Nutrition and Physical Activity
Speaker: Gary Scheiner MS, CDE
Expert Tips For Prescribing Physical Activity
Webinar Description: An exercise prescription is a way to incorporate the critical component of physical activity into the diabetes self-management plan for people with diabetes. The Johnson & Johnson Diabetes Institute is thrilled to have Gary Scheiner, MS, CDE share his expertise in this area. Gary describes the essential role physical activity plays in diabetes management, reviews strategies to minimize risks associated with physical activity in people with diabetes, and provides the tools necessary to design individualized physical activity plans for people with diabetes. >> Download Slides
Expert Tips for Prescribing Exercise Q&A
with Gary Scheiner, MS, CDE
1. Question related to slide 33 (snacking to prevent hypo): Does this depend on their blood sugar before the workout--do you recommend that they check their blood sugar prior to exercise and have a snack if it is at a certain level?
Very good observation! The amounts on the chart assume that the blood glucose (BG) is within the patient's target range pre-workout. If higher, less carb is needed. If lower, more is needed.
2. What are the hormones that are part of causing hyperglycemia during activity?
Predominantly adrenal hormones (epinephrine/norepinephrine) along with cortisol.
3. Do you find most people whose blood glucose rises during exercise have type 1 vs. type 2 diabetes?
Depends on the "insulin dependency" of the person with diabetes. Those who can still produce a fair amount of their own insulin can produce enough to compensate for the adrenaline rush.
4. What would be the best option for activity for someone on multiple daily injections to avoid both hypo and hyperglycemia?
I don't think there is a single activity that works best for everyone. Intensive activities have the propensity to cause more dramatic BG changes, so moderate intensities are probably best for achieving stable BG.
5. What education is recommended for patients that might be trying to follow ketone type diet that want to exercise, risk for ketosis and safety?
Lots and lots of hydration is going to be essential. Performance may be hindered somewhat with very-low-carb diets, but it can still be done if adequate insulin is taken and hydration is maintained.
6. For a person that experiences hyperglycemia post-exercise in the morning hours before eating breakfast - what would you recommend to prevent those glucose spikes?
They may need to take insulin proactively prior to the workout. A conservative dose of rapid insulin is usually best.
7. How do you use continuous glucose monitoring (CGM) technology around exercise?
CGM is a great tool for seeing the direction BG is headed going into the workout, as well as to ward off lows during exercise and evaluating post-workout patterns.
8. What about someone with diabetes taking steroids for asthma and exercising and taking insulin? Due to different peak times with steroids and insulin, how do you incorporate exercise with these 2 conditions when steroids are prescribed long-term on daily basis?
I'd start out assuming that the inhaler has no effect… apply the usual insulin adjustments and see what happens. If BG rises, adjust the insulin accordingly.
Speaker: Paula Clinton, RD, CDE
Advanced Carbohydrate Counting
Webinar Description: Carbohydrates can have a significant impact on glucose; therefore, carbohydrate counting has become a cornerstone of diabetes education. Advanced carbohydrate counting is a method used to determine bolus insulin doses based on carbohydrate consumption, and also takes into account the impact of protein and fat on glucose. >> Download Slides
Speaker: Hope Warshaw, MMSc, RD, CDE, BC-ADM
Helping People Make Healthy Lifestyle Changes – from Evidence to Practice
Webinar Description: Eating healthy and being healthy is a lifelong process, and weight loss and weight maintenance are crucial aspects of this process. People require different skill sets and behaviors for weight loss and weight maintenance. Losing weight is an important first step, which is then followed by more a permanent way of living so the weight stays off. Please join the Johnson & Johnson Diabetes Institute as Hope Warshaw, MMSc, RD, CDE, BC-ADM FAADE discusses principles of both weight loss and weight maintenance. >> Download Slides
Answers to Questions:
Q: With so many people not being diagnosed with diabetes, why don't physicians add the A1c testing, so that we can prevent prediabetes from becoming T2D?
A: Good question! As we know an early diagnosis of type 2 diabetes as well as an early diagnosis of prediabetes is critically important to slowing the progression of the disease which really is a continuum. Prediabetes and type 2 diabetes, according to the American Diabetes Association’s diagnostic criteria (http://care.diabetesjournals.org/content/39/Supplement_1/S13.full.pdf+html), can be diagnosed with either an A1c measure or blood glucose measures. While the awareness of prediabetes is rising, it is still very low. All healthcare providers need to do whatever we can to raise awareness and provide the important message that early action can help reverse or, more likely, slow the progression of prediabetes to type 2 diabetes. Let’s not just depend on busy primary care providers. In addition, it’s the provision of appropriate and adequate education and support, such as that provided by a variety of programs recognized by the National Diabetes Prevention Program recognition process (http://www.cdc.gov/diabetes/prevention/recognition/) and discussed in this webinar, that are and will make the impact. Unfortunately, screening or detection alone does not accomplish this.
