Children and adults with type 1 diabetes mellitus who consumed a very low-carbohydrate diet had exceptional glycemic control of their disease and very few adverse events, according to recently published study results in Pediatrics.
“Despite major medical and technological advances, the management of type 1 diabetes remains suboptimal,” Belinda S. Lennerz, MD, PhD, of the Division of Endocrinology, and New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital and Medical School, Harvard University, and colleagues wrote. “With an average overall hemoglobin A1c (HbA1c) of 8.2%, only 20% of children and 30% of adults achieve the glycemic targets of HbA1c less than 7% for adults and less than 7.5% for children as set forth by the ADA to reduce long-term complications.”
“The greatest challenge in this regard involves difficulty controlling postprandial glycemia, which is a major determinant of HbA1c,” the researchers wrote. “Even with modern insulin analogs and technical advances, a mismatch between carbohydrate absorption and insulin action typically exists after meals. Beyond a point, measures to lower postprandial hyperglycemia inevitably increase risk for hypoglycemia, with potentially life-threatening consequences.”
Lennerz and colleagues collected primary data using an online survey of people with type 1 diabetes who followed a very low-carbohydrate diet (VLCD) who were part of a closed international social media group. Current HbA1c (primary measure), change in HbA1c after self-reported beginning of VLCD, total daily insulin doses and adverse events were measured. Diabetes care providers and medical records were used to confirm data.
There were 316 respondents to the survey, including 131 parents of children with type 1 diabetes, with 42% children and 57% females in the study population.
"Even with modern insulin analogs and technical advances, a mismatch between carbohydrate absorption and insulin action typically exists after meals," the researchers wrote.
Age and weight at diagnosis, pancreatic autoimmunity, insulin requirement and clinical presentation were used in a 3-tiered scoring system to determine suggestive evident of type 1 diabetes in 86% of the respondents.
Participants reported a mean age at diagnosis of 16 ± 14 years, with diabetes duration of 11 ± 13 years, and had been following a VLCD for 2.2 ± 3.9 years. This included a mean VLCD duration of 1.4 ± 1.2 years for pediatric participants, according to an accompanying commentary.
The commentary also reported that the mean HbA1c for all study participants before beginning VLCD was 7.15% ± 1.15%.
A mean daily carbohydrate intake of 36 ± 14 g and a mean HbA1c of 5.67% ± 0.66% were reported for all participants.
There were 127 participants who reported a change in HbA1c from pre-VLCD to post-VLCD of –1.45% ± 1.04% (P < .001).
Diabetes-related hospitalizations were reported by only seven respondents (2%). The hospitalizations included four patients for ketoacidosis and two for hypoglycemia.
The researchers noted that children had similar reported HbA1c and other clinical parameters when compared with adults in the study.
“In this survey of children and adults who follow a VLCD for the long-term treatment of type 1 diabetes mellitus, we observed measures of glycemic control in the near-normal range, low rates of hypoglycemia and other adverse events, and generally high levels of satisfaction with health and diabetes control,” the researchers wrote. “These findings are without precedent among people with type 1 diabetes mellitus, revealing a novel approach to the prevention of long-term diabetes complications.”
“Additional research is needed to determine the degree of carbohydrate restriction (and other dietary aspects) necessary to achieve these benefits, optimal insulin regimen to accompany a VLCD (specifically with regard to avoiding severe hypoglycemia), safety and efficacy (in randomized controlled trials),” they concluded.
In an accompanying commentary, Carly Runge, BS, and Joyce M. Lee, MD, MPH, of the Child Health Evaluation and Research Center, Division of Pediatric Endocrinology, and Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan, reported that endocrinologists have traditionally focused on adjustment of insulin rather than diet as primary means of controlling glucose.
“We must recognize that even if therapy is determined to be efficacious, the uptake by patients and providers may be a barrier,” Runge and Lee wrote. “The authors uniquely assessed the participants’ satisfaction with their diabetes management and care team with a focus on VLCD. Interestingly, 27% of participants reported not discussing their VLCD with their provider, and only approximately one-half of those who did agree that their providers were supportive. This finding reveals the need for improved communication and shared decision-making between the patient, caregiver and provider regarding the overall management of type 1 diabetes and the need for greater dialogue within the type 1 diabetes community regarding standards of care.” – by Bruce Thiel
Disclosures: Lennerz reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Runge and Lee report no relevant financial disclosures.