Postprandial Glucose Dynamics and Associated Symptoms in Type 2 Diabetes Mellitus

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       Postprandial Glucose Dynamics and
       Associated Symptoms in Type 2
       Diabetes Mellitus
       Boris Kovatchev, PhD*
       Daniel J. Cox, PhD*
       Kent H. Summers, PhD†
       Linda Gonder-Frederick, PhD*
       William L. Clarke, MD*

       *University of Virginia Health System, Charlottesville, Va
       †
        Eli Lilly & Company, Indianapolis, Ind

       This research was supported by Eli Lilly & Company, Indianapolis, Ind.

       KEY WO R D S : postprandial glucose,              limit the magnitude of post-meal BG fluc-
       hyperglycemia, type 2 diabetes mellitus           tuation may reduce its symptomatic and
                                                         cognitive consequences.

                                                         INTRODUCTION
       ABSTRACT                                          In nondiabetic individuals postprandial glu-
       Objectives: This study examined the               cose (PPG) fluctuations are limited in both
       dynamics of postprandial glucose (PPG)            their peak value [rarely exceeding 7.8
       and symptoms among adults with type 2             mmol/L (140 mg/dL)] and in their dura-
       diabetes mellitus (T2DM) in their natural         tion, with a peak PPG approximately 1
       environment. Using a hand-held computer           hour after the start of a meal, returning to
       for 70 trials, 36 adults with T2DM rated          preprandial levels within 2-3 hours. 1 In
       symptoms, performed tests, and measured           individuals with type 1 diabetes (T1DM) or
       their blood glucose (BG).                         type 2 diabetes mellitus (T2DM) a number
                                                         of factors, such as inadequate available
       Results: The mean peak PPG value was
                                                         insulin, delayed insulin action, or abnor-
       11.3 mmol/L achieved 2-3 hours after meal,
                                                         malities in glucagon secretion, contribute
       while highest symptom ratings and cogni-
                                                         to delayed peak PPG, and higher and pro-
       tive slowing were observed within the first
                                                         longed PPG elevation.1 The American
       hour after meal, at a time corresponding to
                                                         Diabetes Association Consensus Statement
       the steepest slope of PPG increase. Thus,
                                                         on postprandial hyperglycemia concluded
       we hypothesized that postprandial symp-
                                                         that “in general, a measurement of plasma
       toms maybe related to a higher rate of BG
                                                         glucose 2 h after the start of a meal is prac-
       increase, which was confirmed by high cor-
                                                         tical, generally approximates the peak value
       relations (r = 0.5-0.75) between symptom
                                                         in patients with diabetes, and provides a
       ratings and BG rate of increase.
                                                         reasonable assessment of postprandial
       Conclusions: We conclude that postprandi-         hyperglycemia.” 1
       al symptom elevation is related to the rate
                                                              However, the dynamics of PPG are
       of BG increase, thus treatments designed to
                                                         complex, dependent on many factors, such

