Wrong. People with Type 1 and Type 2 diabetes don't require snacks, and anything eaten between meals should contain as few carbohydrates as possible.

I recently joined Pinterest and came across  this link as I was looking  for images to pin to my "Healthy Low Carb Board":  10 Low-Carb Snack Ideas for People with Diabetes.  Looking at the list of foods had me scratching my head. These snacks are low carb? Then I read this:

"'If you need a pick-me-up between meals, a snack with 15-20 grams of carbohydrate is often the answer. For someone with diabetes, it’s important to eat a fiber-filled and nutrient-rich snack to curb the appetite before the next meal,' says Angela Ginn-Meadow, a registered dietitian and a spokesperson for the American Dietetic Association . "

So the person who wrote this article is not an RD but obtained information on snacks for PWDs from a dietitian and spokesperson for the AND (Academy of Nutrition and Dietetics).

As a diabetes educator, the suggestions in this article bother me on a number of levels. First of all, why are we still promoting snacks to people with diabetes? In the days of insulin peaking in the middle of the night and causing overnight lows this was  understandable, but most people are on modern insulins that do not cause this problem.  I know that many dietitians and nutritionists recommend eating every 3-4 hours, but I strongly disagree with that strategy.  First of all, I find that people generally end up eating more if they are snacking or grazing.  If someone eats 2-3 meals a day containing adequate protein and fat, there is no need to snack in between.  Snacks with 15-20 grams of carbohydrate can hardly be called "low carb." I consider an item with less than 5 grams of carb, preferably less, to be low carb. 

There are a number of reasons to avoid carb-containing snacks in people with all types of diabetes. For T2s with insulin resistance, eating carbs between meals causes a rise in blood sugar, resulting in the pancreas needing to produce more insulin, perpetuating hyperinsulinemia and promoting weight gain. Blood sugar is expected to rise after eating; the extent to which it does depends largely on the amount of carbohydrate consumed. Fasting/premeal blood sugar targets differ slightly between the American Diabetes Association (80-130) and American Association of Endocrinologists  (80-110), but the idea is for blood sugar to return to a healthier lower level by the time the next meal comes around. By eating snacks containing more than a minimal amount of carbs, the likelihood of meeting this goal is significantly reduced, and the person ends up well over the target range for most of the day. Snacking on carbs between meals is an equally terrible suggestion for  people with T1 diabetes and people with T2 on mealtime insulin. Bolusing insulin to cover snack carbs places a T1 at risk for hypoglycemia due to stacking doses from the previous and subsequent meal, and foregoing the insulin is certain to spike blood sugar to extremely high levels. 

In my opinion, the only time someone with diabetes should eat carbs in between meals is to treat hypoglycemia, universally defined as blood glucose less than 70. In that case, the treatment is 10-15 grams of rapid-acting carbs, preferably glucose tablets or gel (alternatively 4 oz juice, soda, etc). The snacks in the list above contain some fiber, which would delay recovery and  therefore would not be a good choice.

Although I think carbohydrate restriction is the ideal way to manage diabetes, I know not every person wants to adopt it, and I respect a person's right to make that decision. However, I think promoting "balanced" snacks containing carbs to PWDs is terribly misguided. If truly hungry between meals, a hard-boiled egg, piece of cheese, or a few nuts makes much more sense in terms of maintaining stable blood sugar levels, satiety, and decreasing potential for weight gain.




 

To say my husband has never been a low-carber would be an understatement. Mark's favorite foods include pizza, burritos, and pasta. A typical snack is pretzels right out of the bag. He also has a bit of a sweet tooth and enjoys frozen custard, cookies, and candy. I know, it's difficult to reconcile that with a dietitian wife who promotes and lives a very-low-carb lifestyle, but we make it work :) He's never had to worry about his weight and doesn't have blood sugar issues or other health problems.

 Recently, though, he decided to start cutting back on sugar and refined carbs.  A couple of weeks ago he began a moderate-low-carb diet (about 120-150 grams a day) and replaced his beloved pretzels with almonds, cheese, and beef jerky. I think my success with carbohydrate restriction prompted him to try it for himself.  We're in our mid-forties, and he's seen how energetic and satiated I've been since I adopted low carb (He's also witnessed the vast improvement in my glucometer readings). Needless to say, I'm very happy he's replacing a lot of his carbs with protein and fat sources.

One of his favorite treats at our local farmers market is cinnamon almonds, which are delectable but loaded with sugar. I decided to try making a low-carb version of a recipe I found online.  Verdict:  Mark loved it (The two holes  in the middle are evidence that he couldn't even wait for the pan to cool down)!  These are delicious, very easy to make, and healthy to boot. Win-win for the Spritzlers! 


Low-Carb Cinnamon Almonds

Ingredients

• 1 egg white 
• 1 Tbsp vanilla extract
• 2 cups raw almonds
• Sweetener of choice equal to 2/3 cup sugar (I've found that erythritol works best)
• 1 teaspoon salt
• 1/2 teaspoon ground cinnamon

Directions

• In a large bowl, beat egg white until frothy; beat in vanilla. Add almonds; stir gently to coat. Combine the sugar substitute, salt, and cinnamon; add to nut mixture and stir gently to coat.
• Spread evenly into a greased 15-in. x 10-in. x 1-in. baking pan. Bake at 300° for 25-30 minutes or until almonds are crisp, stirring once. Cool. Store in an airtight container.  

