Understanding Food and Alcohol

For many years, people with type 1 diabetes (T1D) were told that they needed to eat three meals and three snacks a day to keep their blood glucose levels from swinging too high or too low. Thankfully, with the advent of modern insulin delivery and monitoring technology, most people with T1D no longer need to live with such a regimented diet. They can eat a little or a lot depending on what they feel like doing. While at first it may seem like your former life of carefree and spontaneous eating and drinking is over, your health care team can help you tailor your insulin treatment to your lifestyle. 

To make sure you are getting the correct amount of insulin, you will need to consider what and how much you eat so you can match the glucose entering your bloodstream with the insulin dose you take. Your blood glucose level after you eat will depend most on the amount of carbohydrates contained in your meal or snack. 

It is a common myth that people with T1D need to avoid all sugar. This is not true. As part of general healthy eating, you should cut down on foods containing sucrose (eg. table sugar, candies, and regular soft drinks) because they have little nutritional value and won’t satisfy your appetite. This doesn’t mean they are banned from your diet. Small amounts are unlikely to do you any harm, especially if used in cooking or in tea or coffee, or eaten with other foods. Fruit and milk products contain naturally occurring sugars but, unlike sucrose, these foods do offer significant nutritional value and play an important role in a healthy diet.
Glycemic index 
The glycemic index is something you will probably hear a lot about. We used to think that starches were broken down into glucose at a slower rate than sugars, but we now know this is not always true. You digest different types of carbohydrate foods at different rates, and they can have different effects on your blood glucose level. Some foods that are quickly digested, for example, carbohydrates with high sugar content, may result in a sharp rise in your blood glucose level soon after you eat. Other foods, such as whole grain bread, can take longer to digest and therefore it takes longer for the glucose to enter the bloodstream.

The effect of different carbohydrate foods on blood glucose levels is the glycemic index (GI). Foods with a low GI cause less of a spike in post-meal blood glucose than those with a high GI. However, you still must consider how many carbohydrates are in what you are eating.

Some clinicians and researchers believe that the GI concept can be useful in managing the diets of people with T1D. It is important that you speak to your health care team to identify whether this method is suitable for you. You can also learn more about the glycemic index at glycemicindex.com. 

Protein and fat
Protein and fat are vital components of a healthy diet. Protein is important for growth and repair of cells. It also plays a role in producing antibodies that help fight infection and in creating hormones to keep your body working well. The best sources of protein in the diet are meat, poultry, fish, eggs, dairy products, and legumes. Fat is a rich source of energy and is important for carrying fat soluble vitamins A, D, E, and K, as well as antioxidants. Certain types of fats supply the essential fatty acids that play a role in regulating many body functions.

While carbohydrate foods have the largest and most direct effect on blood glucose levels, proteins and fats in the diet can influence blood glucose levels, too. Excess protein is ultimately converted to glucose by the liver. This means that consuming large amounts of protein can result in an increase in blood glucose levels several hours after eating. Fat can have variable effects on your blood glucose levels, the most significant of which is to slow down the rise in blood glucose after a meal. Fat delays the rate at which the stomach empties, which slows down the absorption of glucose from digestion. This might sound like a good thing, but a high fat diet is not usually a healthy diet. In fact, eating too much fat (particularly saturated or animal fat) can be harmful and increase your risk of obesity and heart disease. A high-fat meal can also make it more difficult for your insulin to work well, resulting in your blood glucose level being higher than expected. 

Determining what is in foods
In Canada, most packaged foods have a nutrition information panel, and you can use this to ensure you know what you are eating. But not all food comes in a packet. Using resources such as the ‘Calorie King, Fat & Carbohydrate Counter book (2009)’ or guides from your dietitian can help you assess the carbohydrate, fibre, fat, and energy content of foods that do not come with labels. 

Counting carbs
To have good control of your blood glucose levels, you will need to learn how to count carbohydrates. This is because research has shown that it is the total amount of carbohydrates and fibre you eat that matters most to your blood glucose control.

If your doctor has instructed you to take set doses of rapid-acting or short-acting insulin with your meals, you will need to be able to count carbs to ensure you eat the same amount of carbohydrates at the same times each day to balance the insulin and keep your blood glucose levels in the target range.

