4/5/05njm

3/30/06njm

Q. Are there alternatives to the oral glucose tolerance test? A
breakfast tolerance test?

A. Yes, there are several alternatives. Polycose is best. Mixed meals
are not as reliable.

The best tolerated and most accurate alternative method is the polycose
solution below. Polycose is an ingredient to infant formula.

Mixed meals with jelly beans or breakfast foods are helpful if the
patient is intolerant of other methods, but they are less reliable for
accuracy and precision. Please see the recipes for 50 g and 100 g loads
below.

######## Appendix A

**[Alternative Options for Screening]{.underline}**

[Regional center based screening]{.underline}

A.  Give 50 g of Polycose solution. Polycose is the best tolerated,
    e.g., no nausea, bloating, or lightheadedness and most reproducible.

> Polycose can be prepared ahead of time in the Pharmacy in the
> following manner:
>
> 50 g of Polycose\*, 50 mL of unsweetened club soda, and 1.5 gm of
> unsweetened lemon-lime Kool-Aid mix. Use standard blood glucose
> screening cut-off.
>
> \* This can be easily prepared in the Pharmacy: Polycose 50 g = 100 mL
> of 43% polymer solution
>
> (2 cal / mL)

B.  Give either 28 each Brach, No. 110, or 18 each of the Brach 150
    jellybeans per pound. Use

> standard blood glucose screening cut-off.
>
> Please note: This has poor sensitivity compared to Polycose.

C.  **[50 gram Breakfast load]{.underline}**

Menu

Two scrambled eggs (3 oz)

Two slices toast or one English muffin

Two pats of butter or margarine

8 oz orange juice

8 oz whole or skim milk

One cup coffee or tea (no sugar)

Contents

Carbohydrate 52 gm (210 kcal)

Protein 28 gm (110 kcal)

Fat 31 gm (280 kcal)

D. **100 Gram Carbohydrate Test Breakfast**

On the morning of the test, your breakfast must follow one of the three
breakfast

menus listed below [exactly]{.underline}. The right amount of
carbohydrate is needed for accurate test results. Take no more than half
an hour to eat breakfast. Eat nothing more until the test is over, and
do not take a nap. The blood sample must be drawn fasting, 1 hrs., 2
hrs., and 3 hrs. after you began to eat, so please note the time you
started eating.

Breakfast #1 Breakfast #2

½ cup cold cereal 10 gms 4 (4" across) pancakes 30 gms

(not sugar coated) 2 ½ tablespoons syrup 30 gms

1 cup milk 12 gms 1 cup milk 12 gms

2 slices toast 30 gms 1 cup orange juice or

1 tablespoon jelly 15 gms one small banana 30 gms

1 teaspoon sugar 5 gms Total: 102 gms

1 cup orange juice or

one small banana 30 gms

Total: 102 gms

Breakfast #3

"Lemonade" Mix:

¼ cup lemon juice 4 gms

½ cup sugar 96 gms

1 cup water \--

Total 100 gms

If you are unable to eat the types or amounts of foods indicated,
contact your clinic for help with substitutions.

####### **Village clinic based screening**

A variety of methods are being tried. The most accurate, is to send a
glucola drink to the health aide to be administered in clinic. A gray
top tube is drawn at 1 hour and the plasma separated off within 2-3
hours, refrigerated, and sent in.

Other options include:

Have the health aide obtain a capillary random glucose value by using a
portable glucometer. If a value of 120 mg/dL or greater is found, then
consult the referral physician.

Send a Standard 100 gram glucose drink to the health aide and have
him/her

administer half of it, followed by a 1 hour capillary glucose. If a
value of 120

mg/dL or greater is found, then consult the referral physician.

Have the health aide give a simulated glucola drink, made by dissolving
four tablespoons table sugar in eight ounces of water. Flavor with some
lemon juice, if possible. Follow with a 1 hour glucose determination. If
a value of 120 mg/dL or greater is found, then consult the referral
physician.

[Please note]{.underline}:

Table sugar, or sucrose, is metabolized differently than glucose. The
table sugar method is better than nothing, but sending out a glucola
bottle is far superior.

**[Background]{.underline}**

**#1 What is polycose?**

Polycose is an actually a very old solution this problem and well
tolerated.

Polycose is a carbohydratre polymer, e. g., a longer chain of standard
glucose rings.  In some laboratory methods manuals it is also referred
to as a mixture of glucose-based oligosaccharides, or
oligopolysaccharides. It is non-sweet neutral tasting white powder.

Other names for similar glucose polymer solutions include:

-Partial hydrolysates of starch

-Starch hydrolysate

-Linear oligosaccharide of glucose
([www.ajcn.org/cgi/content/full/78/4/843S](http://www.ajcn.org/cgi/content/full/78/4/843S))

-nonsweet oligosaccharide

-Polyglucoses

-Caloreen

-Fortical

The advantage is that polycose has a high glycemic index, like glucose
or sucrose, but it has a low osmolarity. It does not exacerbate the
physiologic gastroparesis of pregnancy (osmolarity \>1380 mmol/L for
glucose monomer vs 340 mmol/L for glucose polymer)

It is the lower osmolarity that makes polycose better tolerated and more
effective in those patients who otherwise experience nausea, vomiting,
lightheadedness, or simply become prostate with vasovagal symptoms,
which are unfortunately not uncommon with the glucose monomer oral load.

An established benchmark reference text dates back to the 1981 on the
subject of screening for diabetes mellitus by Mayer B. Davidson\* notes
other more palatable forms of oral carbohydrate loading:

"The form of the oral carbohydrate does not seem to matter clinically,
as similar glucose concentrations are achieved after ingestion of the
simple sugar itself and after ingestion of more palatable solutions of
oligopolysaccharides, which must be hydrolyzed to monosaccharides in the
gastrointestinal tract before absorption."