Q: Was mindfulness compared or mentioned in the Obesity Guideline paper? What does the research say about this approach vs "lower calorie?"
A: To the best of my knowledge mindfulness as a “dietary approach” was not mentioned in this report (Jensen MD, et al. Guideline for the Management of Overweight and Obesity in Adults: A Report of the ACC, AHA, TOS Task Force on Practice Guidelines. Circulation. https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739....). However, the mindfulness approach and teaching concepts can be integrated into any dietary approach or be used alone to raise awareness and help a person change their relationship with food.
Q: High restraint and low disinhibition sound like contrary terms. How can both be factors?
A: I’ve gone back to the paper I referenced which recapped 10 years of follow up from the National Weight Control Registry (Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23). I realize the terms seem contrary but perhaps these definitions will help. Dietary restraint is defined as a tendency to consciously restrict or control food intake so high restraint is the ability to restrain from intake when around food. Dietary disinhibition is defined as a tendency to overeat in the presence of palatable foods or other disinhibiting stimuli, such as emotional stress. Therefore low disinhibition is the ability to not overeat in these situations.
Q: Are there any apps that you like or recommend to your clients to track food intake?
A: There are many good apps available to help clients track their food intake such as myfitnesspal, fatsecret, livestrong, calorieking, and many others. However, what is most important is that the tracking tool a clinician suggests speaks to the individual and they can easily (and will) continue to use it. For some people just tracking intake with pencil and paper or in an excel document suffices. They don’t need or want a fancy, complicated app, while others want the latest tool.
Q: Can you suggest some menu planning websites (other than ADA) to assist patients in their weekly efforts to lower calories?
A: As with apps there are a multitude of menu planning and shopping websites and apps (some related). What’s most important is that clinicians offer a few of their picks to clients and then encourage them to try them out and see what they like best and feel they will use over time.
Q: How do you address inaccurate ideas that a client may cling too that are preventing them from being successful (e.g. I don’t over eat, I’m just sedentary).
A: I think its best that you try to dance with clients rather than doing battle. There’s usually plenty to focus on in the area of healthy lifestyle and behavior change. You may want to use the technique of asking if they are willing to try an experiment for a week or two to try something out that focuses on a concept they are clinging to. Therefore they will likely prove it incorrect. However, if a client is taking some actions that according to your knowledge are hazardous to their health, then you should let them know this or address it with their provider.
Q: Can you quantify "good glucose control?"
A: There are two sources of goals for glucose management for diabetes which includes both fasting and post-meal goals and A1c. First are the glycemic goals from the American Diabetes Association’s Clinical Practice Recommendations (http://care.diabetesjournals.org/content/39/Supplement_1/S13.full.pdf+html). The other set, which differ slightly, are the goals from American Association of Clinical Endocrinologists (AACE) at this link: https://www.aace.com/files/dm-guidelines-ccp.pdf. With either set of goals, it’s important to differentiate between diagnostic numbers and management goals.
Q: Is it ok to use a 2-3 carb per meal in females and 3-4 carb per meal for males for weight loss?
A: I don’t necessarily provide people with prediabetes or type 2 diabetes with a meal plan unless this is something that they ask for or I ascertain that it will be helpful. I’m much more inclined to help a person assess their current eating habits and food choices, particularly amounts of food they eat. With this information I would review their findings. I would encourage them to choose a few simple to achieve goals to tackle first, perhaps it’s what they are drinking (non-alcoholic and alcoholic beverages) or their portions or lack of fruits and vegetables. I recommend that you let a person’s food habits guide recommendations rather than overlaying a plan that might not work for them.
Q: I've seen research indicating limiting food intake to an 8-10 hour period per day boosts metabolism and decreases insulin resistance. Any comments?
A: I’m not familiar with this research. What we know decreases insulin resistance and increases insulin sensitivity is weight loss and sufficient physical activity. They’re both powerfully effective if implemented.
Q: What about timing of eating? PM? Nighttime?
