The clinical challenge
Carbohydrates are the major source of nutrition for the vast majority of humans. This becomes a challenge for persons living with diabetes, who, by definition, are intolerant to carbohydrates. Due to a variety of reasons, including taste, sociocultural expectations, and cost, it becomes difficult to limit carbohydrate consumption in many cases. This leads to hyperglycemia, as well as excessive glycemic variability. This in turn promotes the development of chronic vascular complications, and may precipitate acute metabolic crises.
Modern guidelines provide comprehensive information regarding strategies for glucose management, but do not focus specifically on the care of individuals who continue to consume high amounts of carbohydrate. A pragmatic approach is needed to address the needs of such persons.
A pragmatic solution
A straightforward way of mitigating carbohydrate intolerance would be to reduce carbohydrate load. This can be done by reducing the total carbohydrate intake, and distributing intake over small, frequent meals throughout the day. Glycemic load can be reduced by following the “protein first” approach (consuming proteins, salads, and soups before taking carbohydrates), and by preferring complex carbohydrates. Examples include eating beans, lentils, fish, or meat before taking rice, and using unrefined flour in place of refined flour.
The timing, duration, and intensity of exercise can be modified to reduce glycemic excursions after carbohydrate-rich meals. A post-meal walk can help improve the postprandial glycemic profile.
If pharmacologic measures are needed, certain diabetes medications are particularly well-suited to aiding the management of postprandial hyperglycemia. Alpha-glucosidase inhibitors (acarbose, voglibose) act by retarding the digestion of carbohydrates, while meglitinides (repaglinide, nateglinide) and sulfonylureas (glimipiride, gliclazide) promote insulin secretion. Immediate-release preparations of metformin may assist in lowering post-prandial glucose spikes after carbohydrate intake. Glucagon-like peptide 1 receptor agonists (liraglutide, dulaglutide, semaglutide) reduce appetite, and facilitate glycemic control by reducing food intake, as well as changing food preferences.
In insulin-requiring persons, postprandial control can be achieved by using ultra-rapid-acting insulin analogues (Fiasp/faster aspart, Lyumjev/lispro-aabc). These provide better 1-hour post-prandial control as compared with other rapid-acting insulins.
These non-pharmacological and pharmacological measures can help in controlling hyperglycemia due to carbohydrate intake.
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