Reference
Lennerz BS, Barton A, Bernstein RK, et al. Management of type 1 diabetes with a very low-carbohydrate diet. Pediatrics. 2018;141(6):e20173349.
Objective
To characterize glycemic control; determine adverse events; assess objective health characteristics (weight, blood parameters, etc.); compare pre- and post-parameters of glycemic control with adoption of VLCD diet; and characterize participant satisfaction with both diabetes management and the healthcare system.
Design
Cross-sectional, observational cohort study using an online survey of members from a social media support group
Participants
All participants were members of an international social media group for people with type 1 diabetes mellitus (T1DM) who follow a very low carbohydrate diet (VLCD). A total of 316 people responded to the survey. Of the 316 respondents, 273 gave suggestive evidence of T1DM, 131 were parents with children with T1DM, 57% were female, 42% were children, 88% were white and non-Hispanic, and 84% were college-educated. Mean age at diagnosis was 16±14 years, mean duration of diabetes was 11±13 years, and the mean period of time they had been following a VLCD was 2.2±3.9 years.
Study Parameters Assessed
The survey asked questions about the following: daily dietary carbohydrate intake; diabetes-related complications and hospitalizations in the last year, specifically for ketoacidosis or hypoglycemia; average total daily insulin dose; blood glucose concentrations as measured by continuous glucose monitor or glucose meter; adverse events; weight/height/BMI; metabolic labs (serum lipids); patient-physician relationship; and hemoglobin (Hb)A1C (glycosylated hemoglobin). Confirmatory data was obtained from diabetes care providers or medical records.
Primary Outcome Measure
Change in HBA1C after beginning VLCD
Key Findings
Exceptional glycemic control of T1DM with low rates of adverse events was reported by a community of children and adults who followed a VLCD. The mean daily carbohydrate intake was 36±15 grams a day, and the mean HbA1C was 5.6%±0.66%. Nearly 97% of participants achieved American Diabetes Association (ADA) glycemic goals.
The results of this observational study of T1DM participants are outlandishly positive compared to results from conventional care cohorts.
Participants saw their HbA1C fall on average −1.45±−1.04%. Although few participants needed to be hospitalized for hypoglycemia (2%) or ketoacidosis (1%), symptomatic hypoglycemia was much more frequent; 69% of surveyed patients reported struggling with hypoglycemia in the month prior to completing survey, the majority (55%) reporting 1 to 5 episodes a month.
Practice Implications
The results of this observational study of T1DM participants are exceedingly positive compared to results from conventional care cohorts. According to a 2015 report from a large database, conventional care of T1DM patients results in an average HbA1C of 8.2%, and only 20% of children and 30% of adults achieve target HbA1C values (ADA glycemic goals).1
One problematic statement made by 27% of VLCD adherents in the present study was that they did not share with the diabetes practitioner that they were following a VLCD. For those who did share, less than half (49%) believed their practitioners supported their dietary choice. For naturopathic/integrative practitioners who are knowledgeable about and much more openly support a low-carbohydrate diet for their diabetic patients, a better doctor/patient relationship can no doubt be fostered and maintained.
Given that diabetes could be defined as “the loss of the metabolic capacity to process carbohydrates, due to insulin resistance or lack of produced insulin,” restricting carbohydrates in dietary treatment makes both common sense and also medical sense.
However, a survey is not the most rigorous example of medical validation. Conducting the survey via a social media platform could exclude those who did not achieve favorable results, as they may have dropped out of the group or simply did not complete the survey at all. Those who do find success with a given treatment may be more motivated than others to share the experience. That said, there has been a more formal review of the topic to corroborate the observations found in this study.
A 2015 study from Richard Feinman and colleagues entitled “Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: Critical Review and Evidence Base” brought together numerous studies that clearly show diabetes is best treated, and should be first treated, with a low-carbohydrate dietary regimen.2 This 12-point medical review analyzed the positive results of many studies proving that dietary carbohydrate restriction reduces high blood glucose, does not require weight loss (although it is excellent for weight loss), and leads to the reduction or elimination of medication. The review analyzed VLCD studies relevant for both type 2 and type 1 patients.
Any naturopathic physician working with diabetic patients should focus on introducing their patients (and supporting adherence) to a VLCD of less than 40 grams a day from all food sources. Beginning treatment with this protocol is foundational for successful glucose control in our patients with diabetes.
