Endocrine Society Report Addresses Post-Meal Glucose in Diabetes

Miriam E. Tucker

October 15, 2019

A new report from the Endocrine Society highlights the challenge of postprandial glucose management for people with insulin-requiring diabetes, providing some recommendations but also pointing out the major knowledge gaps. 

Mealtimes can be a difficult experience for individuals with diabetes. After a meal, blood glucose levels may soar as the food digests or unexpectedly plummet if an insulin dose was more than the meal required.

Although advances in the field are providing more data on post-meal blood glucose, further research is needed to help adults with diabetes set concrete goals, according to the recommendations, which summarize a meeting convened by the Endocrine Society that took place in December 2018 and are now published in the Journal of the Endocrine Society.

The meeting and subsequent document were prompted by the ongoing challenge of managing glucose levels after a meal, but also the opportunity afforded by newer faster-acting insulins and non-insulin medications, and the increasing uptake of continuous glucose monitoring (CGM), said John (Jack) L. Leahy, MD. Leahy led the expert panel that made the recommendations and is professor of medicine and chief of the Division of Endocrinology, Diabetes, and Metabolism at the University of Vermont College of Medicine in Burlington.

CGM Will Help Inform How to Gauge a Healthy Postprandial Glucose

The report authors point out that many questions remain about optimal postprandial targets and ways of achieving them, as well as the relative contributions of postprandial, fasting, and overall glycemia to hemoglobin A1c levels and to long-term complications.

Thus, although providing some recommendations, the document is not a guideline because of the dearth of data, Leahy told Medscape Medical News.

"Postprandial glycemic control is clearly important, both high and low. But we're lacking specific guidelines. There are new and novel interventions but we don't know yet how best to use them," Leahy said.

"We still have a distance to go to know what a healthy postprandial state is and how to use CGM to obtain it," he noted.

At the same time, he said that the document is also a call for increased awareness — among both clinicians and patients — that "there's more to defining blood glucose control than just hemoglobin A1c. Fasting glucose levels are routinely measured but postprandial often remains a blinded area unless patients are using CGM."   

Thus, despite the current lack of specific data on optimal use, the panel does recommend the use of CGM for anyone on multiple daily insulin dosing, including those with type 2 diabetes as well as type 1 diabetes, Leahy said, noting that Medicare's coverage for CGM that began in 2017 marked a turning point.

"We're going to see more and more type 2 patients on CGMs as they become more visible...I think CGM is moving into the primary care world slowly, as patients are asking for it," he said.

The document also addresses quality of life.

"What's underappreciated is the impact of postprandial highs or lows or swings on quality of life. That's discussed in some detail in this document. Sometimes with CGM people see things they don't want to see," Leahy observed.

"We're Lacking Key Information. We Need Well-Designed Studies"

The report comprises six sections: 1) postprandial dynamics and biology, 2) current understanding of the clinical and quality of life impact of postprandial excursions, 3) managing postprandial excursions, 4) current and emerging management technologies, 5) need and recommendations, and 6) discussion.

Section 3 addresses lifestyle interventions such as low-carbohydrate diets and exercise timing, as well as pharmacologic approaches including fast-acting and inhaled insulin, pramlintide, and sodium-glucose cotransporter type 2 (SGLT2) inhibitors, which improve both fasting and postprandial glycemia.

Section 4 covers the roles of CGM, insulin pumps, and emerging closed-loop technologies in optimizing postprandial glucose levels.

And section 5 lays out the many unknowns around optimal postprandial targets, the contribution of postprandial glycemia to A1c, and the risk of diabetes-related complications. It also highlights the best strategies for minimizing postprandial excursions, including the use of technologies.

Leahy told Medscape Medical News: "One of the major conclusions from our meeting was that we lack important information to be able to make guidelines."

"It's in part a call to action that postprandial control is fundamentally important. CGM is changing our understanding...A lot of the recommendations in the document are pointing out important studies that are needed to allow guidelines. The message is we're still lacking key information. We need well-designed studies."

Leahy has reported serving as a member of advisory boards for Novo Nordisk and Merck.

J Endocr Soc. 2019;3:1942-1957. Full text

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