Carbohydrate Restriction for Type 1 Diabetes: Inspiration vs. Criticism

My Position on Very Low Carbohydrate Diets for Type 1 Diabetes 

Last week, I saw a Facebook post from a low-carb proponent (who does not have diabetes) criticizing this article for being a negative way to view type 2 diabetes management. Riva Greenberg is a well-known author and diabetes advocate who has lived with type 1 diabetes mellitus (T1DM) for over 40 years. Her article was intended for people with type 1 rather than type 2 diabetes. There are hormonal and other factors in type 1 diabetes that make it impossible to control 24/7, regardless of diet. Riva does follow a carbohydrate-restricted diet, although not as low as Dr. Richard Bernstein's < 30 grams daily recommendation. From what I've read about her online, for several years her A1c has been in the upper 5's, which is better than the majority of  people with diabetes.

I'm a staunch advocate of carbohydrate restriction for people with diabetes and anticipate I always will be. While I personally avoid pretzels and the other higher-carb items mentioned in the article and would definitely do so if I had T1DM, I understand that not everyone feels the same way. Riva has her reasons for not eating exactly as Dr. Bernstein prescribes, and I respect them. Would she have better control if she switched to a very-low-carb diet? It's likely she would, but it's not my place to criticize her or anyone else for their decision about how to manage the disease. Nowhere did she denigrate or in any way speak negatively about carbohydrate restriction in her article.

Benefits (Potential and Confirmed) of Carbohydrate Restriction for Type 1 Diabetes

A couple of days ago I heard about a case report regarding a 19-year-old man newly diagnosed with type 1 diabetes who was initially prescribed a "standard" diabetes diet (6 small meals for a total of 240 grams of carbohydrates daily) with multiple daily insulin injections including rapid-acting mealtime insulin to "match" his carb intake.  After being switched to a grain-free, dairy-free, very-low-carbohydrate, ketogenic diet (VLCKD), his blood glucose levels improved to the point that he no longer required insulin to remain within normal blood glucose range. This is only one case, and it's too early to say whether the disease process has been arrested or the "honeymoon period" simply extended. There was another study reporting similar results  in a six-year-old boy on a gluten-free diet. He eventually required insulin therapy, as will likely be the case for this man as well, but it will be interesting to see what happens. On Twitter a few days ago, Brazilian doctor Jose Carlos Souto reported similar results in his own patient, a young woman diagnosed with T1DM who has been insulin free for the past year on a similar dietary protocol. Dairy and gluten have been posited as potential triggers for developing Type 1 diabetes via increased immunity to cow's milk (in the case of dairy) and the loss of intestinal permeability (in the case of gluten), leading to an autoimmune attack on the beta cells of the pancreas. 

I want to make it clear that people with type 1 diabetes require insulin to prevent diabetic ketoacidosis (DKA). Those with T1DM should not assume that switching to a very-low-carbohydrate, ketogenic Paleo diet will result in remission, as these are very unusual cases where dietary therapy was started early in the disease process and closely monitored by doctors. Basal insulin is generally a requirement even if no carbohydrates are consumed. However, a very-low-carb diet may result in a significant reduction in rapid-acting insulin dosage at mealtime and possibly its elimination altogether in the case of newly diagnosed T1DM.

A wonderful example of such a case would be that of Dr. Troy Stapleton, whom I had the pleasure of meeting when we were presenters at the Melbourne Low Carb Down Under conference in August. Troy is an Australian radiologist who was diagnosed with T1DM in October of 2012. Unable to achieve stable blood glucose values on the high-carbohydrate diet with multiple daily insulin injections he was prescribed at diagnosis, he began following a VLCKD two months later. Since making this change, he has been able to discontinue use of rapid-acting insulin for meal coverage and requires only a small amount of long-acting insulin daily. His honeymoon phase has been significantly extended, likely as a result of preserving beta cell function by keeping blood glucose levels within normal limits at all times via a carb-restricted diet. Troy recognizes that he will probably require a small amount of insulin for mealtime coverage at some point. He experiences few if any lows, has an A1c of 5%, and once again has enough energy for working long hours at a demanding job, spending time with his family, and engaging in his favorite activities (including surfing and cycling) without the constant fear of having a hypoglycemic event. In short, following a very-low-carbohydrate diet has changed his life for the better in a very dramatic way: "It's given me my life back."

Appreciation of a Difficult to Control, Often Misunderstood Disease

I remain committed to promoting carbohydrate-restricted diets for people with all types of diabetes and will continue speaking out even though I risk being targeted by those who disagree and believe my recommendations are dangerous. But as a certified diabetes educator, I also feel that people with T1DM who opt not to follow a very-low-carbohydrate lifestyle shouldn't be criticized for their choices. I dislike the "us vs. them" mentality when it comes to diabetes management, and I don't understand how anyone who hasn't had to deal with the day-to-day management of T1DM can criticize someone who has the disease. I get emails from people every day, and some definitely find VLCKDs easier to stick with than others do. My hope is that hearing stories like Troy's will inspire and motivate them, but either way, I wish them well in their journey.

References

1. Toth C, et al. Type 1 diabetes mellitus successfully managed with the paleolithic, ketogenic diet. Int J Case Rep Images Oct 2014;5
2.  Sildorf SM, et al.  Remission without insulin therapy on gluten-free diet in a 6-year old boy with type 1 diabetes mellitus. BMJ Case Report Jun 2012 pii: bcr0220125878
3.  Viser, J et al. Tight Junctions, Intestinal Permeability, and Autoimmunity Celiac Disease and Type 1 Diabetes Paradigms Ann N Y Acad Sci. 2009; 1165:195-205 
4. Sarugeri E, et al. Cellular and humoral immunity against cow’s milk proteins in type 1 diabetes. J Autoimmun 1999 Nov;13(3):365–73. 
5. Nielsen JV, et al:  Low carbohydrate diet in type 1 diabetes, long-term improvement and adherence: a clinical audit. Diabetol Metab Syndr 2012; 4:23 
6. Nielsen JV, et al. A low carbohydrate diet in type 1 diabetes: clinical experience – A brief report. Ups J Med Sci 2005, 110(3):267–273