A: As noted in the response to the last question, there are very few conclusions and consensus guidance on recommendations regarding the timing of eating or frequency of eating. I would emphasize that people you work with are likely to be more successful with weight loss and diabetes control with fewer behaviors they are asked to try to change. Let their current habits and food choices drive the process.
This study was mentioned by Kim Kelly, Pharm D, who was moderating our webinar: Jakubowicz D.: Fasting Until Noon Triggers Increased Postprandial Hyperglycemia and Impaired Insulin Response After Lunch and Dinner in Individuals With Type 2 Diabetes: A Randomized Clinical Trial. Diabetes Care. 2015;38:1820–1826.
Q: One of the recommendations for successful weight loss was not to count carbs. Often, patients must count carbs to determine their insulin doses. Any comments/suggestions on how to handle this?
A: This statement does not accurately reflect my statement during the webinar. The point I was making was about the research-based factors for long term successful weight loss and weight maintenance. Typically speaking these are individuals who are overweight and have been diagnosed with prediabetes or type 2 diabetes. The research shows that eating a relatively lower fat intake (<30%) is helpful. It’s important to note that the weight loss plan in both the Diabetes Prevention Program and in the Look AHEAD study focused on lower fat and total calories. They didn’t focus on a specific amount of carbohydrate or carbohydrate counting. I was not referring in my comments to people with type 2 diabetes who take meal-time bolus insulin and making dosing decisions based on the amount of carbohydrate they consume.
Webinar attendees provided the following responses to this discussion question: What are a couple of successful strategies you’ve used in your clinical practice to assist clients with their weight control efforts, either weight loss or long term control?
- Identifying eating triggers and reducing them is key
- Having the person develop 1-2 specific action plans/SMART goals, keeping food/activity journal, regular follow-up, team-based care
- Logging all they eat using an app
- I've seen the most success by tailoring the meal plan to the patients eating style with consideration to the amount of carbohydrate and glucose control
- Strategies - portion control, using a smaller plate, journaling
Speaker: Chris Jordan MS, CSCS, NSCA-CPT, ACSM EP-C/APT
Physical Activity and Diabetes
Webinar Description: Physical activity along with dietary intervention represents first-line therapy for the management of diabetes mellitus. Aerobic exercise is recommended for its beneficial effects on glycemic control, and the glucose-lowering effects of resistance training have also been documented. However, exercise can present challenges to people with diabetes due to coexisting health conditions and the risk of hypoglycemia. >> Download Slides
Physical Activity and Diabetes Q&A
1.Is he saying retinopathy? If so, why? Should it be neuropathy perhaps?
Individuals with diabetes and retinopathy are at risk for retinal detachment and vitreous hemorrhage associated with vigorous intensity exercise. This risk may be minimized by avoiding activities that dramatically elevate blood pressure. Consequently, for individuals with diabetes and retinopathy, vigorous intensity aerobic and resistance exercise should be avoided. (Note: deep squats/leg presses, isometric exercises, and the Valsalva maneuver (holding your breath under exertion) can all dramatically increase blood pressure).
2.If interval training is used, is it appropriate to decrease the time the exercise is done?
Exercise duration is inversely related exercise intensity. One minute of vigorous intensity exercise provides the similar health and fitness benefits as two minutes of moderate intensity exercise. Put another way, by increasing exercise intensity, you can decrease exercise duration and achieve similar health and fitness benefits. Interval training (alternating between short periods of high and low intensity exercise) can allow the individual to exercise at a greater intensity than traditional continuous training (constant exercise intensity for entire exercise duration). Thus, typically interval training workouts are shorter than traditional continuous training workouts. IMPORTANT: INDIVIDUALS MUST RECEIVE MEDICAL CLEARANCE FROM THEIR PHYSICIAN PRIOR TO STARTING ANY EXERCISE PROGRAM. Moderate intensity exercise is recommended for individuals with diabetes, but as physical fitness improves with regular exercise, vigorous intensity exercise may be appropriate if approved by their physician.
3.Any advice or resources for individuals with Type 1 diabetes that pursue endurance events? How to adjust insulin, and nutrition to maximize exercise outcomes.
