Impact of Bedtime Snack Composition on Prevention of Nocturnal Hypoglycemia in Adults With Type 1 Diabetes Undergoing Intensive Insulin Management Using Lispro Insulin Before Meals
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OBJECTIVE—To determine the impact of four bedtime (HS) snack compositions on nocturnal glycemic control, including frequency of hypoglycemia (<4 mmol/l) and morning hyperglycemia (>10 mmol/l), in adults with type 1 diabetes using lispro insulin before meals and NPH insulin at bedtime. RESEARCH DESIGN AND METHODS—Substitutions of 15 g carbohydrate (one starch exchange) for an equivalent amount of uncooked cornstarch or pure protein were compared to a standard snack (control: two starch + one protein exchange) and to no snack (placebo) in 15 adults using a randomized, cross-over design. All snacks were equivalent in kcal, fat, and total available glucose. An intravenous facilitated hourly blood glucose sampling during the night (11:00 p.m. to 7:00 a.m.). RESULTS—The glycemic level at bedtime (<7, 7–10, and >10 mmol/l) mediated the effects observed. A total of 14 hypoglycemic episodes, in 60% of patients, and 23 morning hyperglycemic episodes occurred over 50 nights. Most hypoglycemic episodes (10 of 14, 71%) occurred with no snack compared to any snack (P < 0.001) and at HS levels of <7 mmol/l (P = 0.05). The standard and protein snacks resulted in no nocturnal hypoglycemia at all HS glucose levels (P < 0.001). Only HS glucose >10 mmol/l was protective against hypoglycemia, even in the absence of a snack (P = 0.05); 46% of morning hyperglycemic episodes were associated (r = 0.37, P = 0.07) with this HS glucose level. CONCLUSIONS—The need for and composition of an HS snack depends on the HS glucose such that no snack is necessary at levels >10 mmol/l. At levels between 7 and 10 mmol/l, any snack is advised, and at <7 mmol/l, a standard or protein snack is recommended.
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The best bedtime snack to prevent overnight hypoglycemia in patients with type 1 diabetes has been investigated without clear consensus.
“The best bedtime snack to prevent overnight hypoglycemia in patients with type 1 diabetes has been investigated without clear consensus (108–112).”
From Hypoglycemia and Diabetes: A Report of a Workgroup of the American Diabetes Association and The Endocrine Society (2013) · cites this paper as [109]
Nocturnal hypoglycemia is a concern for T1DM patients, particularly when bedtime glucose concentrations are ≤180 mg/dL (≤10 mmol/L).
“Similar to those with Type 1 GSD, nocturnal hypoglycemia is also a concern for T1DM patients, particularly when bedtime glucose concentrations are ≤180 mg/dL (≤10 mmol/L) [54].”
From The Health Impact of Nighttime Eating: Old and New Perspectives (2015) · cites this paper as [54]
Bedtime feedings of cornstarch and/or protein have been useful in reducing hypoglycemic occurrences in populations with T1DM.
“Likewise, bedtime feedings of cornstarch and/or protein have been useful in reducing hypoglycemic occurrences in populations with T1DM [54,68,69,70].”
From The Health Impact of Nighttime Eating: Old and New Perspectives (2015) · cites this paper as [54]
In patients with T1DM, the incidence of next morning hyperglycemia in response to nighttime snacks was greatest for the protein snack (33%), followed by the standard (29%) and cornstarch snack (29%), with the no snack treatment being the lowest (8%), although not significant.
“However, although not significant, the incidence of next morning hyperglycemia in response to these nighttime snacks was greatest for the protein snack (33%), followed by the standard (29%) and cornstarch snack (29%), with the no snack treatment being the lowest (8%).”
From The Health Impact of Nighttime Eating: Old and New Perspectives (2015) · cites this paper as [54]
In patients with T1DM undergoing intensive insulin management, both standard and protein-rich bedtime snacks were most successful at preventing nocturnal hypoglycemia, while the no snack treatment had the greatest hypoglycemic episodes.
“In this study, both the standard and protein-rich snacks were most successful at preventing nocturnal hypoglycemia while the no snack treatment had the greatest hypoglycemic episodes.”
From The Health Impact of Nighttime Eating: Old and New Perspectives (2015) · cites this paper as [54]
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References 33 · Cited by 82
Research works printed but not linked: 1
- [38]38. Sherwin RS, Felig P: Effect of glucagon on amino acid metabolism and gluconeogen- esis. In Glucagon: Physiology, Pathophysiol- ogy, Morphology of Pancreatic A-Cells. New York, Elsevier, 1981, p. 256 -271
- Authors
- Kalergis, M., Schiffrin, A., Gougeon, R., Jones, P. J. H., & Yale, J.-F.
- Affiliations
- McGill University Health Centre (CA)
- Jewish General Hospital (CA)
- McGill Nutrition Centre, Royal Victoria Hospital, MUHC, McGill University, Montreal, Quebec, Canada
- McGill University (CA)
- ORCID
- Jones, Peter J.H.
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2003-01-01
- Volume
- 26
- Issue
- 1
- Pages
- 9-15
- ISSN
- 0149-5992 (ISSN-L)
- 1935-5548
- OpenAlex
- W1965272288
- Cited by
- 82
- References
- 33
- Citations by year
- 2026: 5 · 2025: 4 · 2024: 1 · 2023: 1 · 2022: 2 · 2021: 2 · 2020: 3 · 2019: 7 · 2018: 5 · 2017: 6 · 2016: 2 · 2015: 3 · 2014: 5 · 2013: 11 · 2012: 3
- FWCI
- 1.95
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Diabetes Care (publishedVersion)
- PubMed (publishedVersion)
- 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
- bedtime snack, nocturnal hypoglycemia, type 1 diabetes, insulin lispro, NPH insulin, carbohydrate substitution
- MeSH terms
- Adult, Aged, Blood Glucose, Diabetes Mellitus, Type 1, Dietary Carbohydrates, Dietary Proteins, Eating, Female, Humans, Hypoglycemia, Hypoglycemic Agents, Insulin, Male, Middle Aged, Treatment Outcome, Cross-Over Studies, Insulin Lispro
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