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     as the amount and the composition of the          physiological as well as epidemiologic stud-
     meal, and still not well understood. Even         ies that excessive post-load glucose excur-
     though a linear relationship between post-        sions have acute and chronic harmful
     prandial and post-challenge (after a 75-g         effects on the endothelium and vessel
     oral glucose load) glucose 2 hours after a        wall.”3 Thus, an assessment of PPG dynam-
     meal was established in laboratory condi-         ics in the natural environment would be a
     tions,2 the dynamics of this relationship in      valuable tool for evaluation of glycemic
     the field is difficult to assess.3 Perhaps as a   control.
     result of the lack of a standard PPG assess-           In addition to the long-term negative
     ment, the usual clinical appraisal of             effects of elevated PPG, clinical experience
     glycemic control includes only better-            suggests a relationship between postprandi-
     defined and more stable measures, such as         al hyperglycemia and acute and transient
     fasting plasma glucose (FPG) and/or glyco-        increases in psychological symptoms and
     sylated hemoglobin (HbA1c). However,              cognitive disruptions.2,16-18 However, there
     FPG reflects blood glucose (BG) values            have been no prospective and objective
     after the effect of carbohydrate intake has       investigations of the relationship of such
     been eliminated and HbA1c represents the          symptoms/cognitive dysfunctions with post-
     average BG over a certain period of time,         prandial BG parameters, especially with
     which makes both of these measures insen-         parameters of postprandial BG dynamics in
     sitive to BG excursions throughout the            the natural environment of people with dia-
     day—in particular to PPG fluctuations. For        betes. For example, it is unclear whether
     example, a recent study4 of more than 800         the peak absolute value of PPG is responsi-
     people with T2DM found that after meals,          ble for triggering symptoms, or symptoms
     many subjects had glucose levels >8.9             are mainly related to the speed and magni-
     mmol/L (160 mg/dL) and/or glucose excur-          tude of BG increase post-meal. This study
     sions >2.2 mmol/L (40 mg/dL) despite              investigates when BG peaks in T2DM
     HbA1c
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       Procedure                                        (Lifescan, Milpitas, Calif.). Three precau-
       Subjects completed a series of psychomet-        tions were taken to encourage and monitor
       ric instruments, including the Beck              whether symptom entries and cognitive test-
       Depression Inventory. They were then             ing preceded SMBG. (1) Each HHC trial
       instructed to use the Handspring Visor           began with the message, “No blood sample
       Platinum, (Handspring, Inc, Mountain             yet.” (2) The HHC tracked the elapsed time
       View, CA) hand-held computer (HHC)               between the prompt “Measure your BG”
       immediately before self-monitoring of            and the entry of this SMBG reading. Since
       blood glucose (SMBG). No specific SMBG           at least 10 seconds are required for a sub-
       schedule was given to the subjects; they         ject to lance a finger, collect a blood sam-
       were required only to complete 70 HHC tri-       ple, and analyze BG level with the One
       als within 3-4 weeks. The HHC was                Touch Ultra, any readings entered in less
       equipped with our custom-developed symp-         than 10 seconds were considered invalid.
       tom/behavioral assessment software. At           (3) The BG readings entered by the subjects
       each trial the HHC first collected data on       into the HHC were compared to data in the
       perceived symptoms and cognitive perform-        glucometer’s memory to ensure accuracy of
       ance. Then, subjects measured and entered        SMBG results. An earlier version of this
       their BG level.                                  HHC routine developed for Psion 250 HHC
       Symptoms. At each trial the HHC presented        was used in our previous studies of symp-
       in a random order 16 symptoms and                toms and behaviors related to hypo-
       prompted subjects to rate them on a scale        glycemia.19-21
       from 0 = none to 6 = extreme. There were 6       Data Analysis
       physical symptoms (need to urinate;              BG values were averaged across all subjects
       sweet/funny taste; dry eyes, nose, mouth;        in 10 time intervals post-meal and plotted
       tired/fatigued; thirsty; nausea), 6 mood         and compared using univariate ANOVA. To
       symptoms (nervous/anxious; irritable/frus-       obtain comparable estimates of average BG
       trated; restless/jittery; sad/blue;              across these intervals, each time interval
       giddy/funny; don’t care/apathetic), and 4        was at least one half-hour in duration and
       cognitive symptoms (difficulty concentrat-       was required to contain at least 200 SMBG
       ing; difficulty speaking; uncoordinated;         readings, that is, at least 8% of all
       slowed thinking).                                HHC/SMBG readings. This approach
       Cognitive tests. The HHC presented the fol-      resulted in approximately equal weights (in
       lowing tests: (1) 10 mental subtraction prob-    terms of number of readings) of the time
       lems that used randomly generated 3-digit        intervals.
       numbers, with subjects entering answers on       Symptoms and cognitive test performance.
       a number pad; and (2) 2 levels of the Paced      In order to eliminate the influence of hypo-
       Serial Addition Test (PSAT) presenting a         glycemia, symptom ratings and test results
       sequence of single-digit numbers for which       were considered only if BG was greater
       the subject has to enter the sum of each pair    than 6.7 mmol/L (120 mg/dL). In order to
       of sequential numbers. Levels 1 and 2 of         evaluate the magnitude of each individual
       the test present numbers at 4-second and 2-      postprandial symptom its ratings were aver-
       second intervals, respectively.                  aged across subjects at 1-hour time inter-
       Other parameters. The HHC asked subjects         vals post-meal and compared using
       to enter the time when “you began eating         univariate ANOVA. The average symptom
       your last meal” and at the end of each trial,    magnitude in each category, (physical,
       the subjects were prompted to measure and        mood, and cognitive) was computed as well.
       enter their BG. For the latter all subjects      Similarly, cognitive impairment was
       used One Touch Ultra glucometers                 assessed using the time to complete 10

