Following a very low carbohydrate diet (VLCD), "exceptional" glycemic control can occur in both adults and children with type 1 diabetes, new research suggests.
The results of more than 300 patients with type 1 diabetes were reviewed online on May 7 in Pediatrics by Belinda S. Lennerz, MD, PhD, of the Boston Children's Hospital and the Harvard Medical School, Massachusetts.
The study participants all followed the VLCD scheme described in the book . Bernstein's Diabetes Solution the author of which is Richard K Bernstein, MD, of the New York Diabetes Center in Mamaroneck and Type 1 has diabetes itself, was a study investigator.
Both adult and pediatric study participants were able to achieve near-normal HbA 1
"We suggest that VLCD can provide exceptional control of type 1 diabetes without increased risk of adverse events, which is mechanistically plausible because of the dominant effects of carbohydrates on postprandial glycaemia and lower insulin doses in VLCD However, Lennerz and colleagues warn.
However, they warn: "Given the limitations of the study, these findings should not be considered sufficient to justify a change in diabetes management."
In an accompanying editorial, Carly Runge, BS, and Joyce M. Lee, MD, MPH, both of the University of Michigan, Ann Arbor, cite the study as "an important contributor to the literature" given the lack of information on optimal nutritional strategies for type 1 diabetes.
In Indeed, Runge and Lee note current guidelines for patients with type 1 diabetes – as opposed to type 2 diabetes – concentrate carbohydrates are almost exclusively insulin-engineered, despite the fact that the timing of the action itself, even of short-acting analogues, lags behind carbohydrate absorption, resulting in post-meal glucose spikes.
In fact, a father from one of Lee's patients told her that he asked for his opinion on the disease. Advice to the family at the time of diagnosis: "You should never have told us that our son can eat anything It just is not true. "
But the editors also point out that the generalizability of the findings and the long-term safety of carbohydrate restriction remain unknown, and" even if the therapy proves effective, the uptake Patients and vendors can pose a barrier. "
" Exceptional "Blood Glucose Control
The study involved 316 individuals, of whom 54% were adult patients and 42% were parents of children with type 1 diabetes Facebook group for humans with type 1 diabetes, follow Bernstein's recommended VLCD diet.
The approach involves a weight-based carbohydrate regulation of no more than 30 g / day, derived from fibrous vegetables and nuts with a low glycemic index. Proteinaceous foods replace carbohydrates, and insulin doses are empirically adjusted by postprandial and fasting glucose levels.
Most participants came from the United States, Canada, Europe or Australia the majority (88%) was white and 84% were college graduates. The mean age at diagnosis of diabetes was 16 years, the duration of diabetes was 11 years and the time after the VLCD diet was 2.2 years.
Confirmation data were obtained from diabetes care providers and medical records, including a multi-step investigation to assure all participants had type 1 diabetes – not type 2 diabetes or a genetic variant. However, not all data points were available to all respondents.
Participants claimed to consume an average of 36 grams of carbs per day. The averaged HbA 1c was 5.67%, a decrease of 1.45 percentage points after approval of the VLCD ( P <.001). The mean blood sugar level was 104 mg / dL in 137 patients with continuous glucose monitoring data.
In a regression analysis, the carbohydrate uptake target was the only significant predictor of variations in HbA 1c ()] P = 0.001), with an increase in HbA 1c of 0.1% per 10 g of carbohydrate consumed. The average daily insulin dose was 0.40 U / kg / day
Short-term adverse events not increased
Only seven participants (2%) reported 14 hospitalizations last year, including four hospitalizations for diabetic ketoacidosis and nine for other reasons , Just over two-thirds (69%, n = 205) of participants reported symptomatic hypoglycaemia last month, but only seven (2%) reported severe hypoglycaemia with seizures or coma, and 11 (4%) required glucagon.  Fasting lipid profiles were mixed. Triglyceride levels were low (mean 74 mg / dl) and high HDL cholesterol (74 mg / dl), but overall and LDL cholesterol levels were high (234 mg / dl and 147 mg / dl, respectively).
HbA 1c and other parameters were similar for children and adults.
Among the children, the standard deviation values (SDS) for the height given by the participants and the provider were 0.26 and 0.25, respectively, and there was no correlation of height SDS with carbohydrate intake target ( P = .20 ) or diet duration ( P = .16).
Patient-based communication is lacking
Worryingly, 27% of respondents said they did not discuss their VLCD therapy with their diabetes care provider. And of those who discuss it, less than half (49%) agreed that these providers were supportive.
Reasons not to discuss the VLCD with providers were disagreements over treatment goals and approaches, perceived disinterest of subjects or lack of familiarity with VLCD's desire to avoid a conflict with the provider, and among parents accused of the fear of child abuse to become.
By contrast, 82% of participating providers found the therapeutic relationship to be very good or excellent and were significantly more likely to be patients / parents when they said they were actually supporting the VLCD ( P =. 007).
Not Ready for a Universal Recommendation
Lennerz and colleagues write: "Additional research is needed to determine the degree of carbohydrate restriction (and other dietary aspects) necessary to achieve these benefits optimal insulin regimen to specifically accompany a VLCD in relation to the prevention of severe hypoglycemia, safety and efficacy (in randomized controlled trials). "
And they add that once these are established, studies should be performed To evaluate the effectiveness of VLCD in the prevention of long-term diabetes complications. Runge and Lee, addressing the communication problem of patient and provider, state: "This finding demonstrates the need for improved communication and shared decision-making between patient, caregiver, and provider regarding the overall treatment of type 1 diabetes and the need for more dialogue within the Type 1 diabetes community about nutritional standards of care. "
The study was supported by the National Ins titte of Diabetes and Digestive and Kidney Diseases. Bernstein receives royalties for books on diabetes management. Runge and Lee have not reported any relevant financial relationships.
Pediatrics. Published online May 7, 2018. Full text, Editorial
For more news on diabetes and endocrinology, see Twitter and Facebook