Blood Glucose Control: A Balancing Act
Optimizing glycemic control in type 1 diabetes can be extremely challenging but is essential to prevent life-threatening, short-term complications such as DKA. Long-term glycemic control is also important to reduce the risk of microvascular complications and perhaps macrovascular complications . However, preventing hyperglycemia comes with the risk of inducing frequent or severe hypoglycemia, which can lead to lower quality of life, hospitalization, coma, and death.
Much of the challenge in maintaining euglycemia in patients with diabetes lies in the difficulty in matching carbohydrate intake with insulin administration, owing to errors in estimating the carbohydrate content in meals, variable insulin absorption, timing of insulin administration, and gastroparesis. Given these complicating factors, it is plausible that low carbohydrate intake and resulting lower prandial insulin bolus requirements may lead to better glycemic control, less blood glucose variability, and improved quality of life.
Management Of Type 1 Diabetes With A Very Lowcarbohydrate Diet
POTENTIAL CONFLICT OF INTEREST: Dr Bernstein reported receiving royalties for books on the management of diabetes . Dr Hallberg reported stock options and research support from Virta Health, a company that provides health care services for type 2 diabetes, and consulting fees from Atkins. Dr Rhodes is the site principal investigator in clinical trials for pediatric type 2 diabetes that are sponsored by Merck and AstraZeneca. Dr. Westman has ownership interest in companies using low-carbohydrate principles, and he receives royalties for books related to low-carbohydrate diets. Dr Ludwig reported receiving royalties from books on nutrition and obesity the other authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: Dr Yancy received research grants from the National Institutes of Health and the US Department of Veterans Affairs for projects involving veterans health related to a low-carbohydrate diet. Drs Ebbeling and Ludwig received research grants from the National Institutes of Health, the Nutrition Science Initiative, the Laura and John Arnold Foundation, and other philanthropic organizations unaffiliated with the food industry the other authors have indicated they have no financial relationships relevant to this article to disclose.
To evaluate glycemic control among children and adults with type 1 diabetes mellitus who consume a very lowcarbohydrate diet .
How To Lower A1c Diet
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Animal Studies Have Mixed Results
A few animal studies have examined the effect of a ketogenic diet in type 1 diabetes, but their significance in humans is unclear. Poplawski et al examined the effects of an 8-week ketogenic diet vs a high carbohydrate diet in rat models of type 1 diabetes with nephropathy. The ketogenic diet group had a drastically improved albumin-creatinine ratio, indicating reversal of diabetic nephropathy.
Al-Khalifa et al placed 42 rats on either a normal diet, low carbohydrate diet, or high carbohydrate diet, all ad libitum, for 8 weeks. Half of each group was injected with streptozotocin to induce diabetes. Blood glucose levels and food and water intake increased with the normal and high-carbohydrate diets but not in the low-carbohydrate group . Weight gain was also significantly lower in the low-carbohydrate group . In the low-carbohydrate group, the number of beta cells did not differ between the control group and the group with the streptozotocin injection, while the other diet groups had a significant decrease in beta-cell mass in the streptozotocin groups vs controls. These results suggest that a low-carbohydrate diet may attenuate or prevent the development of diabetes.
Make Sure To Monitor Your Ketone Levels
In addition to closely monitoring your blood sugar levels, be sure to test your ketone levels regularly when following a keto diet.
Many people with type 1 diabetes may be familiar with ketone testing already, as its used to detect early stages of diabetic ketoacidosis .
There are several methods for testing ketones:
- Blood testing. You can purchase meters with test strips that work similarly to blood glucose meters.
- Urine testing. You can buy test strips that indicate ketones by color when submerged in a urine sample.
- Breath analyzer. These devices measure acetone levels, a ketone byproduct, in your breath.
Specifically, you should check your ketone levels if your blood sugar level is above 300mg/dl or youre feeling sick, confused, or in a fog .
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A Guide To Healthy Low Carb Eating With Diabetes
Diabetes is a chronic disease that affects many people across the globe.
Currently, more than 400 million people have diabetes worldwide .
Although diabetes is a complicated disease, maintaining good blood sugar levels can greatly reduce the risk of complications .
One of the ways to achieve better blood sugar levels is to follow a low carb diet.
This article provides a detailed overview of very low carb diets for managing diabetes.
With diabetes, the body cant effectively process carbohydrates.
Normally, when you eat carbs, theyre broken down into small units of glucose, which end up as blood sugar.
When blood sugar levels go up, the pancreas responds by producing the hormone insulin. This hormone allows blood sugar to enter cells.
In people without diabetes, blood sugar levels remain within a narrow range throughout the day. For those who have diabetes, however, this system doesnt work in the same way.
This is a big problem, because having both too high and too low blood sugar levels can cause severe harm.