Consult with your physician for medical clearance and guidance. General guidelines for exercise/endurance training and type 1 diabetes: Ingest 15 to 30 g of carbohydrates for each 30 minutes of intense exercise, consume a carbohydrate snack after exercise, decrease insulin dose by 30-35% on the day of exercise (for intermediate-acting insulin), or omit the dose if it precedes exercise (for intermediate- and short-acting insulin), or reduce the dose before exercise by 30% and supplement carbohydrate intake (for multiple doses of short-acting insulin), or eliminate mealtime insulin increment that precedes or follows exercise (for continuous subcutaneous insulin infusion), avoid exercising for 1 hour those muscles receiving short-acting insulin injection, avoid exercising in the late evening. In addition, monitor blood glucose, postpone exercise if blood glucose is greater than 250 mg/dL, but exercise at moderate intensity if blood glucose is 100-240 mg/dL with no ketone bodies and feel well. Exercise with a partner, monitor for signs and symptoms of hyper and hypoglycemia. Wear a diabetes identification tag. Again, consult with your physician for medical clearance and guidance. The American Diabetics Association website may be helpful http://www.diabetes.org/food-and-fitness/fitness/exercise-and-type-1-diabetes.html .
4.Is exercising for 10 minutes 3 times a day throughout the day just as good as doing the exercise at one time for 30 minutes? Would you recommend this for 5 or 7 days per week?
Generally, 30 minutes of moderate intensity exercise will provide similar health and fitness benefits as three bouts of 10 minutes of moderate intensity exercise performed in the same day. The volume of exercise (total duration and intensity) is the same. For individuals with diabetes there may be an additional benefit of performing three bouts of 10 minutes throughout the day. It is the cumulative effect of each acute exercise session on insulin sensitivity, rather than fitness improvement that improves longer term glycemic control. Regular and consistent, safe and appropriate physical activity is the key.
Speaker: Marion J. Franz, MS, RD, CDE
Nutrition Therapy and Diabetes
Webinar Description: Staying current on the nutrition therapies used in treating diabetes can be a challenge to healthcare professionals of all levels. Whether you are new to diabetes care or a veteran, this overview of current nutrition therapies and evidence of their effectiveness in diabetes management will help improve your clinical knowledge. >> Download Slides
Thank you for your questions and comments! I hope the responses will be of interest and helpful.
Is there an ideal time to do the nutrition therapy education to maximize benefits? Is there a study for ideal time for education?
Randomized controlled trials and other outcome studies of diabetes nutrition therapy document decreases in A1C of ~1-2% depending on the type, duration of diabetes, and level of glycemic control. In UKPDS adults with newly diagnosed type 2 diabetes (A1C of 9.0%), during the initial 3-month period of nutrition counseling, the mean A1C decreased by 1.9% (~9% to 7%) (1). Also in the UK and in newly diagnosed individuals with type 2 diabetes (A1C of 6.7%), at 6 months A1C had not improved in the usual care group but had improved in the intensive nutrition intervention groups (-0.3%), which was highly significant. These differences persisted to 12 months despite the use of fewer diabetes drugs in the nutrition intervention group (2). An older study in individuals with an average duration of diabetes of 4 years, intensive nutrition therapy decreased A1C by 0.9% (8.3% to 7.4%) and in subjects with a duration of diabetes <1 year, nutrition therapy decreased A1C by 1.9% (8.8% to 6.9%)(3). However, as type 2 diabetes progresses and additional medications, including insulin, are required, the medications are usually more effective when combined with nutrition therapy. Unfortunately, despite evidence documenting effectiveness of diabetes nutrition therapy, in a study of 18,404 patients with diabetes, only 9.1% had at least one nutrition visit within a 9-year period (4).
- UKPDS. Effects of three months’ diet after the diagnosis of type 2 diabetes on plasma lipids and lipoproteins. Diabet Med 17:18-523, 2000
- Andrews RC et al. Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomized controlled trial. Lancet 378:129-139, 20113. Franz MJ et al. Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized controlled trial. J Am Diet Assoc 95:1009-1017, 1995
- Robbins JM et al. Nutritionist visits, diabetes classes, and hospitalization rates and charges: The Urban Diabetes Study. Diabetes Care 31:655-660, 2008
Can you comment on “non-diet” approaches and the movement of Health at Every Size. Aren’t we suppose to “first do not harm” and we know significant weight loss can actually lead to weight gain?
Weight loss is regulated by many factors and weight management is a physiological and psychological struggle for many individuals. Unfortunately many individuals with type 2 diabetes are made to feel guilty and at fault when the emphasis of nutrition therapy is on weight loss, regardless of the approaches used. It should be noted that the first goal of nutrition therapy for adults with diabetes is to promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, in order to improve overall health and to assist in attaining the metabolic goals for diabetes management. It is recommended that health professionals work collaboratively with individuals who have diabetes to integrate and implement healthy lifestyle strategies and behavioral changes they are willing and able to make. It would be great if this was the primary emphasis of nutrition counseling for diabetes and not weight loss.
