FUDiabetes

Recent research: do night snacks decrease hypoglycemia? Does protein help?

hypoglycemia
low_bg

#1

Conventional wisdom, as dispensed by most endos today, appears to say that bedtime snacks help in preventing nighttime hypoglycemia, and that snacks including protein are better because the effect lasts longer.

But @MM2 recently cited a 2000 article that debunked many protein myths (Protein Controversies in Diabetes: debunking myths in diabetes). This very interesting article concluded, among other things, that protein ingestion does not increase blood glucose, and that nighttime snacks with protein are not better than carb-only snacks, except in increasing calory count. Intrigued, I decided to review the primary evidence.

I viewed every source to the original article to which I could gain access, or its summary when I could not get to the full article. I was somewhat disappointed to find that much of the research listed was a bit weak, due to low numbers of participants. It appears from some of the research that:

  • glucose normals do not react to protein ingestion the same way as T1s, or T2s

  • it is possible that, for T2s with significant insulin-producing capability, adding protein to a carb meal generates more insulin production ( Nuttall et al, : Effect of protein ingestion on the glucose and insulin response to a standardized oral glucose load, Diabetes Care, 7:465-70, 1984)

  • the amount of insulin additionally used by a glucose normal in the presence of protein represents 25% of that required by the same weight of carbs ( Krezowski et al, The effect of protein ingestion on the metabolic response to oral glucose in normal individuals. Am J Clin Nutr 44:847-56, 1986)

  • a solid study, but with few participants, which specifically reviewed carb vs carb+protein snacks, found zero protective effect from the additional protein ( Gray et al, RO, Comparison of the ability of bread versus bread plus meat to treat and prevent subsequent hypoglycemia in patients with insulin-dependent diabetes., J Clin Endocrinol Metab 81:1508-11, 1996)

  • in another solid study, also with few participants, the addition of protein to carb meals marginally increased the glucose response (and significantly increased the insulin requirements) ( Peters et al, Protein and fat effects on glucose responses and insulin requirements in subjects with insulin-dependent diabetes mellitus, Am J Clin Nutr* 58:555-60, 1993)

When I reviewed more recent research, I found a disappointingly small number of relevant studies. The most convincing one was also the most recent (2014), and concluded that post-dinner protein intake was inversely associated with nighttime hypoglycemia ( Desjardins, Katherine, et al, Association between post-dinner dietary intakes and nocturnal hypoglycemic risk in adult patients with type 1 diabetes, Diabetes research and clinical practice 106.3 (2014): 420-427). Unfortunately, the same authors, in an article submitted in the same year ( Desjardins, K., et al. Are bedtime nutritional strategies effective in preventing nocturnal hypoglycaemia in patients with type 1 diabetes?, Diabetes, Obesity and Metabolism 16.7 (2014): 577-587), concluded that…

Overall, the level of evidence was low. Results indicated that a calibrated bedtime snack based on bedtime blood glucose (BG) level could be effective to reduce NH occurrence for patients treated with human or animal insulin (short‐acting combined with lente, ultralente and/or intermediate‐acting insulin), but there is no evidence for patients treated with insulin analogues as part of multiple daily injections or insulin pump regimen. […] On the basis of the available evidence, a bedtime snack cannot be recommended systematically but it might be useful if prescribed in an individualized fashion; further research is needed to evaluate these strategies.

As for us:

  • we find no additional benefit to protein to sustain nighttime BG levels when comparing skim milk (carbs + protein) to candy (Skittles)

  • we also find no additional benefit to a bedtime snack when compared to starting the night at the same BG level that follows the bedtime snack

In other words, for us, the only significant factor is how high your BG is at bedtime. As always, a big YDMV.


#2

That’s pretty much me, too. My BGs are effected by both protein and fat with delayed BG rise sometimes hours later, so I suppose this is what the studies are trying to evaluate? So, this might be a valid technique to combat hypos in the middle of the night :slight_smile:


#3

Mine are also but only when I take large quantities of fat or protein. I often take protein snacks when I am high if I am hungry and they don’t appear to affect my BG, even later.


#4

Wow, that is fortunate :slight_smile: What sort of protein snacks? I love cheese but it effects me like candy, immediately. But this may be due to its lactose, not its protein!


#5

That’s too badI I do eat cheese sometimes, but mostly I eat deli turkey and roast chicken. My mom buys expensive turkey slices from the deli that don’t have any carbs so I can snack any time I am hungry. We also try to keep roast chicken at home in the fridge. I eat a lot of it! Be careful with the deli turkey though: lots of kinds have 2 carbs per slice.