There are several types of diabetes, but the two most common ones are type 1 and type 2 diabetes. Both of these conditions can occur at any age.
In type 1 diabetes, an autoimmune process destroys the insulin-producing beta cells in the pancreas. People with diabetes take insulin several times a day to ensure that glucose gets into the cells and stays at a healthy level in the bloodstream .
Low Carb In Type 2 Diabetes
Some people with Type 2 Diabetes may find a low carb diet useful in managing their weight, and this has shown to be effective and reasonably safe, in short term trials. However, like in Type 1 Diabetes studies, there is limited evidence for long term weight management.
The best dietary strategy for weight management is whatever you can stick to. If you think low carb is something thats easy to follow, helps you lose weight and manage you blood glucose levels, then it could be the right diet for you.
Often, people find it difficult to stick to very low carb diets and find a more moderate carbohydrate approach is easier .
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Low Carb And Type 1 Diabetes
How many carbs should someone with type 1 diabetes eat every day?
The short answer is that optimal daily carb intake varies among people with type 1 diabetes. As shown in the studies above, restricting carbs to fewer than 100 grams daily is often sufficient to improve blood sugar control and reduce the risk of severe hypoglycemia.
However, a very-low-carb approach will require the least amount of insulin, possibly resulting in even more predictable blood sugar control and a greater likelihood of remaining within the healthy range throughout the day and night.
How people with type 1 diabetes can safely achieve great blood sugar control with low carb
People with type 1 diabetes who want to start eating low carb should ideally work with a doctor, nurse, dietitian or other health professional who specializes in diabetes and understands carb restriction.
This is because, in addition to decreasing the amount of insulin you take to cover carbs, you may need to make other adjustments, such as reducing your basal insulin dosage. Although the principles of management apply to everyone, you will need to assess the effects of a low-carb diet on your body chemistry. The best and safest approach is one that includes frequent testing, keeping detailed records, and evaluating your results.
Failing to account for protein may result in excellent blood glucose levels an hour or so after a meal but higher levels several hours later.26
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What Foods Should I Avoid When I Have Type 1 Diabetes
There are some specific foods that people with type 1 diabetes need to avoid because they can cause blood sugar levels to spike.
These foods include those with high sugar contents such as candy, cake, cookies, ice cream, fruit juices, soda, and other sugary drinks.
This is not because the sugar in these foods directly enters your bloodstream, but it is due to the fact that sugar contains empty calories that eventually break down into glucose.
It is also important to avoid eating large amounts of carbohydrates at one time by carb counting.
You dont need to avoid carbs completely, but you can control how much you eat and how to monitor your insulin levels so you can learn to keep your blood sugar levels in the desired range.
Unhealthy fats, like trans fat and saturated fats, should also be avoided when you have type 1 diabetes because they can also raise blood sugar levels.
Foods that contain unhealthy fats include processed foods, fast food, and junk food.
How To Adjust Insulin
Insulin dosages usually need to be reduced after starting a ketogenic diet in type 1 diabetes, this usually entails decreasing the amount of insulin received per gram of carbohydrate. The following strategy can be used:
If a patients HbA1c is near target, the daily dosage of basal insulin may need to be decreased by 10% to 20%
If the HbA1c is elevated, no adjustments may be required
It is often safest to adjust insulin with the aim of reducing the risk of hypoglycemia the patient can be instructed to take additional correction doses of short-acting insulin to address hyperglycemia
Insulin dosages often need to be adjusted weekly in the initial stages as weight loss and adherence to the ketogenic diet will impact the necessary insulin adjustments, and these factors are highly individual.
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Safety In Pediatric Patients
There is a lack of observational and prospective studies in children following a ketogenic diet, but several case reports have discussed its benefits in children with type 1 diabetes.,, They have found reductions in glycemia and glycemic variability and improvements in HbA1c level, growth rate, and lipid profiles, and many have been without severe adverse effects, like DKA and hypoglycemia.
Henwood et al described a 4-year-old girl with pyruvate dehydrogenase deficiency, seizure disorder, and type 1 diabetes who was treated with a ketogenic diet. During 28 months follow-up, she had improved activity, better glycemic control, significant developmental advances, and an increase in linear growth from less than 5th percentile to 50th percentile. However, the diet was discontinued when she developed severe DKA.
Other case reports have revealed concerns about the diets safety in children with and without diabetes. de Bock et al described 6 children with type 1 diabetes who were treated with carbohydrate-restrictive diets for epilepsy . Some children experienced weight loss and growth delay. Commonly observed effects were fatigue, reduced enjoyment in physical sports, and eating disorders. Ultimately, most families opted to return to a more liberal carbohydrate-containing diet.
