Like many people who become diabetes care and education specialists, it was a family member’s diabetes diagnosis that motivated me to learn everything I could to support that person’s future wellness. Absolutely one of the most confusing pieces of diabetes management was the meal plan. Instructions were easy back then . . . never ever eat sugar. If you must eat carbohydrates, keep portion sizes small.
As time went on, nutrition and behavior modification strategies improved. Counting carbohydrates gained support over the exchange diet. With the popularity of the glycemic index and the keto diet, the grocery store offered expanded food options: mashed cauliflower for potatoes, riced cauliflower, zucchini noodles, and more. All along the way alternative sweeteners and sugar substitutes became more plentiful and flavorful.
As our knowledge of diet improved, diabetes monitoring technology was improving also. Blood glucose meters have transitioned to continuous glucose monitors (CGMs) allowing knowledge of glucose levels about every five minutes, twenty-four hours a day, and up to fourteen days. If glucose data couldn’t be better, cell phone apps have allowed sharing glucose results and alerts with caregivers and healthcare providers. More glucose data has enabled us to learn how glucose responds to food, exercise, medication, and more.
Healthy eating is one of seven self-care behaviors that support healthy diabetes self-management. After all these years, meal planning can sometimes seem just as confusing as before. I’ll explain.
Carbohydrates do count. It is recommended that persons eat 30 - 60 grams of carbohydrates per meal. The recommended carbohydrate intake is best decided by your healthcare provider and a registered dietitian. Controlling carbohydrates depends on carbohydrate source and serving size. Some carbohydrates are low in carbohydrates (eg, green leafy vegetables) and some are higher in carbohydrates (eg, fruits and starchy vegetables). The bigger the carbohydrate serving, the more carbohydrates consumed. The more carbohydrates consumed, the higher blood glucose will rise.
No food is forbidden. Food choice and serving size determine carbohydrates. If you have 45 grams of carbohydrates available to eat, you get to decide how to “spend” those carbohydrates. You could decide to eat lower carbohydrate foods so you could have larger portions or you could eat higher carbohydrate foods and eat smaller portions.
Think of recommended carbohydrates as “banked” in a checking account. You write carbohydrate checks every time you eat. If you’re allowed 30 - 60 grams of carbohydrates per meal, you can spend your “banked” carbohydrates your way. While heart healthy and carbohydrate controlled is the goal, indulgent foods can usually be worked into the diet occasionally without “breaking the bank”. Remember thought that just like over drafting a money account carries a penalty, writing a “carbohydrate check” without carbohydrates in the bank will penalize you also . . . frequently you can measure it in your glucose. Over time, you can measure it in complications.
Problem solving the diet. The more you know about carbohydrates, the better you can control your food choices. The more you know about how your body responds to the food you eat, the better you can reduce risks that might lead to complications. Simple concepts that ride on the skill of problem solving.
- Problem solving: define the problem. Blood glucose monitoring is like turning on the light in a dark room. The more data the brighter the light. Adding one thing to another thing becomes a result. While we can predict that 2 + 2 = 4, what do we do when the math adds up to an unexpected solution? We reexamine the math or the work from the first step to the final solution.
- Is it really a problem? Is the problem annoying or does it disrupt normal activities when it occurs? Glucose results are seldom “perfect”. The frequency of the result could be enough to take efforts to “deep dive” into the problem. A discussion with your healthcare provider and/or a diabetes care and education specialist can help decide and how to gather data if necessary.
First it should be remembered that an unexpected blood glucose level does not mean failure. It might suggest a learning opportunity. Begin by considering what’s been going on over the last 4 - 6 hours. Keep in mind glucose can be impacted by things other than food eaten and if there might be non-food events impacting results.
May make glucose go up:
May make glucose go down:
If the trigger for the unexpected results don’t jump out at you, keep notes. Overtime you may find that certain foods have a predictable effect on your glucose that doesn’t necessarily agree with the number of carbohydrates in the serving size. While your lesson may not hold true for everyone, it provides useful information for you. Knowing that a certain food produces an exaggerated blood glucose response allows a choice: (1) to avoid the food altogether; (2) eat a smaller portion of the food; or (3) eat the food and modify activity to lower glucose levels after the meal.
Keep in mind there really is no “one-size-fits-all” in meal planning. What amount of macronutrients (proteins, fats, and carbohydrates) in a food or meal can make a difference in how fast food is metabolized and it’s impact on blood glucose. Many people find a meal/snack higher in fat tends to have a slower glucose rise after eating than a fat-free meal/snack. The food matrix, how a food is put together or processed, also makes a difference how that food is absorbed.
Additionally, and this may surprise you, we don’t all digest food the same way. That is persons with diabetes don’t all get the same glucose rise from a food. Consider two problem solving situations from my past:
Pediatric child who could easily bounce up to a 300+ mg/dL blood glucose after eating anything with oats (oatmeal, Cheerios cereal) but eating rice was a non-event (cooked rice and Cocoa Pebbles cereal). We actually discovered this by coordinating Mom’s excellent food diary with the child’s (newly added) continuous glucose monitoring results. It’s a nice feeling to be a hero in the eyes of a child . . . she loved Cocoa Pebbles.
Adult patient performed pre- and 2-hour post-meal glucose checks at recommendation of healthcare provider. Discovered favorite snack of fresh blueberries and non-fat yogurt was spiking blood glucose. This patient was genuinely sad about giving up this snack combination. After we modified the snack to include blueberries with yogurt with fat . . . the blood glucose spike went away. Results brought a smile and better control . . . painlessly. Cha-ching! Trifecta!
While the above short review may make the problems and solutions look easy, don’t be deceived. There were many frustrating hours along the way. These situations were unique but the process of problem solving was not; event history and glucose monitoring results -- or data -- led to solutions beyond the obvious.
While knowing where the target is may seem simple, hitting the target may be challenging. Glucose monitoring is not an indication of good or bad behavior. It’s an image of what’s happening in your blood. With so many variables having an effect on glucose going up or down, it’s unlikely you can control them all. If there’s a glucose result you don’t like, try to figure out the “why”. Jot down notes on a calendar or in a notebook. Seek the advice of a health care professional that specializes in diabetes. Sometimes it is truly amazing what you will discover.