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     Figure 1. Postprandial blood glucose (BG) levels and postprandial increase in overall symptom
     reporting are plotted against elapsed time after a meal (x-axis in minutes). The postprandial BG
     values (black squares) are presented in the primary y-axis and demonstrate a peak PPG value
     at approximately 2.5 – 3 hours after a meal. The number of elevated postprandial symptoms
     (symptoms with ratings greater than 0 over the course of PPG) is presented in the secondary y-
     axis (black triangles) and demonstrates a peak symptom reporting within 1 hour after a meal.

     mental subtractions and the number of cor-         ject’s BG rate of increase (BGRI). This
     rect additions on the faster (Level 1) and         variable is similar to the previously reported
     slower (Level 2) PSAT, averaged at 1-hour          BG rate of change,22 but takes into account
     intervals post-meal. Average postprandial          only increases in BG, not overall fluctua-
     BG 1, 2, and 3 hours after meal was corre-         tions. Specifically, BGRI was computed as
     lated with corresponding symptom ratings           the average of the ratios (BG(t2)-BG(t1))/(t2-
     and cognitive performance results. In order        t1), where BG(t2) > BG(t1) were any two
     to account for multiple tests we used              increasing consecutive SMBG readings of a
     Bonferroni corrections, accepting only             subject taken at times t2 and t1 within the
     results significant at P 6.7 mmol/L.                                     days). However, since fast BG increases are
     Rate of BG increase. From each subject’s           predominantly observed after meals, we
     SMBG data collected concurrently with the          assumed that BGRI was mostly influenced
     HHC, we computed an estimate of this sub-          by postprandial BG elevation.

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       Table 1. Average Postprandial Symptom Ratings* and Cognitive Test Performance.

                                              Pre-prandial        Postprandial Ratings              F (P)
                                                              1h            2h         3h

              Need to urinate                        1.0      1.7           1.3        1.2      7.7 (
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       Table 2. Correlations of Average Symptom Ratings* and Cognitive Test Performance with
       Blood Glucose Rate of Increase.

                                                                      Correlation Coefficients**
                                                               1h              2h              3h
                 Need to urinate                              0.48            -0.02           0.02
                 Sweet/funny taste                            0.39            0.01            0.08
                 Dry eyes, nose, mouth                        0.46            -0.05           -0.02
                 Tired/fatigued                               0.41            0.21            0.18
                 Thirsty                                      0.33            0.08            0.03
                 Nausea                                       0.42            0.02            0.12
                 Average magnitude of physical
                  symptoms                                    0.52            0.06            0.09

                 Nervous/anxious                              0.69            0.48            0.43
                 Irritable/frustrated                         0.56            0.28            0.33
                 Restless/jittery                             0.50            0.52            0.45
                 Sad/blue                                     0.68            0.53            0.44
                 Giddy/funny                                  0.50            0.07            -0.06
                 Not care/apathetic                           0.66            0.54            0.37
                 Average magnitude of mood
                  symptoms                                    0.70            0.49            0.44

                 Difficulty concentrating                     0.60            0.39            0.30
                 Difficulty speaking                          0.75            0.34             .25
                 Uncoordinated                                0.76            0.52             .22
                 Slowed thinking                              0.58            0.34             .31
                 Average magnitude of cognitive
                  symptoms                                    0.74            0.44            0.30

                 Time to complete 10 mental
                  subtractions (sec.)                         0.27            0.06            0.02
                 PSAT – Level 1
                 Number correct answers                       -0.21           -0.21           0.18
                 PSAT – Level 2
                 Number correct answers                       -0.26           -0.02           0.15

       * Using a scale from 0 = none to 6 = extreme.
       ** With this sample size correlations above 0.37 yield P-levels below P= 0.05, while correlations above
       0.47 are significant at P = 0.01. The latter are indicated in bold.

       Postprandial Symptoms and Cognitive                   (Table 1).
       Slowing                                                   Specifically, 5 of the 6 physical symp-
       Most physical, mood, and cognitive symp-              toms were rated higher post-meal: subjects
       toms displayed similar patterns of highest            reported a greater need to urinate (F = 7.7,
       average rating within the first hour after            P
KovatchevJARFall03     12/29/03    2:40 PM    Page 455