Carb Counting Vs Low Carb For Type 1 Diabetes
Prior to the discovery of insulin in 1921, many doctors placed their patients with diabetes on very-low-carb diets because they recognized that carbs raise blood glucose much more than does protein or fat.11 While this wasnt sufficient to manage type 1 diabetes, it did help to prevent extreme carb-related spikes.
The advent of injectable insulin allowed those with type 1 diabetes to eat carbohydrate without dramatically raising their blood sugar. However, even with insulin, controlling blood glucose levels can be a major challenge for them.
Today, diabetes educators often tell people with type 1 diabetes that they simply need to take insulin to match the amount of carbs they eat at each meal. In fact, many people who use ICRs have repeatedly heard, You can eat whatever you like as long as you take the right dose of insulin.
However, there are several issues with this approach, including:
For many people with type 1 diabetes, eating high-carb foods and taking large doses of insulin can cause blood sugar levels to resemble a rollercoaster rather than remaining within a narrow range.
In his book, Dr. Bernsteins Diabetes Solution, Dr. Richard K. Bernstein explains that eating very small amounts of slowly-digested carbs and taking very small doses of insulin leads to more predictable results and essentially normal blood sugar levels. He calls this The Law of Small Numbers.
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What Did They Find
The mean HbA1c of participants following this low carb diet was 5.67%. A whooping 97% of participants achieved the ADA glycemic targets, which is amazing on average, only 14% of people between 18 and 25 with Type 1 diabetes meet ADA glycemic targets, and 30% of older adults reach this target. The mean daily insulin dose was .40 U/kg per day. And even though these people were eating a low-carb diet, the rates of severe hypoglycemia were relatively low 2% reported seizure or coma due to hypoglycemia.
Another interesting piece was how the participants felt about their health and their healthcare on this low-carb diet. Although they reported high levels of overall health and satisfaction with their diabetes management, they did not feel similarly positive about their healthcare providers. Many were hesitant to discuss their diet with their diabetes healthcare providers, and of those that did tell their doctors or endos about their low-carb diet, only 49% felt their providers were supportive.
Some People Should Avoid The Keto Diet
Due to potentially negative overall health effects, some people with type 1 diabetes should not follow a keto diet, including:
- those with a history of chronic low blood sugar levels
- people who are underweight or have an eating disorder
- people undergoing or recovering from a medical procedure
- children or adolescents under 18 years old
- pregnant or breastfeeding mothers
- cholesterol hyper-responders
These populations have an increased risk of complications and are not advised to start a keto diet without medical clearance .
Some people with type 1 diabetes can safely follow a keto diet, though close medical supervision is crucial. Other groups of people should avoid the diet. Its important to monitor ketone levels, especially if your blood sugar levels are elevated.
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What To Consider Before Following A Low
If you treat your diabetes with insulin or any other diabetes medication that puts you at risk of hypos, following a low-carb diet may increase this risk. Speak to your healthcare team about this so they can help you adjust your medications to reduce your risk of hypos. Your team may also support you to check your blood sugar levels more often.
I make sure I balance out my diet with what suits my insulin, but with a bit of tweaking, most things can be persuaded to suit my insulin!
I won’t eat a load of pasta with a side of garlic bread and not much else, because the carb load would be difficult to bolus for. But neither would I eat a completely carb free meal. It’s all a question of balance, and a healthy diet is good for all of us, diabetic or not.
– Online forum user living with type 1.
Depending on the approach, following a low-carb diet may also lead to other side effects, such as constipation or bad breath.
Although these can be unpleasant, they are usually temporary and shouldnt be harmful in the long term. Speak to your healthcare professional if youre concerned about any of these.
Its really important to first reduce your carb intake from unhealthy sources such as sugary drinks, pizzas, cakes, biscuits, chips, white bread, fruit juices and smoothies.
Whats The Optimal Carb Intake For People With Diabetes
The ideal carb intake for people living with diabetes is a somewhat controversial topic, even among those who support carb restriction.
Many studies found dramatic improvements in blood sugar levels, body weight, and other markers when carbs were restricted to 20 grams per day (
The optimal amount of carbs may also vary by individual, since everyone has a unique response to carbs.
According to the American Diabetes Association , theres no one-size-fits-all diet that works for everyone with diabetes. Personalized meal plans, which take into account your dietary preferences and metabolic goals, are best .
The ADA also recommends that individuals work with their healthcare team to determine the carb intake thats right for them.
To figure out your ideal amount of carbs, you may want to measure your blood glucose with a meter before a meal and again 1 to 2 hours after eating.
As long as your blood sugar remains below 140 mg/dL , the point at which damage to nerves can occur, you can consume 6 grams, 10 grams, or 25 grams of carbs per meal on a low carb diet.
It all depends on your personal tolerance. Just remember that the general rule is the less carbs you eat, the less your blood sugar will rise.
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