White-bread

Rethinking Bedtime Snacks for Type 2 Diabetics

I had an obese Type 2 diabetic patient at one of my jails recently who wrote a long grievance about not receiving a bedtime snack.  He argued in the grievance that he had received a bedtime snack at previous facilities where he was incarcerated (which was true) and a bedtime snack was “the standard of care” for Type 2 diabetics.  I thought that this argument was ridiculous, especially since this patient routinely purchases lots of candy bars and Ramen Noodles from the commissary (think 30-40 candy bars a week).

However, despite the fact that bedtime snacks are routine at many correctional facilities, I believe that bedtime snacks for Type 2 diabetics in a correctional setting is, in most instances, a bad idea and bad medical care.   I would like to discuss why this is so by discussing what our overall goals for Type 2 diabetic management are, where the whole idea of diabetic snacks came from in the first place, and then present three cases.

What Are Our Dietary Goals for Type 2 Diabetics?

Let’s begin by agreeing on our overall treatment goals for Type 2 diabetics.  Type 2 diabetics have a disorder of carbohydrate metabolism.  We call this “Insulin Resistance.”  However, this does not mean that the insulin that the patient produces is damaged or malfunctioning; it means (simplistically stated) that the insulin is being overwhelmed by the amount of work it has to do.  So the first principle of Type 2 diabetes management is to decrease consumption of carbohydrates, especially quickly absorbed “white” carbohydrates like sugar and processed flour.  When we order a “Diabetic Diet” in a correctional setting, that is what we are getting:  Fewer carbs, especially sugar and other quickly absorbed carbs.  This decreases the pressure on the pancreas to make ever more insulin.

The second overall treatment goal of most Type 2 diabetics is for most patients to lose weight.  Type 2 diabetes is intricately tied to fat stores, to that point that many Type 2 diabetics can literally be cured if they lose enough weight.

Therefore, the first two fundamental principles of treatment of Type 2 diabetes are for the patient to lose weight and to decrease their consumption of carbohydrates. Compared to a non-diabetic, the Type 2 diabetic should consume fewer calories (so he can lose weight) and should consume fewer carbohydrates (to reduce the work load that his insulin has to perform).

But what happens when we prescribe a diabetic snack?  As is routinely done in the correctional centers I have seen, the diabetic who gets a snack receives MORE calories and MORE carbohydrates than the non-diabetic counterpart.

History of the Diabetic Snack

So where did this idea that diabetics need a night time snack come from?  As far as I can determine, there were 2 historical sources of this practice.  The first was a concern for hypoglycemia.  When the oral hypoglycemics and long acting NPH insulin came on the market, the concern was that if a patient was not absorbing carbs steadily throughout the night, the hypoglycemic agent would make them hypoglycemic during the night.  It is important to remember that at the time, there was no quick and easy way to measure current blood sugar levels.  The first oral hypoglycemics, the sulfonylureas, were introduced in the the 1940s and NPH insulin was introduced in 1950.  However, the first finger stick glucose measuring systems were not mass marketed until the 1980s.  So for the first 30 years or so that long acting insulin and oral hypoglycemics were used, there was no way to easily know what a patient’s blood sugars were running.  Night time was thought to be the time of highest risk for hypoglycemia, so it made sense for the patient to have a stomach full of carbohydrates in case they were needed.

That is not the case nowadays.  We can quickly and easily know exactly what an individual patient’s bedtime sugar is.  If the patient’s bedtime blood glucose level is 400, there is little chance they are going to become hypoglycemic overnight.

The second historical source of the bedtime snack comes from the idea that a more constant and consistent absorption of carbohydrates would be easier for the diabetic to metabolize than a few big boluses.  In other words, six smaller meals would be better than three larger meals.  The idea, though, behind this is that the total number of calories and carbohydrates consumed during the day would be the same—the patient would have a target number of calories and carbohydrates and they can divide these among  6 meals rather than 3.  However, this is not what is usually done in corrections.  The diabetic snack is added on top of the diabetic diet.  The diabetic and the non-diabetic eat the same number of calories for breakfast, lunch and dinner and then the nighttime snack is added on as EXTRA calories and carbs for the diabetic.

