Minimizing Hypoglycemia Using a Five-Step Diabetes Management Program

People with type 1 or type 2 diabetes who have a glucose meter or CGM system are free to personalize their meals and exercise using evidence-based healthy practices. It is useful to check fasting blood glucose (FBG) every day and postprandial glucose (PPG) 1 hour after major meals, as needed. When starting the five-step program described here, initial FBG and PPG levels indicate the pre-intervention status of diabetes management. FBG influences PPG and A1C (13). PPG, in turn, influences FBG and A1C. Normal FBG indicates sound disease management. High and low FBG levels can be brought within the target range of 90–110 mg/dL, per American Diabetes Association guidelines (11). PPG levels >180 mg/dL (11) call for intervention in real time.

Individuals who are on insulin and have a FBG level <100 mg/dL may be encouraged to lower their basal insulin dose by 2 units. If their PPG is <150 mg/dL, lowering the mealtime insulin dose is preferred.

Most people would benefit from eating a moderate breakfast, regular lunch, and light, early supper (all else being equal). This is because glucose tolerance is poor in the evening for most of us, and this type of eating pattern is in phase with the body’s circadian clock (12,14–17). People with diabetes have poor glucose tolerance in the morning, as well (14). Adding a high-protein low-carbohydrate pre-breakfast snack 90–120 minutes before breakfast provides a second-meal effect (18), moderating the post-meal glucose surge. In practice, after having a morning snack, PPG levels for all meals throughout the day seem to be lower, as shown in Figure 1. The second meal effect may be less impressive in people with type 1 diabetes because they have exogenous insulin present in the body.

Here is my preferred meal plan:

• Morning snack (0.5 carbohydrate serving [carb; 15 g]); coffee with 1/2 cup milk plus an egg or a handful of nuts

• Moderate breakfast 90–120 minutes after the snack (2–3 carbs)

• Regular lunch 120–180 minutes later (3–4 carbs)

• Light afternoon snack (0.5–1 carb, optional)

• Early, light supper (0.5–1 carb)

It is well established that meal composition improves when fiber, lean protein, nonstarchy vegetables, and healthy fats are added to appropriate carbs (11,12). Carb intake should be lowered if post-meal glucose is >180 mg/dL (11). When meal composition improves, glucose is absorbed slowly, glucose surges are wider, and glucose variability is lower, leading to minimal hyperglycemia and hypoglycemia (Figure 2).

In certain circumstances, nutrient sequencing can attenuate PPG: eat protein and vegetables first and then eat carbohydrates or dessert 10–30 minutes later (12).

High-intensity pre-breakfast exercise offers multiple benefits, including the absence of hypoglycemia during the activity, a delayed insulin sensitivity improvement that lasts for 24 hours or more, and better FBG (12,19,20). It also generates post-exertion hyperglycemia, leading to glucose dysregulation for 1–3 hours (12,19) and, in people who take insulin, delayed hypoglycemia (21). Because of this risk for hyperglycemia and hypoglycemia, the role and utility of pre-breakfast exercise in diabetes management remain unsettled (22–24). According to my CGM data, a pre-breakfast walk of moderate intensity, followed by a morning snack every other day, has been especially valuable for metabolic control. This meal– exercise combination mitigates the negative effects of pre-meal exercise on glycemia.

Training during fasting is known to improve physical health, body composition, glucose tolerance, FBG, glycogen content, and GLUT-4 protein levels (19,20,25,26). Figure 3 shows the effect of pre-meal walks on glycemia.

Decades of studies in various populations have established that moderate, timely, post-meal exercise can lower the post-meal glucose surge after bigger meals through contraction-mediated glucose uptake (12,27–31). If the goal is to blunt the post-meal glucose surge, an appropriate amount of glucose needs to be expended. Excessive energy expenditure through high-intensity or long-duration exercise may result in hyperglycemia or hypoglycemia, depending on the hepatic involvement (12). Because exogenous glucose is the main fuel for moderate post-meal activity, the resulting glucose tolerance is short-lived (32) and may not improve FBG (20). Post-meal exercise performed at the right time and of the right intensity is still quite valuable for day-to-day diabetes management (27–31).

A 30-minute post-meal walk 30–45 minutes after any big meal would blunt the glucose surge in real time. (A short-duration, high-intensity exercise such as 12 minutes of resistance exercise would also work, but may increase the risk of hypoglycemia for people on insulin [12], whose glucose level should be monitored closely.) Patients may not need mealtime insulin when appropriate post-meal exercise is performed. Figure 3B shows the effects on glycemia of both pre-meal and post-lunch walks performed on the same day.

Smart CGM alerts is a good tool specifically for people who use CGM: I recommend setting the high alert at 150 mg/dL and the low alert at 90 mg/dL. After a high alert, they may take a 20- to 30-minute brisk walk. After a low alert, they may eat a small snack (e.g., three grapes or a mandarin orange). Smart alerts provide adequate time to take countermeasures to regulate glucose proactively.

Six days of CGM data are displayed in Figures 1–3, showing the benefits of healthy practices. Figure 1 shows the role of meal timing in glucose regulation. The nutritional components of the meals (e.g., 8 carbs/day) remain the same on both days. Breakfast is cold cereal (toasted oats, blueberries, and whole milk), and lunch is a smoothie (1 banana, 1 cup of whole milk, and 1 Tbsp peanut butter). Supper is chicken, vegetables, and a slice of avocado plus 2/3 cup of rice. On day 1 (Figure 1A), with a delayed breakfast and late supper, meal timing is poor. On day 2 (Figure 1B), with an early-morning snack and most carbohydrates (5 carbs) consumed early in the day, meal timing is better, leading to improved PPG after breakfast (from 231 to 125 mg/dL), TIR (from 94 to 100%), and mean glucose (from 124 to 117 mg/dL).