What is the role of whole grains and high fiber foods for blood glucose management?
Although whole grains and fiber are components of a healthful eating pattern, usual intake is not likely to improve glycemic control. Research studies have shown diets containing 44 to 50 grams of fiber daily can have beneficial effects on glycemia. More usual intakes (up to 24 g/day) have not shown beneficial effects. No trials have reported beneficial effects on glycemia from whole grains. They have not been shown to slow digestion; the shape of the glucose response curve is similar to similar foods (1). Consumption of whole-grain foods and fiber are more likely to reduce cardiovascular disease risk. In an observational study in women with type 2 diabetes, intakes of whole grain, cereal fiber, and bran were inversely associated with all-cause and cardiovascular disease mortality during a 26-year follow-up (2).
- Brand-Miller et al. Glycemic index, postprandial glycemia, and the shape of the curve in healthy subjects: analysis of a database of more than 1000 foods. Am J Clin Nutr 89:97-105, 2009
- He M et al. Whole-grain, cereal fiber, bran, and germ intake and the risks of all-cause and cardiovascular disease-specific mortality among women with type 2 diabetes. Circulation 121:2162-2168, 2010
Why does the protein addition to a CHO snack continue to be stressed when the science doesn’t support this? Books promote high protein low carb diets because they say there is less insulin response thus less fat storage, are their assumption incorrect? Is there no need to add protein to a follow up snack after correcting a low BG with CHO? Is there no need to include protein as part of a bedtime snack for patients on NPH at supper or for women with GDM?
It has been commonly assumed that adding protein (or fat) to carbohydrate in a snack (or meal) would slow or delay the absorption of glucose from the carbohydrate. However, research studies that have added up to 50 grams of protein (or fat) to carbohydrate do not show a change in the postprandial glucose response. The shape of the curve and the peak response time remain very similar. It has also been assumed the glucose from the gluconeogenesis of protein would appear in the general circulation later and prevent post hypoglycemia. Research has also shown this also does not happen. In general, unless the individual with diabetes wants the extra protein or fat, adding the extra protein (or fat) to snacks for prevention/treatment of hypoglycemia just adds unnecessary (and often unwanted) calories. Getting this message to the public has been difficult; the research is not new and yet we continue to hear inaccurate messages given to people with diabetes.
In regard to the insulin response to protein and carbohydrate, in studies in persons with type 2 diabetes, equal amounts of carbohydrate and protein are reported to result in similar insulin responses, suggesting that gram for gram carbohydrate and protein require equal amounts of insulin for metabolism, even if the glucose from protein (gluconeogenesis in the liver) does not enter the general circulation. I know of no evidence that eating a high protein low carb diet results in a less insulin response and thus less fat storage. Fat storage is caused by excessive energy intake.
In what is now an older study they added 50 grams of protein to the treatment of hypoglycemia with no added benefit. There is no research to suggest that adding protein to a follow up snack would have any beneficial effect either.
In regard to gestational diabetes, usual advice for women with gestational diabetes has been a lower carbohydrate intake (40% of total kcal) and additional protein and fat to meet caloric needs. However, a recent study questions the accuracy of this recommendation. In a study comparing low-carbohydrate (40%) to a control diet (55% of CHO), the use of a low-carbohydrate diet did not reduce the number of women needing insulin and produced similar pregnancy outcomes; it did not influence insulin need or pregnancy outcomes (1). This study likely supports the assumption that total energy intake (and a healthy eating pattern) is a higher priority than the source of the energy during GDM.
- Moreno-Castilla C et al. Low-carbohydrate diet for the treatment of gestational diabetes mellitus. Diabetes Care 36:2233-2238, 2013
No benefit in restricting protein in DKD? How about those who have large amounts of protein? Is it no longer recommended to limit protein to the RDA with CKD patients in stage 3 or 4 to slow progression of the disease?
Previous recommendations to reduce protein intake for DKD were based on studies showing that lowering protein intake reduced albuminuria. Today, glomerular filtration rate (GFR) is used to define the stages of chronic kidney disease. Reducing the amount of protein below the usual intake (15-20% of total kcal) does not alter glycemic measures, cardiovascular risk measures, or the course of GFR decline. Therefore, protein restriction is not recommended (at any stage of DKD). However, avoiding excessive intake of protein (intake above usual amounts) is generally recommended.
Intramyocellular effects of fat and diabetes?
