Janine Freeman, RD, LD, CDE
Education Program Specialist,
Department of Food and Nutrition

Document Use:

Picture yourself sitting on a pretty blanket covering the grass beneath you, the warm sun shining through the trees, perhaps a lake just down the hillside, a picnic basket next to you, and your best friend beside you. The perfect picnic! Well, perhaps your idea of a picnic is a little more elaborate, but the idea is the same – sharing food outdoors with loved ones on a beautiful summer day. The warm weather signals the start of picnic and barbecue season. We get together starting Memorial Day weekend through Labor Day to enjoy the traditional barbecue or other popular picnic foods. To really enjoy the day and keep your blood glucose in good control, plan ahead and take a few precautions.

Not only is summer a good time for picnics and barbecues, but also for bacteria to multiply and cause food poisoning. Food left out of refrigeration for more than 2 hours (or 1 hour in temperatures above 90 degrees) may not be safe to eat. Perishable foods like luncheon meat, cooked meats, chicken and potato or pasta salads should be put on ice once you finish eating so they don't spoil. If you don't plan to carry a cooler with ice, take only non-perishable foods like fruits, vegetables, hard cheese, canned meat or fish, chips, bread, crackers, peanut butter, jelly, mustard, and pickles.

General safety tips:

1. Keep perishable food cold to minimize the growth of bacteria. Use an insulated cooler with enough ice or ice packs to keep the food at 40 degrees. Keep the cooler in the air conditioned part of the car (not the trunk) and in the shade at the picnic.
2. If you marinate food to tenderize or add flavor, do so in the refrigerator. It's best to discard the marinade after use.
3. Make sure to keep meat and poultry securely packed so that the juices don't contaminate other foods. Be sure to bring extra platters because you should not use the same platter for raw and cooked meat and poultry.
4. Don't keep perishable food that has been left out longer than 1-2 hours. If you have any doubts, throw it out.

Interested in giving up a little tradition for a little more nutrition? You don't have to eat ribs, fried chicken, and potato salad and cole slaw with loads of mayonnaise. There are some delicious and healthier alternatives.

1. Roast chicken without the skin
2. Marinated beef flank steak (see recipe)
3. Chicken and vegetable kabobs
4. Tossed green salads with tomato, broccoli, carrots, artichoke hearts and a low-fat dressing
5. Cole slaw with a light vinaigrette dressing
6. Fresh fruit salad or fruit kabobs
7. Whole grain rolls or bread without butter

Make your picnic fun by planning activities in which everyone can participate. Take a little hike after your meal to get a little more activity in your day. With a little planning, you can enjoy your summer get-together and stay healthy at the same time.

If you've had problems with low blood glucose reactions in the early morning hours or in the middle of the afternoon, a new insulin might be just the answer for you. Insulin glargine is a new type of longer-acting insulin that has virtually no peak. Therefore, the effect on blood glucose is much more predictable. The FDA has just approved it and it should be available in September.

Insulin glargine can be used very effectively at night since it will last all night (up to 24 hours) without any peaks. Some problems with current longer-acting insulins like NPH or Lente are that they may not last through the entire night, resulting in high blood glucose levels when you awaken. Or they can cause low blood glucose at times when the insulin peaks or is more effective. The peak action is not the same in everyone and is often difficult to predict.

People with type 1 or type 2 diabetes may benefit from the new insulin. In people with type 2 diabetes, the insulin glargine may be taken at bedtime and other diabetes medications taken during the day. In type 1, insulin glargine can act as a basal or background insulin with regular or fast-acting insulin taken at mealtime. The biggest advantage in the clinical studies was that people had fewer hypoglycemic (low blood glucose) reactions.

Insulin glargine (brand name Lantus) is manufactured by Aventis, a new player in the insulin market in the US. Approval of this insulin will mark a breakthrough for people taking insulin and their physicians and health care teams. With less low blood glucose to worry about, you may be able to dispense with the extra snacks during the day, making it easier to reach and keep your weight and blood glucose goals.

Rezulin (troglitazone), a diabetes medication that has been the center of attention due to safety concerns, was pulled from the market in March due to the risk of severe liver damage. Anyone taking this medication should contact their doctor before discontinuing the drug to get an appropriate alternative. Remember that monthly liver tests may be necessary depending on which alternative drug your doctor selects.

Two herbs that were found to contain high levels of glyburide, a prescription drug, were also recalled. The herbs sold under the names Dianolyn Capsules and Dimelstat. Many people taking these herbs developed unexpected hypoglycemia, or low blood glucose. Since herbs are not required to be regulated by the Food and Drug Administration, experts were not aware of their content. If you take any type of herbal supplement, be sure to let your physician know in order to avoid dangerous side effects or interactions with other medications you are taking.

If you're somewhat bewildered about what types of snacks are best to prevent or treat hypoglycemia (low blood glucose), you're not alone. Advertiser's messages promising "slow-release" carbohydrate in their snack bars sound pretty convincing. But, do they work and are they worth the cost?