So there is a correct way to incorporate a bedtime snack for a Type 2 diabetic, that is to basically have four meals instead of three.  At breakfast, lunch and dinner, the diabetic will consume fewer calories thatn the non-diabetic counterpart, but will make up those calories with the fourth meal–the bedtime snack.  I just have never seen it done that way.

To summarize, the benefit of a bedtime snack for a Type 2 diabetic is to prevent hypoglycemia.  The potential adverse consequence of a bedtime snack is that the patient receives extra calories and extra carbohydrates that not only are not needed, in fact are bad for the long term health of the patient.

Let’s discuss these principles in relation to three hypothetical patients:

  1.  Patient one weighs 350 pound.  His last HbA1C was 11.5.  He is treated with metformin and Lantus.  His average blood sugar at bedtime is 280.  Would this patient benefit from a bedtime snack?  The answer is no.  With an average bedtime blood sugar of 280, he is highly unlikely to experience hypoglycemia at night.  Also, he needs to lose weight and cut carbohydrate consumption.  A bedtime snack will add calories and add carbs to his diet, both bad ideas.  He should not receive a night time snack.
  2. Patient two takes only Metformin for her diabetes.  Her last HbA1C was 7.4.  Should she get a bedtime snack?  To answer this question, we need to remember that Metformin is not a hypoglycemic agent.  It will not lower blood sugar.  With regards to hypoglycemia, this patient is actually less likely to experience night time hypoglycemia than a non-diabetic patient.  Her blood sugars run higher than normal and she is not taking a hypoglycemic agent.  A night time snack will not reduce her chance of hypoglycemia, since she will never experience it in the first place.  Again, a bedtime snack will just give her more calories and carbohydrates.
  3. Patient 3 takes a hypoglycemic, say Lantus, and his night time blood sugars have actually been trending towards hypoglycemia, say ranging from 65-85.  Should this patient receive a bedtime snack?  The answer to this is no; instead this patient should have his Lantus stopped.  If his blood sugars are trending that low at bedtime, he does not need Lantus or any other hypoglycemic agent.  He is being over-treated.

I actually cannot think of a situation in which a night time diabetic snack would be beneficial to a Type 2 diabetic.

The last factor to consider with regards to this practice is the cost.  How much money does your institution spend on bedtime snacks?  If they are not helpful, and maybe even harmful, that is money wasted that you could better spend on other things.  As an example, the Idaho Prison system (a small prison system by national standards) spends just over $84,000.00 a year on bedtime snacks for diabetics.  That may not be much in a budget of millions of dollars, but $84,000.00 is $84,000.00.  If bedtime snacks give little or no benefit, then this money would be better spent on something else.  I personally can think of at least one way this money could be used much more beneficially in the Idaho Department of Corrections–$84,000.00 a year would easily fund an Electronic Medical Record system.  Patients in the IDOC, in my opinion, would get much more tangible medical benefit from an Electronic Medical record than they are getting from bedtime snacks.

This is an editorial.  You are free to disagree. 

Do you have an opinion about diabetic diets?  Please comment!

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9 thoughts on “Rethinking Bedtime Snacks for Type 2 Diabetics

  1. Lynda Ellis

    I totally agree with not giving Type 2 diabetics an HS snack. We stopped giving Type 2 diabetics HS snacks about 7-8 yrs. ago. After talking to a local dietitian we have put all diabetics on the same diet as other inmates. We have less extremely highs and lows in the younger more brittle diabetics. Diabetics were trading food and commissary items to get what they wanted so at least by putting everyone on the same diet the physician could better manage their insulin doses.