I also snack on pretty much any meat I find in the leftover shelf :slight_smile: Sometimes my dad is unhappy, but, well, better that than a worse high.

When I need to miss a regular meal because I am high, my parents make me a special meal with very low carb veggies and meat. Any kinds of greens, tomato, peppers, for a salad, and cooked vegetables like broccoli, turnips, or cauliflower to go with any kind of meat with have. They are full of bulk and I practically don’t see any effect, it’s perfect for me. Not ideal but it works fine. I get lots of peaks so I would miss many meals otherwise.


#6

Yep, this is my go-to food, too, for dinner when I’m on the high side. :slight_smile: I can’t add the meat because I’m vegetarian but you need that extra protein for sure! Have to be careful if eating a salad out because often the dressing contains all sorts of unexpected ingredients so I always stick to oil and vinegar :smile:


#7

Then it’s not good news that you can’t eat cheese/lactose. I am wondering: have you tried low-lactose cheese?

Also, I just read an article on BBC.com about parmegiano: the article said that most people with lactose intolerance can eat it because the aging process makes it possible for them. I think it is also true of some other cheeses that are aged a lot. Maybe you won’t spike on these?


#8

No, I haven’t, but that is a great idea! :smile: Thank you for the link. Parmegiano is one of my favorite cheeses, too :slight_smile: I will let you know if I see a difference! Fingers crossed that I do!


#9

I found this while looking for low lactose cheese…

Parmigiano is on the list, as is gouda :slight_smile: It says the hard, aged cheeses usually have low lactose.


#10

I’m lactose intolerant, and I can eat pretty much any aged cheese fine without lactaid. It’s only fresh cheeses that tend to cause problems. Eating hard cheese tends to have almost no effect on my blood sugars.

That said, one other possibility for reactivity to cheese might be an immune or inflammatory response to the dairy protein—I’ve known more than one diabetic who found ingesting dairy led to high and reactive blood sugars and cutting it out was very helpful for them, independent of carb consumption. That would make sense given that immune reactivity/inflammation goes hand in hand with elevated blood sugars.


#11

By cutting it out, do you mean they had to stop eating cheese? :thinking: The BG spike usually comes almost immediately for me, maybe even faster than a glucose tab! :persevere:


#12

I am sure that is what she meant :frowning:

Why don’t you try a couple and experiment? It will be easy to test.


#13

I can only speak to our own experience with Liam, but we most certainly need a bedtime snack with protein before bed. If we give no snack, he goes low (with with basal suspended). If we give a snack containing protein, his sugars go up some, then coast for hours.


#14

Another one of the YDMV things: it never ceases to amaze me how diverse indiviudual reactions can be. It is a bit worrisome too: how can you come up with solutions when so much is different between everyone?


#15

I don’t know; however, if I’ve ever actually tested a night time snack containing carbs but no protein. The snacks he usually eats at night contain carbs and protein (3g) so not a ton of protein…I guess we could test some other slow carbs without protein and see what happens. I just don’t like fixing something that isn’t broken. :stuck_out_tongue:

But bedtime snacks in general, for us, are vital. Maybe this has to do with the honeymoon phase he’s existing that has resulted in us suspending basal for a good portion of the night…maybe that phase is over. Time will tell.


#16

Yes, I actually meant cut out dairy entirely for those folks (sometimes non-cow dairy is ok though, and clarified butter/ghee should be ok), including cheese. And that does not sound like the minimal carbs in cheese could be responsible for that kind of spike—even for cheeses with carbs/lactose in it, there’s enough protein and/or fat usually that it shouldn’t be a super quick spike.


#17

Also some of the people I am thinking of only realized it was a thing when they cut out dairy for other reasons—in one case, it was because a nursing infant was allergic, and when she did that, her blood sugars suddenly became way more manageable, to a point where she never went back to dairy.


#18

Gosh, I would love to find something my son is allergic to, that would take out all his peaks if he stopped eating it :slight_smile:

Only half joking…


#19

These might be worth trying. They are formulated to have a very slow release of carbs and protein.

Here is their website.

On Amazon:


#20

Just had parmigianno and gouda cheese for lunch. But, I took 1U bolus for it. I really should just eat one of these aged cheeses alone w/out bolus and see what happens for the test :thinking: Next time.

Yes, that is why it is so confusing!

I think you are right, I must have some immune/inflammatory response to the dairy protein. It is totally unnoticeable to me other than my BG spikes. My stomach seems to be perfectly happy :wink: