Full Service Prison Cafeteria

In my previous post on Rethinking Diabetic Snacks for Type 2 Diabetics, I mentioned that there are two theoretical justifications for the practice or prescribing bedtime snacks for type 2 diabetics.  I would like to expound on these two issues here and also comment on another issue that I failed to mention in the first article but that is important:  the non-medical security issues of having diabetic snacks.

Myth:  Four Meals are Better than Three for Type 2 Diabetics

The first justification for diabetic snacks is the idea that if Type 2 diabetics eat several small meals rather than 3 big meals, there will be more even absorption of calories and carbs.  This would cause smaller blood sugar spikes at meals.  In other words, four meals (counting the bedtime snack) is better than three meals.

There are several problems with this theory.  The most important problem is that this theory has been categorically disproved.  Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications states “Food intake frequency–three meals or smaller meals and snacks–is not associated with long-term differences in glucose, lipid, or insulin responses.”   That statement is important.  Read it again.

The second problem with this theory is this:  If it is really healthier to eat more frequent, smaller meals, why stop at four meals?  Why not serve diabetics five total meals and snacks?  How about six?  And if that eating regimen is really healthier, why limit it to the diabetics?  Why not serve everyone the “healthier” regimen?

The third problem with serving three meals and a snack to diabetics is that they will be served more calories and more carbohydrates that non-diabetics.  I think that this is true even if your facility’s diabetic diet plan calls for the same number of calories and carbs divided four ways instead of three.  Look at it this way–you have kitchen workers (probably inmate workers), who are serving up hundreds of meals with, say, one cup of a certain food–and then a few diabetic trays with a smaller serving portion of that food.  Are the diabetic trays really going to have the smaller serving size?  I suspect instead that the inmate workers usually put approximately the same amount of food on the diabetic trays anyway.

Don’t believe it?  Then prove me wrong.  Do this experiment:  Pull twenty regular diet trays and twenty diabetic diet trays at random.  Include breakfast, lunch and dinner trays.  Pick something that is present on both trays but is supposed to be a smaller amount on the diabetic trays.  Weigh the portions.  Report back to me.  I suspect that you will find no difference.  So the bedtime snack for diabetics will be extra calories and extra carbs that they not only don’t need, but that is bad for their overall health.

Hypoglycemia.  Is it a concern in everyone?

The second reason theoretical justification for ordering a bedtime snack for diabetics is hypoglycemia.  By the way, hypoglycemia is the only reason given by the American Diabetic Association for ordering bedtime snacks in corrections.  The ADA has authored a position statement entitled Diabetes Management in Correctional Institutions.  This document should be required reading by all correctional practitioners.  With regards to snacks, Diabetes Management says “The use of insulin or oral medications may necessitate snacks in order to avoid hypoglycemia.  These snacks are a part of such patients’ medical treatment plans and should be prescribed by medical staff.”  Notice a couple of things about this statement.  First, there is no mention at all of the idea that four meals are healthier than three.  The only reason given for a diabetic snack is to negate the risk of hypoglycemia.  Second, the statement infers that not every patient who has Type 2 diabetes will need a snack to avoid hypoglycemia.  Snacks are part of an individual patient’s overall treatment plan.  Just like we don’t prescribe antibiotics to everyone with a cough, we should not prescribe snacks to everyone with diabetes.

Consider for a minute the newly diagnosed diabetic patient who receives counselling on lifestyle modification and losing weight but is not prescribed any medications (an appropriate first step according to many treatment algorithms).  What is this patient’s risk of hypoglycemia?  Should he receive an order for a night-time snack?  The answer is, of course, that this patient has less risk of hypoglycemia than non-diabetics. His blood sugars will run consistently higher than a non-diabetic.  There is no reason to order this patient a bedtime snack to prevent nighttime hypoglycemia.

What about the patient on metformin?  Well, metformin is not a hypoglycemic agent.  So again, the risk of hypoglycemia is less than that of a non-diabetic.  No snack.  Several other medications used for Type 2 diabetes are likewise not hypoglycemics, such as Actos, Avandia and Januvia.

What about patients on Lantus or Levemir?  I asked this question to my favorite diabetic education specialist (thank you Cindy Horrocks, RD, LD, CDE!) and here is part of her response:

“Generally, the guidelines regarding snacks dates back to the old types of intermediate insulin that peak (NPH, Lente, pre-mixed).  Now that there is great variability in the types of insulin and oral medications, it is generally thought that the meal plan can be set up safely without snacks.” 

Finally, as I mentioned in my previous article, we have technology available to us now that was not available when the first hypoglycemic agents were invented.  I speak, of course, of glucometers that can instantly tell us what a patient’s blood sugar is.  Why not use this technology to help decide which patients should be prescribed a diabetic snack?   Why give a patient a diabetic snack if her bedtime blood sugar is consistently 400?  She is in no danger of hypoglycemia.  A snack will make her worse, not better.

Security Implications of Diabetic Snacks

We practitioners in correctional institutions need to take into account the security implications of diabetic snacks.  Whether we intend it or not, inmates consider diabetic snacks to be a valuable commodity that confers status and power to those granted this privilege.  Inmates who do not get snacks are jealous of those who receive them.  Diabetic inmates can and do trade snack food for favors in the inmate black market.  Security officers have told me that this is a true problem in their facilities.

Personally, I think that the downside of diabetic snacks far outweighs the potential benefit in the vast majority of diabetic patients.  I don’t prescribe them.

But this is an editorial.  Feel free to disagree!