Treatment of Hypoglycemia
The best treatment for hypoglycemia is obviously whatever you have on hand at the time. All types of carbohydrate, including orange juice, milk, crackers, raisins, glucose tablets, and hard candy will eventually raise blood glucose. However, glucose tablets are probably the best choice since they raise the blood glucose very quickly and contain a pre-measured amount of glucose. That prevents you from "over-indulging" when you have the desire to "eat everything in sight," a typical reaction to hypoglycemia. Therefore, your blood glucose is less likely to jump from 55 to 300 following a reaction.

Chocolate bars are often a favorite "treatment", but only because of the taste. Snacks and bars that contain fat, including chocolate bars, are not as likely to relieve your symptoms of hypoglycemia as quickly. Fat generally delays absorption of the carbohydrate. Adding protein to your snack to treat hypoglycemia is also not necessary. Although this was recommended for years, this has not been shown to aid treatment. These snacks merely provide extra calories and fat which make it more difficult to lose or maintain your weight.

Prevention of Hypoglycemia
Anyone taking insulin or diabetes pills has the potential for hypoglycemia. Diabetes pills that increase your body's release of insulin like Micronase, Glucotrol, Diabeta, Amaryl, and Prandin are more likely to cause hypoglycemia than other diabetes medications. Other types of diabetes pills help lower your blood glucose in other ways by either slowing the release of glucose by the liver, improving your body's resistance to insulin, or slowing the absorption of carbohydrate after a meal. Therefore, they are not as likely to cause low blood glucose reactions. These medications include Actos, Avandia, Precose, Glyset, and Glucophage.

Eating at regular times, avoiding skipped meals, and monitoring your blood glucose on a regular basis to determine your usual blood glucose patterns can help prevent unexpected low blood glucose. Although exercise usually lowers blood glucose, snacks are generally not needed if you're able to eat one to three hours before you exercise. If you're exercising with a goal of losing weight, avoid the extra calories of a snack. However, if you plan to exercise after work or before a meal, you may need a snack. Most people find that a snack of fruit, crackers or yogurt works quite well. Energy bars are expensive and many have been shown to cause a greater increase in blood glucose followed by a steeper drop in glucose compared to a regular candy bar.

Diabetes Snack Bars
Diabetes snack bars claim to slow absorption and prevent night-time hypoglycemia, a problem of primary concern in people with type 1 diabetes who may have fewer symptoms to alert them of hypoglycemia. They often contain a type of starch that is designed to be released more slowly. However, few studies support the claims that the bars cause less rise in glucose and prevent hypoglycemia for a longer period of time. In addition, they tend to cost about $1 per bar.

There is limited evidence to support the benefits of diabetes snack bars or energy bars for most people with diabetes. However, if convenience is more important to you than cost, you may find them useful. Blood glucose monitoring is the most effective tool in helping to prevent hypoglycemia. Your blood glucose results can help you and your health care team determine if your insulin or diabetes pills need to be adjusted or if making some changes in your food plan would be beneficial.

If you monitor your blood glucose only before meals and at bedtime, you may be missing part of the big picture. What happens after meals or between meals? Was your last hemoglobin A1c higher than you expected based on your monitoring records? Monitoring your blood glucose levels only before you eat does not tell you and your health care team what's happening the rest of the time. And since most of us eat at least 4-6 times a day, your blood glucose may be high at other times when you're not testing. Your hemoglobin A1c gives you a picture of how high your blood glucose has been over the past two months - at all hours of the day and night. So, if it was higher than your before-meal tests indicated, consider monitoring your blood glucose after meals.

If you do test after meals, your health care team can give you goals for your blood glucose results. The Diabetes Association does not have specific goals for after-meal glucose levels at this time. However, studies have shown that people with after-meal glucose levels above 180 mg/dl were more likely to develop complications of diabetes. Some experts recommend keeping blood glucose levels below 160 mg/dl 2 hours after meals.

If you have high after-meal glucose levels, what can you do? First of all, look at the size of your meal. Large portions of foods containing carbohydrate will cause a greater rise in glucose after a meal. For example, a large plate of spaghetti along with a couple of garlic rolls can add up to a lot of carbohydrate at one time. Also, eating meals and snacks too close together will result in higher glucose levels. It's best to space out your carbohydrate fairly evenly throughout the day. If you eat some sweets, be sure to leave off some of the other carbohydrate at that meal. Remember -- the total amount of carbohydrate you eat at one time is more important than the type of food you eat.

Secondly, your doctor may recommend a type of diabetes medication that works very quickly and is taken before each meal. These include Precose (acarbose), Prandin (repaglinide), Glyset (miglitol), and one that will likely be approved for use later this year, Starlix (nateglinide.) If you take insulin, your doctor may recommend a rapid-acting type that works primarily to cover a meal like Humalog (lispro).

Obviously, one of your major goals is to keep blood glucose levels as close to normal as possible. Results of several large studies like the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study have shown that doing so can help prevent many of the complications of diabetes like eye disease, damage to nerve endings, kidney disease, and heart disease. Currently, a long-term measure of glucose control like the hemoglobin A1c test is the best way to show you and your doctor if your diabetes is in good control. The American Diabetes Association recommends less than 7 percent ais the goal for most people with diabetes. However, your health care team can tell you what the best number is for you.

So, if you're in the dark about your diabetes control, remember that blood glucose monitoring is your key to good control. Your results can help you and your health care team decide what measure to take to achieve your blood glucose goals.