An Eating Philosophy for Diabetics
As a pediatric diabetologist, I am confronted daily with complex issues related to day-to-day management of diabetes. Recent blogs have tackled major research studies targeted to finding a cure for type 1 diabetes mellitus. But what about dealing with the simple tasks of daily living in the meantime? What about the slippery path of stable blood sugar control maintenance and eating well? What about quality of life? Food issues, along with blood glucose monitoring, remain the most discussed issues in clinic visits when it comes to practical concerns in diabetes management. Not a visit goes by without a discussion of food related concerns. Food and related eating behavior must be discussed in the context of insulin regimes. Each form of insulin management has its strengths and weaknesses in terms of both insulin injections and food choices.
The conventional split-mixed dose regime of NPH/Regular or rapid acting analog at breakfast, regular or rapid acting analog at dinner, and NPH at bedtime requires a rigid eating pattern. To avoid the risk of hypoglycemia, consistent counted carbohydrate counted meals and snacks are necessary at specific times to match the action of the insulin. No "grazing" or "pigging-out" is allowed. These eating behaviors will cause hyperglycemia and marked variability of blood sugars. This regime can be fraught with frustration in families that do not have established routines, deal with multiple caregivers, or have very busy kids. Finding candy wrappers or soda cans hidden in places around the house is a common occurrence due to the restrictive meal and snack timing
In basal/bolus therapy, increased flexibility in terms of meals, snack timing, and amounts rule along with increased blood glucose monitoring and multiple insulin injections. The price for flexibility is increased attention to self-care skills and details. Therein resides the evolution of two divergent adolescent and child eating philosophies: "piglet" vs. "cow" in terms of eating style. Each style has major ramifications in diabetes control. The most adaptive style would be the marriage of the two extremes. These eating patterns became crystal clear after multiple patient visits on a busy day. After downloading blood glucose meters, and reviewing blood sugar logs and continuous blood glucose sensor data, different patterns emerged: impressive spikes and valleys versus continuous fluctuations of blood sugars in the upper blood glucose ranges notably between 3 to 7 pm. Upon careful questioning, this time period is identified as the prime snacking time when students arrive home from school. We have our "piglet" behavior (eating huge amounts at one sitting) and our "cow-like" or grazing behavior (a bit now/a bit later). The amount of carbohydrates consumed over several hours adds up.
Many of my patients devise different strategies to match their eating philosophy. Some are very effective and many backfire with results of high and low blood sugars based on bolusing of rapid acting insulin. If one underestimates the number of carbs eaten after ransacking the kitchen and placing the variety of foodstuffs on the kitchen table; forgets to bolus rapid acting insulin entirely or boluses after eating when he/she remembers, major spiking of blood sugars will occur. The overarching problem is mismatching of insulin with the timing and amount of the carbohydrates ingested. Indeed, even if a hungry teen bolused immediately after eating, he will most likely be high later. The key to the "piglet" strategy is to pile the food choices on the kitchen table. The amount is not the issue (well, it might, if greater than 100 grams). Rather, carb counting based on portion size and timing of the rapid acting insulin is essential. (This does not apply if there are concerns about weight issues.) If one carb counts effectively and boluses before consuming carbs, blood glucose variability will be diminished with the resulting decrease in peaks and valleys. In addition, if one underestimated the carbs, another correction bolus could be administered three hours later. This strategy will work well with either basal/bolus form of insulin therapy: multiple rapid acting insulin injections or the insulin pump.
In the grazing snacking technique, snackers eat small amounts of carbs intermittently over a three-hour interval, resulting in the consumption of a large amount of carbs. Bolusing for these carbs every 15 minutes or so is problematic if using an insulin pen or syringes (without an insuflon or other port). It is tough to manage blood sugars if a grazer employs insulin pens for blousing. A better strategy for a "cow-like grazer" would be to consider insulin pump therapy and bolus as he goes. Even this strategy may not be as effective as one might think due to the complexity of the carbs consumed, accuracy of carb counting, and the "insulin on board" feature. However it is more effective than trying to do a snack recall after one has consumed carbs during the last three hours and giving one bolus by injection or pump.
Another effective strategy, especially for pump users, is to give the correction bolus before the snack or meal. Give the rest of the insulin after they either know what they are eating or have consumed all carbs. It is tough to bolus ahead of time if you do not know what you are going to consume. In small children or toddlers, bolusing after the snack or meal may be the only recourse. Keep in mind, as a result of continuous blood glucose monitor tracings, best blood glucose control has been demonstrated if one boluses before eating (even 15 minutes earlier).
Your eating style may determine the best strategy for insulin management. It is important to be honest with your diabetes team about your eating tendencies so that we may best assist in an eating game plan to improve your quality of life.