Makes about 2 cups. Each 1/4 cup serving has about 7 grams total carbohydrates (vs 16 for the original recipe) and 4 grams fiber, so 3 grams digestible carbs (for those who count digestible/net carbs).

I've been toying with the idea of writing about protein on low-carb diets for a while but until now have resisted due to all the conflicting information I've found on the subject. I decided to address it because I'm often asked how much protein I recommend, and it's a difficult question to answer. Some of the foremost experts on carbohydrate restriction have very different ideas about the optimal amount of dietary protein to consume.

Dr. Rosedale recommends only 0.8-1.0 grams per kilogram of body weight (He has said he sometimes recommends as little as 0.6 g/kg for people with diabetes). Dr. Bernstein is a bit more liberal, allowing his patients as much protein as they would like per meal while cautioning that too much may increase blood glucose levels and lead to weight gain due to increased gluconeogenesis in people with diabetes (It should be noted that he is a fan of small portions of just about everything, including vegetables). Most low-carb research has been conducted with protein intake of 25-30%  of total calories (125-150 grams per day on 2000 calories per day) . Dr. Phinney and Dr. Volek have advised eating  around 1.5 grams protein per kilogram of body weight, and up to 2.5 g/kg for athletes.  Despite having written a best-selling book called Protein Power, Drs. Mike and Mary Eades set protein requirement at a modest 0.6 grams per pound of lean body mass for a moderately active person (about 70 grams protein per day for someone weighing 157 lbs with 24% body fat). 

I've read a lot of research that supports higher protein intake with carbohydrate restriction. It would logically support weight loss/improvement in body composition  due to protein's higher thermic effect (the amount of calories burned from its digestion and processing), satiety factor (higher than fat and carbohydrate),  and ability to promote increased muscle mass.  People attempting to build muscle  via resistance training will benefit by increasing protein intake to support anabolism, particularly on a low-carb diet.

The available research indicates moderate to high protein intake may be beneficial for people with diabetes. In a long-term study of T2's, protein intake of 30% on an 1800-calorie diet (about 135 grams a day), resulted in improvements in blood sugar control and weight.  However, it is unknown whether this is universal among all T2s, and T1s are a different story altogether. Although a recent study found  that significantly higher protein intake at meals does not result in an increase in blood glucose levels in those with T1 diabetes, the anecdotal evidence from many people suggests otherwise. I've had several reports from T1s  about blood glucose spikes after zero-carb high-protein meals.

If you're confused after hearing all of these conflicting recommendations,  you're in good company. I'm a dietitian, and I struggle with making protein recommendations because the ideal amount seems to be so highly individualized.  To me, it seems better to err on the side of getting a little more protein than required versus not enough. My diet  contains a moderate amount of animal protein -- probably 60-65 grams a day -- but I do get a fair amount from plants as well. I eat a lot of nuts and nut butters, and  the several servings of vegetables I consume contain some protein. When I input an average day's intake into FitDay, my total protein is usually close to 100 grams. That comes out to about 1.75 grams/kilogram based on my weight, which is almost double Dr. Rosedale's recommendation. However, my blood sugars remain stable as long as I keep carbs low, and my weight stays exactly where I want it. Based on everything I've read, I wouldn't recommend less than 1 g/kg or more than 2 g/kg ,* but that's obviously a huge range. Some do better at the lower end, while others thrive at the top depending on their fitness goals and unique physiological makeup. As with everything else, I think self-experimentation (monitoring blood sugar and/or weight,  appetite, energy levels, body composition, etc.)  is key to finding the optimal protein intake for you.

* protein g/kg based on current weight if at or near ideal weight.  If overweight or obese, use g/kg ideal weight. There are many charts online, but I use the Hamwi formula:
Men: 106 lbs plus 6 lbs for every inch over 5 feet        (add or subtract 10% for large and small frames, respectively)
Women: 100 lbs plus 5 lbs for every inch over 5 feet  (add or subtract 10% for large and small frames, respectively)

References:
1. Gannon M, et al. Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes. 2004 Sep;53(9):2375-82
2. Nielsen J, et al. Low-carbohydrate diet in type 2 diabetes: stable improvements of body weight and glycemic control during 44 months follow-up. Nutr Metab (Lond) 2008; 5:14 
3. Borie-Swinburn C, et al. Effect of dietary protein on postprandial blood glucose in patients with type 1 diabetes. J Hum Nutr Diet.2013 Mar 22. DOI: 10.1111/jhn.12082 

I wanted to let any interested readers know that my article for the ADA’s Diabetes Spectrum is now viewable by all on their website. Two points to keep in mind:

1. This article was heavily edited by the ADA, and I was asked to modify some of my recommendations and add qualifiers to certain statements. I’m also not thrilled with some of the changes they made in terms of verbiage and sentence structure (there are definitely a few awkward phrases), but that’s a minor concern.
   
   
2. I wrote the article over a year ago and realize there are other studies I could have cited as references. This was my first professional article, and I was pretty green in terms of research.
   

While I did have to make some concessions, I’m still very encouraged that the Spectrum editors asked me to write an article favorable to carbohydrate restriction. Slowly but surely, we are making progress!

I can’t publish the article here because the ADA owns it, but you can access it through this link:

http://spectrum.diabetesjournals.org/content/25/4/238.full.pdf+html