    Reply
      1. chris weede

        Not connected with prison system, just a diabetic looking for info on bedtime snacks and stumbled into this. The only situation where a bedtime snack helps (it helps me)-is where you are ‘dumping’ glucose at night. I eat generally 100gs of carb or less a day – alot of protein and ‘good fats’. Olives, avacados, low at cheese,natural peanut butter. I use about 2000mgs of metformin a day(1000 at night, 1000 in morning) My Fasting was averaging 130ish, sometimes lower, sometimes in the 150+ range. Post prandials with low carbs stay in the under 140 range 1 hr pp. If I get all my carbs from veggies and low sugar fruits and have very little sugar, I usually am in the 120s after 1 hour. Of course I have to make up the calories with chicken, fish, pork chops, lean beef etc.. I have spot checked at night without eating a snack and what happens is I will get down to 85ish and ‘dump’ glucose til it reaches about 160 at 2-3am. 137 at 7am and back to normal if I don’t eat at 12pm. With a night snack (avacado, cheese, peanut butter , lean ham in some combination (250 ish calories) etc.. fat and protein basically – my fasting is averaging about 107. I have been ‘pre’ diabetic a1c 6.8 and on metformin for years and I recently flared up to 8.0a1c and started testing for fasting and before and after meals to see how food affects me. Anyway – this night”dumping” can be tamed with a snack – but it is probably cheaper to put prisoners on insulin than give them massive amounts of veggies for carbs and lean protein – with good fats thrown in to balance sugars. I think this king of high veggie carb, protein and good fat diet keeps sugars low during the day and a snack keeps the body from spiking at night. I have indeed woken up several times to check my levels in the night and I do this dumping every night without a snack.

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  3. Joe

    You wrote that: “…we need to remember that Metformin is not a hypoglycemic agent. It will not lower blood sugar.”

    That has not been my experience. Also, according to the National Library of Medicine:

    Metformin is used alone or with other medications, including insulin, to treat type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood). Metformin helps to control the amount of glucose (sugar) in your blood. It decreases the amount of glucose you absorb from your food and the amount of glucose made by your liver. Metformin also increases your body’s response to insulin, a natural substance that controls the amount of glucose in the blood. Metformin is not used to treat type 1 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood).
    Source:
    http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000974/

    Reply
  4. Mindyleigh

    Another issue this would effectively curtail is the amount of requests for “diabetic evaluation” in hopes of getting that night-time snack. The amount of time that takes is notable. The provider will order two weeks of bid checks and I, as the nurse, may have to spend time twice a shift rolling my supplies into max/seg, for instance, so that I can test the glucose of someone who is not diabetic but hopes beyond hope that they will qualify for extra food. Of course, some of this falls on the provider for…falling for it. ;-)

    Reply
    1. Jeffery Keller MD Post author

      Excellent comment, Mindy! Sometimes practitioners make unnecessary extra work for nurses just because it is easier to order the work than to do it. Why not just do two fasting blood sugars? Or three? Surely that gives you all the information you need. Also, a HbA1C costs just $4.00. That is cheaper than making the nurses do all this work!

      Reply
  5. Tina Marinaccio MS RD CPT

    I did a study in a hospital I worked in where we d/c’d HS snacks x 3 days, and overall, the patients had better glucose control. We used the data to present to the State during survey to show quality improvements, and to justify discontinuing HS snacks, unless the patient asked for it, or if they were low. In the hospital setting, patients are stressed, sedentary, are on a lot of meds – some on steroids, etc., so they tend to run high anyway. I agree with decreasing medication, rather than giving more food if the patient is low, and discontinuing HS snacks saves labor and food costs, and solves infection control issues. However, I have found in the free living population in my private practice, from time to time I will have a patient who has better a.m. glucometers when they have a small snack at night, about 200 kcals, combining fat, pro, and carbs. This may be an example of the Somogyi Phenomenon, where they have a low in the middle of the night which causes the liver to rebound with glucose.

    Reply
    1. Jeffery Keller MD Post author

      Thanks for the comment, Tina! There are indeed patients who would benefit from a bedtime snack–as you have said. They just tend to be far outnumbered (20 to 1?) by those in whom a bedtime snack worsens the condition rather than helps. This is especially true if the bedtime snack is added to the regular diet, thus adding calories and carbs, as is done in many correctional facilities. It probably is never helpful if the patient in question is buying and consuming lots of junk carbs from the commissary.

      Reply

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