Polycose is used extensively throughout the world. Below are \~20
references, plus 6 that detail improved gastric motility with the
glucose polymer.

Glucose polymers has been mentioned in other Laboratory Methods Manuals
as well, e. g., World Health Organization Laboratory and Monitoring of
Diabetes Mellitus, 2002

See brief mention of solutions containing oligosaccharides, page 16

[[http://whqlibdoc.who.int/hq/2002/9241590483.pdf]{.underline}](http://whqlibdoc.who.int/hq/2002/9241590483.pdf)

'Partial hydrolysates of starch of the equivalent content' is also
mentioned in the monograph, World Health Organization. Diabetes
mellitus: Report of a WHO Study Group. Geneva: WHO; 1985. (Technical
Report Series 727.)  

This alterative method is listed in Annex 1 on page 99

Polycose is the gold standard solution in many other parts of the world,
e. g., New Zealand and Australia

In fact, here is information Diagnostic Medlab from New Zealand

<http://www.dml.co.nz/gestation.asp>

As it is used widely throughout the world, it is also found in many
**Patient**

**Education** resources

[[http://www.dml.co.nz/polycose.asp]{.underline}](http://www.dml.co.nz/polycose.asp)

[[http://www.parentscentre.org.nz/pregnancy/diabetes.asp]{.underline}](http://www.parentscentre.org.nz/pregnancy/diabetes.asp)

[[http://www.maternity.org.nz/choices.shtml]{.underline}](http://www.maternity.org.nz/choices.shtml)

[[http://www.everybody.co.nz/page-9d1cff30-47dd-449f-82ba-1cdd169e9755.aspx]{.underline}](http://www.everybody.co.nz/page-9d1cff30-47dd-449f-82ba-1cdd169e9755.aspx)

[[http://www.ethc.co.nz/Diabetes.htm]{.underline}](http://www.ethc.co.nz/Diabetes.htm)

\*Davidson MB. Diabetes mellitus: Diagnosis and treatment Vol. 1, John
Wiley and Sons, New York. 1981

#2

**How to supply Polycose for this test?**

Polycose is used as supplement for infant formula because of its low
osmolarity. It is widely commercially available in the powder form in
the US.

As it is a standard carbohydrate loading solution overseas, it is
commercially a liquid solution there.

It is great to communicate with your laboratory staff, but the degree to
which the issue of vomiting the hyperosmolar glucola needs to be
regulated by the laboratory, is a really local decision.

If a patient does not tolerate the standard glucola solution, then many
providers will simply take over from the laboratory and administer their
own better tolerated (and hence more successful) alternative methods of
carbohydrate loading, e.g., polycose, jelly beans, or a proscribed
standard breakfast

It is really a matter of local politics about who takes over after the
laboratory's standard method has failed.

If your medical staff chooses to have the laboratory continue to try to
document possible glucose intolerance in pregnancy, then polycose is
sometimes easier for the laboratory to administer (using the simple
formula above).

In a way the polycose drink is more similar to a glucola drink, than to
a standard mixed meal or jelly beans, so it may more easily fit into the
laboratory flow.

In many other centers, if the patient has not tolerated her glucola,
then the Clinic takes over and gives the polycose, jelly beans, standard
mixed meal, etc a few days later...instead of the laboratory

In our setting, the laboratory's role prefers its role to be the
performance of the glucose test, not to judge which carbohydrate source
the clinician has chosen to provide the provocative carbohydrate load. 

Some facilities keep polycose in clinic to mix up with the assistance of
the pharmacy, not the laboratory. If you have trouble finding polycose
in your facility, then first contact staff in your nursery.

**Other Resources:**

**Alternate Carbohydrate Sources** page of

DIABETES IN PREGNANCY: PART 1: Screening and Diagnosis

[[http://www.ihs.gov/MedicalPrograms/MCH/M/DP08.cfm]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/DP08.cfm)

**Diabetes Mellitus in Pregnancy Screening and Management Guidelines**

ANMC Women's Health Service

(Look on Appendix 15)

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DMPreg102504_000.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DMPreg102504_000.doc)

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<http://www.who.int/en/>

World Health Organization Laboratory and Monitoring of Diabetes
Mellitus, 2002

(Solutions containing oligosaccharides, page 16)

<http://www.who.int/en/>

**Increased Gastric Emptying with polymer / Delayed Gastric Emptying
with glucose**

[Costalos
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Costalos+C"%5BAuthor%5D),
[Russell
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[Al Rahim
Q](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Al+Rahim+Q"%5BAuthor%5D),
[Blumenthal
I](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Blumenthal+I"%5BAuthor%5D),
[Hanlin
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hanlin+S"%5BAuthor%5D),
[Ross
I](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ross+I"%5BAuthor%5D).
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Foster C, Costill DL, Fink WJ. Gastric emptying characteristics of
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Hunt JN. The duodenal regulation of gastric emptying Gastroenterology
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Leonard JR, Free AH. A note on gastric retention in one hour, two dose
glucose tolerance tests. J Lab Clin Med 1945; 30:1070-1071

Lind T, Hytten FE. Blood glucose following oral loads of glucose,
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<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=5353351>

[Seiple
RS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Seiple+RS"%5BAuthor%5D),
[Vivian
VM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Vivian+VM"%5BAuthor%5D),
[Fox
EL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Fox+EL"%5BAuthor%5D),
[Bartels
RL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bartels+RL"%5BAuthor%5D).
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