However, if you would like more freedom with your diet, your endocrinologist or diabetes team will probably suggest you use the insulin-to-carb ratio, so that you can take a dose of rapid-acting or short-acting insulin to cover the expected rise in your blood glucose level.
Adding up how many grams of carbohydrate you eat will help you decide how much insulin to take with each meal. Monitoring and recording your blood glucose levels before and after each meal will tell you if your insulin-to-carb ratio and your calculations are correct.

It is a good idea to weigh and measure your food until you can visualize portion sizes to help you accurately estimate how many carbohydrates you eat. You don’t need to keep weighing food for the rest of your life, but you might repeat these measures from time to time. For example, if you think you usually eat a cup of rice, use a cup measure when you serve the rice to confirm your estimate. You might also want to measure the amount of food found in different sized plates, bowls, or takeout food containers to make it easier to estimate the carbohydrate amount when you are not at home. For example, measure how much rice is normally included in your Asian lunch take-out and this will help you keep on track at work. 

All this probably sounds daunting, but measuring your food and learning to count carbohydrates will help give you freedom to decide how much you want to eat at each meal. Being confident in estimating carbohydrates will also make eating out a lot easier. A dietitian can help. 

A reminder that this publication is not intended to replace medical advice. Please discuss with your physician what would be considered correct carbohydrate ratios for you. 

Eating out 
Many people eat out at restaurants or buy take–out or delivery a number of times a week. You probably do this because it’s quick, it’s easy, and it’s a great way to catch up with colleagues and friends. The good news is that this routine doesn’t have to change now that you have T1D, although you will need to think a bit more about the foods you eat. 

Today, many fast food chain restaurants have nutrition information about their foods available on their web sites, posted in their restaurants or available if you ask. Using these web sites, you can look up your favourite menu items and plan ahead. 

Nutrition information can be harder to come by when eating at a friend’s house or at a restaurant. In this case, you need to make your best estimate, taking into account the size of the serving and the amount of carbohydrates you think are in the food. Checking your blood glucose before you eat and then several hours after will help to determine if your estimate was correct. In addition, when you eat out, your meal may be served later than usual. To avoid a low, you might want to wait until the meal has arrived to take your insulin.

Although alcohol is not a food, it does provide energy, and the amount you drink is also important to consider when you have diabetes. 

For people with T1D, excess alcohol can also increase the risk of hypoglycemia. When you drink alcohol, the liver has to stop everything to break it down and remove it. While your liver is doing this, it can’t do all the other jobs it normally would do, such as releasing stored glucose if your blood glucose level starts to fall. This effect can last for many hours after you have been drinking, and may continue overnight and into the next day. 

To avoid hypoglycemia, it’s best to avoid drinking large amounts of alcohol in one session, and to make sure you always have some carbohydrates to eat before or while you drink. You should also test your blood glucose level before you go to bed and eat a snack if your level is normal to low. It is also recommended that you don’t include the carbohydrate content of alcoholic beverages in your carbohydrate counting calculations. 

On occasion, you may find that your blood glucose level rises too high after drinking an alcoholic beverage that contains carbohydrates, such as hard alcohol mixed with regular soft drinks, sweetened liqueurs, or large amounts of beer. You may also find that you eat more when you drink alcohol. Where possible, choose a diet soft drink as a mixer and keep an eye on your food intake. 

Avoid hypoglycemia hangover 
While the risk of hypoglycemia is increased by alcohol, there are strategies to reduce this risk. For example, if you are going out drinking, make sure you eat some carbohydrates at the beginning of the night. You should also eat some carbohydrates every few hours while you are drinking and before you go to bed. 

If you have previously experienced problems with low blood glucose levels overnight, it may be worthwhile to reduce your evening dose of insulin slightly, especially if you are planning a very active night, such as dancing, or if you have played a sport during the day. However, you should discuss this with your health care team first.
The morning after a night out can also be problematic. Delaying or missing your morning insulin can result in your blood glucose levels rising too high. To avoid this, set your alarm clock to wake you within an hour or so of your usual waking time and follow your normal routine.

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