines. The best thinking in my view came from Helen, who wrote, “if I aim for pre meal levels to occur an hour after eating, I chance going low two hours PP and for sure three hours PP. My bgs tend to decline from hour two to hour three. Therefore I do not test one hour PP; there is nothing I would do with that information other than aggravate myself.”

    I list this information on postprandial testing as an “update.” It does update and augment—but does nothing to contradict—my article on Starlix, written two years ago just before that drug came on the market. Since Starlix stops your blood glucose from going too high after a meal, when you use it the emphasis must be on postprandial testing.

    I pointed out that a big challenge for Starlix is that few people monitor their blood glucose an hour or two after a meal, which people using Starlix will need to do to determine how effective it is and make sure that blood glucose hasn't gone too low. We are going to have to get a whole new mindset to get people to do some testing after a meal,” William (Reddy) Biggs, an endocrinologist practicing in Amarillo, Texas, told me.

    Now, at least, the medical establishment has that new mindset.

    on September 6, 2002

  • Revised Glycemic Load Numbers
    Shortly after I uploaded the huge new list of glycemic index and glycemic load values on my site a couple of months ago, a correspondent, Ralph Brown, discovered eight inconsistencies in the calculations of glycemic load values. Then, I found six more. This is actually a low error rate, considering that the glycemic loads for some 750 foods were calculated for the first time in the table developed by Jennie Brand-Miller and her associates at the University of Sydney. But when I brought these inconsistencies to their attention, they revised the table and prepared a correction for the publication in which these calculations first appeared, The American Journal of Clinical Nutrition. The “revised” table on my site corrects these 14 glycemic load calculations. It also includes a much smaller serving size for condensed milk (50 grams instead of 250 grams), which has a substantial effect on its glycemic load. The URL is
    http://www.mendosa.com/gilists.htm. I have also made corrections to a table of some advanced data manipulation that Ralph Brown prepared in an on-line Excel spreadsheet at http://www.mendosa.com/advanced_GI_GL_data.xls.

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