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The challenges of achieving postprandial glucose control using closed‐loop systems in patients with type 1 diabetes

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Gingras, Véronique, Taleb, Nadine, Roy‐Fleming, Amélie, Legault, Laurent, Rabasa‐Lhoret, Rémi·2018·Diabetes, Obesity and Metabolism
DOI 10.1111/dom.13052PMC PMC5810921
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Abstract

For patients with type 1 diabetes, closed‐loop delivery systems ( CLS ) combining an insulin pump, a glucose sensor and a dosing algorithm allowing a dynamic hormonal infusion have been shown to improve glucose control when compared with conventional therapy. Yet, reducing glucose excursion and simplification of prandial insulin doses remain a challenge. The objective of this literature review is to examine current meal‐time strategies in the context of automated delivery systems in adults and children with type 1 diabetes. Current challenges and considerations for post‐meal glucose control will also be discussed. Despite promising results with meal detection, the fully automated CLS has yet failed to provide comparable glucose control to CLS with carbohydrate‐matched bolus in the post‐meal period. The latter strategy has been efficient in controlling post‐meal glucose using different algorithms and in various settings, but at the cost of a meal carbohydrate counting burden for patients. Further improvements in meal detection algorithms or simplified meal‐priming boluses may represent interesting avenues. The greatest challenges remain in regards to the pharmacokinetic and dynamic profiles of available rapid insulins as well as sensor accuracy and lag‐time. New and upcoming faster acting insulins could provide important benefits. Multi‐hormone CLS (eg, dual‐hormone combining insulin with glucagon or pramlintide) and adjunctive therapy (eg, GLP ‐1 and SGLT 2 inhibitors) also represent promising options. Meal glucose control with the artificial pancreas remains an important challenge for which the optimal strategy is still to be determined.

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  • Current algorithms are primarily responsive to immediate glycemic changes and may not fully compensate for delayed carbohydrate absorption, especially from meals rich in fat and protein that can induce delayed hyperglycemia.

    “However, current algorithms are primarily responsive to immediate glycemic changes and may not fully compensate for delayed carbohydrate absorption, especially from meals rich in fat and protein that can induce delayed hyperglycemia [131, 132, 158].”

    From Diabetic gastroparesis: pathophysiology and impact on insulin timing choices (2026) · cites this paper as [158]

    The ‘Nutrient absorption and impact of other macronutrients’ section reports prolonged hyperglycemia after fat- and protein-rich meals and increased glucose after a high-fat meal using a closed-loop system (page not provided). The ‘Insulin PK/PD’ section describes reactive insulin delivery and difficulty controlling post-meal excursions. But the paper does not establish that current algorithms fail to compensate for the delayed effects of fat and protein; it says closed-loop systems may have time to adjust and that studies are needed. (LLM, conf=0.85)

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Authors
Gingras, V., Taleb, N., Roy‐Fleming, A., Legault, L., & Rabasa‐Lhoret, R.
Affiliations
  • Montreal Clinical Research Institute (CA)
  • Montreal Children's Hospital (CA)
  • Metabolic Diseases Unit Institut de Recherches Cliniques de Montréal Montréal Québec Canada
ORCID
Venue
Diabetes, Obesity and Metabolism
Publisher
Wiley
Published
2017-08-10
Volume
20
Issue
2
Pages
245-256
ISSN
  • 1462-8902 (ISSN-L)
  • 1463-1326
DOI
10.1111/dom.13052
PMC
PMC5810921
OpenAlex
W2728705426
Cited by
113
References
7
Citations by year
2026: 11 · 2025: 11 · 2024: 10 · 2023: 11 · 2022: 14 · 2021: 13 · 2020: 15 · 2019: 10 · 2018: 13 · 2017: 4 · 2016: 1
FWCI
1.67
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Diabetes Obesity and Metabolism (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health
  • Juvenile Diabetes Research Foundation International
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Keywords
type 1 diabetes, closed-loop systems, artificial pancreas, postprandial glucose control, pramlintide, glucagon, GLP-1 receptor agonists, SGLT2 inhibitors, rapid-acting insulin, sensor accuracy, insulin pump, children and adults
MeSH terms
Adult, Algorithms, Blood Glucose, Child, Combined Modality Therapy, Diabetes Mellitus, Type 1, Diet, Diabetic, Humans, Hyperglycemia, Hypoglycemia, Pancreas, Artificial, Postprandial Period, Meals

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