     thirst (F = 11.2, P
KovatchevJARFall03    12/29/03    2:40 PM    Page 456

     tions with BGRI were highest within 1 hour     design of the study was that the BG rate of
     post-meal, and gradually decreased at 2 and    increase could not be computed strictly for
     3 hours post-meal. Since PPG increase          pre-to-postprandial periods, that is, the
     slowed down at 2 and 3 hours post-meal,        slope of PPG increase could not be estimat-
     and the PPG curve gradually flattened, this    ed directly. This was due to the lack of suf-
     was precisely the effect to be expected if     ficient number of BG readings within a
     symptoms were related to PPG increase and      pre- and corresponding postprandial peri-
     not to extreme PPG values. With this sam-      od; at least two, pre-and postprandial, read-
     ple size (N = 36) correlations above 0.47      ings on several days per subject are needed
     yielded P-levels below 0.01 and were con-      in order to estimate PPG slope.
     sidered significant. Several correlation            Instead, we confirmed a less specific
     coefficients were above 0.6. For example,      hypothesis: higher postprandial symptoms
     the average magnitude of “difficulty speak-    are related to higher overall BG rate of
     ing” and “uncoordinated” 1 hour post-meal      increase. The BGRI was based on a previ-
     produced a correlation coefficient of 0.75-    ously reported measure, BG rate of
     0.76 with BGRI (see Table 2).                  change,22 but it took into account only con-
                                                    secutively increasing SMBG readings, not
     DISCUSSION                                     any two consecutive readings. As computed
          This study used new monitoring tech-      here, BGRI was not specific to postprandial
     nology (HHC and custom software) to            time periods; however, we assumed that it
     assess in-the-field dynamics of postprandial   was most influenced by the largest (per
     BG and associated symptoms and cognitive       hour) BG increases that subjects experi-
     impairment in adults with type 2 diabetes      enced post-meal. Indeed, it was illogical to
     mellitus. Our data allowed for a reconstruc-   expect that large and fast BG elevations
     tion of PPG dynamics in our subjects’ natu-    could have occurred with no relationship to
     ral environment and confirmed laboratory       a preceding significant carbohydrate intake.
     observations and common knowledge that         Thus, we could speculate that the process of
     PPG is most elevated 2-3 hours after meal. 1   PPG elevation contributed to symptoms
     In addition, we demonstrated that after        more than the absolute values of postpran-
     meals self-reported physical symptoms and      dial hyperglycemia. While this speculation
     moods became significantly elevated, and       may be confirmed (or rejected) by future
     that objectively determined cognitive slow-    studies, here we were able to clearly
     ing of approximately 30% was apparent.         observe two related properties: (1) symp-
          Surprisingly, however, symptom eleva-     tom ratings were higher during the first
     tion and cognitive slowing did not follow      hour post-meal and this was the period of
     the course of absolute PPG values. Instead,    steepest slope of PPG increase, and (2)
     for most symptoms highest symptom rat-         postprandial symptoms were highly corre-
     ings were observed within 1 hour after a       lated with subject’s overall rate of BG
     meal (Table 1), not when PPG was at its        increase.
     peak 2-3 hours post-meal. Overall, plotting         In fact, the correlations between mood
     a summary of all symptoms and PPG              and cognitive symptoms and BGRI were
     against the time elapsed after a meal          very high, in some cases higher than 0.7
     revealed that symptoms generally occurred      (Table 2). Given that symptom ratings were
     during the time of steepest slope of PPG       derived from behavioral self-assessment,
     increase (Figure 1). Thus, we hypothesized     while BGRI was derived from concurrent
     that postprandial symptoms occurred during     but quite different sets of SMBG data
     times when BG increase was fastest. With       downloaded from the subjects’ glucometer
     our data, however, we could not definitely     memories, correlations of that magnitude
     confirm this notion. One limitation in the     imply very strong [linear] relationships.

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KovatchevJARFall03       12/29/03        2:40 PM      Page 457

       Thus, the magnitude and speed of BG                       2.   Wolever TMS, Palmason C, Chiasson J, et al.
                                                                      Variation of postprandial plasma glucose, palata-
       increase post-meal may be the single most                      bility, and symptoms associated with a standard-
       significant determinant of postprandial                        ized mixed test meal versus 75 g oral glucose.
       symptoms.                                                      Diabetes Care. 1998;21:336-340.
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       slowing must be considered. For example,                       2029.
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                                                                      1826.
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                                                                 6.   Caputo S, Pitocco D, Ruotolo V, Ghirlanda G.
       to address these issues.                                       What is the real contribution of fasting plasma
            The results of this study imply that in                   glucose and postprandial glucose in predicting
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                                                                      Diabetes Care. 2001;24:2011-2011.
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                                                                 7.   The Diabetes Control and Complications Trial
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