I had an obese type 2 diabetic patient at one of my jails who wrote a long grievance about not receiving a bedtime snack. He argued in the grievance that he had received a bedtime snack at previous facilities where he was incarcerated (which was true) and a bedtime snack was "the standard of care" for type 2 diabetics. While it is indeed true that bedtime snacks for type 2 diabetics are indeed routine at many correctional facilities, I believe that bedtime snacks for type 2 diabetics is, in most instances, a bad idea and bad medical care. In order to understand why we should begin with how diets work in correctional facilities.
Almost all facilities adhere to a national standard that all inmates must be offered at least 2,500 calories of food a day. Most jails offer closer to 3,000 calories per day to make sure that they don't ever go below the 2,500 threshold. Of course, 2,500-3,000 calories a day is more than most sedentary inmates need. If they eat everything offered to them, some inmates gain weight while in jail. The situation is even worse for women since women are served the exact same number of calories as men are, but of course, generally, need less.
Also, since feeding inmates is an expensive part of operating a jail, correctional facilities typically work hard to keep inmate food costs low. Most jails (believe it or not) pay less than $2.00 per inmate per day for food. Since carbie foods like bread are cheaper than protein, jail diets tend to be carb-heavy. It is true despite the fact that most jails have their menus certified as healthy by a licensed dietitian -- even the diabetic diets.
Finally, the foods available for purchase by inmates from the jail commissary are almost universally "junk carbs" such as packets of ramen noodles and candy bars. In my experience, the jail commissary companies resist efforts to offer healthy foods because, well, no one buys them.
To summarize, most jails offer more calories per day than a typical sedentary inmate needs. The meals tend to be "carbie." And more junk carbs (but no healthy food) can be purchased from the commissary.
This can be a problem for our type 2 diabetics. We want them to reduce the amount of "junk carbs" that they eat and also, if possible, to lose weight. To do that, they usually need to eat fewer calories. But what happens when we prescribe a diabetic snack? As is routinely done in the correctional centers I have seen, the bedtime snack of say, a sandwich and milk, is added to the regular 2,500-3,000 calorie diet. So, the diabetic in jail who gets a snack receives more calories and more carbohydrates than the non-diabetic counterpart. This is the exact opposite of ideal medical care for type 2 diabetics.
Where did this idea that all diabetics need a night-time snack come from?
As far as I can determine, there were two historical sources of this practice. First, when the oral hypoglycemics and long-acting NPH insulin came on the market in the 1940s, the concern was that the glucose-lowering drug could potentially make patients hypoglycemic during the night. It is important to remember that there was no quick and easy way to measure blood sugars at that time. You could draw blood for a glucose level but you would not have the results until a day or two later. The first simple fingerstick glucose measuring tests were not mass-marketed until the 1980s! So, for the first 30-40 years that insulin and oral hypoglycemics were used, there was no way to easily know what a patient's blood sugars were running. Patients had the highest risk of hypoglycemia during the night, so it made sense for the patient to have a stomach full of carbohydrates in case they were needed.
That is not the case nowadays. We can quickly and easily know exactly what an individual patient's bedtime sugar is. If the patient's bedtime blood glucose level is 400, there is little chance they are going to become hypoglycemic overnight and a bunch of extra calories and carbs is not going to help them.
The second historical source of the bedtime snack comes from the idea that a more constant and consistent absorption of carbohydrates would be easier for the diabetic to metabolize than a few big boluses. In other words, six smaller meals would be better than three larger meals. However, the total number of calories and carbohydrates consumed during the day ought to be the same, whether divided among three meals or six meals. This is not what is usually done in corrections. The diabetic snack is added on top of the diabetic diet at most jails. The diabetic and the non-diabetic eat the same number of calories for breakfast, lunch, and dinner and then the nighttime snack is added on as extra calories and carbs for the diabetic.
My original patient weighs 350 pounds. His A1C upon admission to the jail was 12.5%. His average blood sugar at bedtime is 360. When I check his commissary purchases, I note that he buys around 15-20 candy bars a week. Sorry, but this patient would not benefit from a bedtime snack. He is highly unlikely to experience hypoglycemia at night. Also, he needs to lose weight and cut carbohydrate consumption. What he really needs is diabetic education and encouragement, which we will give to him.
Paradoxically, despite the crappy diet and poor commissary offerings, most of my type 2 diabetics show a marked reduction of their A1Cs after three months in jail. This is due, in part, to not being able to go to McDonald's or raid the refrigerator at 2 o'clock in the morning. But this is also due to the fact that diabetics usually see medical professionals far more often in jail than they would have on the outside. I intend to review this patient's daily blood sugars every other day and see him in clinic every other week initially. I am confident that this patient will also see his A1C fall in the next three months -- without a bedtime snack.
Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his "true calling" of correctional medicine. He now works exclusively in jails and prisons, and blogs about correctional medicine at .