What should a pregnant patient eat if they wake up at night due to hunger?

Nighttime Eating During Pregnancy: Evidence-Based Recommendations

If you wake up hungry at night during pregnancy, the decision to eat depends critically on whether you have gestational diabetes or pre-existing diabetes—if you do NOT have diabetes, a light snack is reasonable, but if you DO have gestational diabetes, emerging evidence suggests avoiding nighttime eating may be preferable despite traditional recommendations.

For Pregnant Women WITHOUT Diabetes

• A light evening snack before bed is acceptable if you experience nighttime hunger, as adequate energy intake is important for fetal growth and maternal health 1
• The snack should provide adequate protein (0.75 g/kg plus an additional 10 g/day during pregnancy) and be part of your overall healthy eating pattern 1
• Avoid excessive caloric intake at night, as insulin resistance naturally increases across the day due to circadian physiology, making evening carbohydrate consumption less metabolically favorable 2

For Pregnant Women WITH Pre-existing Type 1 or Type 2 Diabetes

• An evening snack is usually necessary to decrease the potential for overnight hypoglycemia and fasting ketosis, given the continuous fetal draw of glucose from the mother 1
• Regular meals and snacks throughout the day are important to avoid hypoglycemia 1
• Blood glucose monitoring should guide whether you actually need the nighttime snack—if your bedtime glucose is >10 mmol/L, no snack may be necessary 3
• If bedtime glucose is 7-10 mmol/L, any snack is advised; if <7 mmol/L, a standard snack containing both carbohydrate and protein is recommended 3

For Pregnant Women WITH Gestational Diabetes (GDM): The Controversy

This is where the evidence becomes contradictory and requires careful consideration:

Traditional Recommendations (Older Guidelines)

• Carbohydrate-containing evening snacks have been traditionally encouraged with the expectation of suppressing hepatic gluconeogenesis to achieve lower fasting blood glucose levels 1
• An evening snack "may be needed" to prevent accelerated ketosis overnight 1

Emerging Evidence Against Nighttime Eating (Most Recent Studies)

• A 2025 randomized controlled trial found that bedtime snacks (25g nuts) did NOT reduce morning fasting blood glucose or hyper-fasting glucose incidence in women with GDM 4
• More concerning, bedtime snacking actually exacerbated lipid markers (higher LDL cholesterol) and increased 1-hour postprandial glucose levels 4
• A 2022 randomized crossover trial demonstrated that both higher and lower carbohydrate bedtime snacks were associated with slightly higher fasting blood glucose the following morning compared to no snack (mean difference 0.09-0.14 mmol/L) 5
• Extending the overnight fasting period has been associated with decreased glucose levels, with a 0.03 mmol/L decrease in fasting glucose for each 1-hour increase in overnight fasting 1, 2
• Women with GDM are more likely to snack at night than those with normal glucose tolerance, which may contribute to impaired glucose metabolism 1

The Circadian Rhythm Problem

• Glucose responses to identical meals are significantly higher from 3 to 9 hours after evening consumption compared to morning consumption 2
• Even when evening meals contain LESS carbohydrate than morning meals, glucose concentrations remain higher at night 2
• Late night eating opposes circadian clock regulation and is associated with hyperglycemia, hyperlipidemia, and abdominal obesity 1, 2
• Reduced glucose tolerance occurs in the afternoon compared to morning in pregnant women, irrespective of diabetes status 1

Practical Algorithm for Decision-Making

For women with GDM specifically:

1. Monitor your bedtime glucose levels and morning fasting glucose patterns for several days 1

2. If morning fasting glucose is consistently elevated (>5.3 mmol/L):

   • Try AVOIDING the bedtime snack for 3-5 days and monitor results 4, 5
   • This contradicts older guidelines but is supported by the most recent high-quality evidence 4

3. If you develop ketones on morning testing:

   • This indicates inadequate energy intake; you may need to add back a small bedtime snack 1
   • Focus on adequate total daily caloric intake distributed earlier in the day rather than concentrating calories at night 2

4. If you're on insulin therapy:

   • The risk-benefit calculation changes; preventing hypoglycemia becomes paramount 1
   • A bedtime snack may still be necessary, but work with your healthcare team to potentially adjust insulin timing/dosing instead 1

What to Eat If You Do Need a Nighttime Snack

• Prioritize protein-containing snacks over pure carbohydrate snacks, as protein snacks have been shown to prevent nocturnal hypoglycemia without causing morning hyperglycemia in insulin-treated patients 3
• Keep the carbohydrate content modest (approximately 15g or one starch exchange) 3
• Examples: small portion of nuts with cheese, Greek yogurt, or a hard-boiled egg with a small piece of whole grain bread
• Avoid high-glycemic index foods and large carbohydrate loads at night 6

Critical Caveats

• The 2024 Clinical Nutrition scoping review explicitly states that current dietary guidance for GDM encouraging late-night snacking may contradict evidence about circadian glucose metabolism 1
• The traditional recommendation for evening snacks was based on theoretical mechanisms (suppressing hepatic gluconeogenesis) rather than robust clinical trial evidence 1
• Individual responses vary, and some women may genuinely need nighttime nutrition to prevent ketosis 1
• Never implement hypocaloric diets during pregnancy, as they result in ketonemia and ketonuria 1

Bottom Line for Clinical Practice

Given the most recent and highest quality evidence from 2025 and 2024, pregnant women with GDM who wake up hungry at night should first try extending their overnight fast (avoiding nighttime eating) while ensuring adequate total daily caloric intake distributed earlier in the day, monitoring both morning fasting glucose and ketones to ensure this approach is safe and effective for their individual situation 4, 5. This represents a significant departure from traditional recommendations but is supported by the strongest contemporary evidence prioritizing maternal and fetal metabolic outcomes 4, 1.