Of concern is the effect of total fat, especially saturated fat, on insulin sensitivity in persons with diabetes. Epidemiologic data and clinical trials have reported that long-term higher total fat intake results in greater whole-body insulin resistance (1,2). Although not well studies in persons with diabetes, reducing saturated fat has been shown to improve insulin sensitivity (3,4). The intramyocellular effects of fat in diabetes requires additional research. The impact of long-term intake of saturated fatty acids and total fat on insulin resistance in persons with diabetes is important because as persons with diabetes decrease their intake of carbohydrate, they increase fat intake, especially of saturated fat. It appears that long-term it is difficult to maintain a very high protein intake and many high protein foods also contain fat.
- Estadella d et al. Lipotoxicity: effects of dietary saturated and trans fatty acids. doi.org/10.1155/2013/137579.
- Riserus U. Fatty acids and insulin sensitivity. Curr Opin Clin Nutr Metab Care 11:100-105, 2008
- Lee JS et al. Saturated, but not n-6 polyunsaturated fatty acids induce insulin resistance: role of intramuscular accumulation of lipid metabolites. J Appl Physiol 100:1467-1474, 2006
- Rosenfalck Am et al. A low-fat diet improves peripheral insulin sensitivity in patients with type 1 diabetes. Diabet Med 23:384-392, 2006
“Cured” vs “in remission”?
Use of the terms “cured” or “in remission” usually relates to persons with diabetes who have undergone bariatric surgery. The American Diabetes Association (ADA) uses the term “in remission.” In 4,434 adults with type 2 diabetes, gastric surgery resulted in 68.2% initial complete diabetes remission within 5 years after surgery. However, 35.1% redeveloped diabetes within the next 5 years and the median duration of remission was 8.3 years. Predictors of relapse were poor preoperative glycemic control, insulin use, and longer diabetes duration (1). As more studies such as this become available, it does support the use of the term “in remission.”
- Arterburn DE et al. A multisite study of long-term remission and relapse of type 2 diabetes mellitus following gastric bypass. Obes Surg 23:93, 2013
In type 2 diabetes classes, would you recommend teaching carb counting or simply reducing portions overall?
The educator must first determine what nutrition therapy approach will be most helpful and useful for the participants. However, it is my assumption that many participants already have tried some type of “reduced portion” approach, some with success and some without success, and are interested in learning about other approaches. Carbohydrate counting is often a new approach and can be a “new” method they can use to determine appropriate number and portion sizes of foods. Participants often come to a class expecting to learn new information and carbohydrate counting often meets that expectation.
The post meal goal for blood glucose is 160-180 mg/dL. Is that at the 2 hour mark?
In persons without diabetes most studies show a peak of post meal glucose at ~1/2 to 1 hour after the start of the meal. However, persons with type 2 diabetes lose the initial acute insulin response and their blood glucose levels peak later. The ADA recommends a peak post meal capillary plasma glucose of <180 mg/dL and note that the glucose measurement should be made 1-2 h after the beginning of the meal, generally peak glucose levels in persons with diabetes.
If you focus on energy reduction for diabetes management, can the glucose levels be controlled if the majority of the calories come from carbs?
You can find studies to support whatever your opinion is on amounts of carbs in diabetes eating plans. However, it is interesting to note that in the US, the majority of persons with type 1 or type 2 diabetes report eating moderate amounts of carbohydrate (~45% of total energy intake) and ~35%-40% from fat, with the remainder (~16%-18%) from protein. Moderation and a healthy eating pattern based on changes the individual with diabetes is willing and able to make would seem to be an appropriate approach.
For energy needs, do you recommend using the BEE or 500 calories less per day?
Assessment of usual energy intake and eating patterns is the usual recommended first step. However, as noted above, total energy intake is best determined in a collaborative situation in which individuals are made to feel comfortable deciding on what they can realistically do. Personal preferences such as tradition, culture, religion, health beliefs and goals, and economics, and metabolic goals determine Eating Plan advice, making individualization essential.
If a person consistently has hypoglycemia in the middle of the night is there a benefit to having a bedtime snack if their glucose is below a certain number prior to bedtime?
The first assessment needed is to determine why the individual is consistently having hypoglycemia in the middle of the night? Is it because of an inappropriate insulin dose or regimen? Often hypoglycemia at night is caused by an evening dose of NPH insulin. A snack can be tried remembering that the peak glucose response from the snack is likely to be between 1 to 2 hours after it is eaten. This may or may not prevent the overnight hypoglycemia. Adding protein (or fat) to the snack has not been shown to be helpful.