Figure 2 demonstrates the role of meal composition on glycemia. Meal timing on day 3 is further improved by making the afternoon snack and supper each smaller. Meal timing, carb intake (8 carbs/day distributed as 0.5, 3, 3, 0.5, and 1), a morning snack (egg and coffee with whole milk), an afternoon snack (two cherries and four blackberries), and supper (chicken, vegetables, and a slice of avocado plus one kiwi) are identical on days 3–6. On day 3 (Figure 2A), meal composition is poor for the two big meals; breakfast is corn flakes (1 g fiber and 3 g protein/serving) plus whole milk, and lunch is rice (0 g fiber and 3 g protein/serving) and yogurt. On day 4 (Figure 2B), meal composition is better because extra fiber and protein are included. Breakfast is granola with 9 g fiber and 9 g protein/serving plus whole milk, and lunch is barley with 7 g fiber and 5 g protein/serving and yogurt. PPG decreases after breakfast (from 184 to 159 mg/dL) and lunch (from 160 to 141 mg/dL) on day 4. Also, TIR increased from 99 to 100%, and mean glucose decreased from 127 to 117 mg/dL.

Figure 3 shows the effects of exercise on glycemia. Figure 3A is the same as Figure 2B (day 4). On days 4–6, meal timing and meal composition are optimal. On day 5, there is a 45-minute pre-breakfast walk. There is also a 30-minute walk taken 40 minutes after lunch (the third meal). On day 5, TIR remains 100%, and mean glucose decreases from 117 to 114 mg/dL. On day 6, no exercise is performed to illustrate the effect of the previous day’s pre-meal exercise. Mean glucose decreases to 104 mg/dL, and TIR remains at 100%.

My experience suggests that this five-step program can meaningfully change glucose levels and CGM data depending on how many habits are practiced. Better glucose regulation in the morning tends to help for the rest of the day. For example, if FBG is in the target range, PPG is likely to be better after meals as well. As shown on day 2 (Figure 1B), when the morning snack moderates breakfast PPG, that seems to help for the rest of the day. People who practice most of these healthy habits tend to stay on a virtuous cycle. As soon as they slip out of the healthy track, they may enter a vicious cycle, and some degree of vigilance may be needed to get back on track.

I will now present three real cases. One patient, a registered nurse, had difficulty keeping his FBG <120 mg/dL. As soon as he corrected his meal timing and started the pre-breakfast walk, his FBG normalized. Another patient was diagnosed with prediabetes in 2007. He started walking for 1 hour in the morning. Now, 13 years later, his A1C remains in the range of 5.2–6.1% despite stopping metformin. A third person, a psychologist, was introduced to the five healthy habits (12). His A1C decreased from 9.8 to 7.3% in 3 months, and his weight decreased from 85 to 76 kg. These three individuals are, of course, highly motivated.

Another observation concerns the mixed effects of pre-meal exercise. Initially, there is post-exertion glucose elevation, leading to glucose dysregulation for 1–3 hours after exercise (19). There is also delayed improvement in insulin sensitivity, which is usually better on the next day (12). The markedly improved glucose profile on day 6 (Figure 3C) is likely the effect of the pre-meal exercise done on day 5 (Figure 3B). In fact, overall glycemia is better when pre-meal exercise is done every other day. Post-meal exercises can be done after bigger meals on the remaining days.

The roles of meal timing, meal composition, and nutrient sequencing in improving glucose control are well documented. The positive and negative effects of pre-meal and post-meal exercise on glucose levels are also well studied. By practicing these five evidence-based habits and monitoring my progress via CGM, I found that the value of a morning snack was clear: Circadian-friendly eating and second-meal effects were helping PPG of both breakfast and lunch. Also, a pre-breakfast walk followed by the morning snack every other day turned out to be especially valuable; it mitigated the negative effects of pre-meal exercise and enhanced the positive effects. When I practiced what Lynn et al. reported about smart CGM alerts, I readily minimized hyperglycemia and hypoglycemia.

Both the existing scientific evidence and my own experience in self-managing type 2 diabetes with CGM for more than 2 years suggest that the five-step program described here is likely to yield good metabolic outcomes. The meal-time insulin dose at breakfast may be lowered or even eliminated with the help of the second-meal effect from the morning snack, and the timely post-meal walk after lunch can obviate mealtime insulin for lunch. The basal insulin dose can also be minimized as FBG improves.

This lifestyle is especially designed to prevent hypoglycemia and restore hypoglycemia awareness. The expected outcomes are normal FBG, moderate PPG, lower A1C, minimum insulin doses (basal and bolus), less hypoglycemia, lower risk of diabetes complications, and improved weight, blood pressure, cholesterol, and cardiometabolic health.

People with diabetes who have a glucose meter or CGM system should be encouraged to test these evidence-based healthy habits for themselves to improve diabetes management. Some may need close guidance and supervision. Randomized, controlled studies of this five-step program in different populations would be helpful.

The author thanks her endocrinologist, Dr. Christine Signore, of Middlesex Hospital in Middletown, CT, for her continued efforts to protect from hypoglycemia by ordering CGM and adjusting medications as needed.

No potential conflicts of interest relevant to this article were reported.

As the sole author, E.C., is the guarantor of this work and, as such, had full access to all the data included and takes responsibility for the integrity of the data and the accuracy of the article.