The ups and downs of low-carbohydrate diets in the management of Type 1 diabetes: a review of clinical outcomes

Dietary recommendations for people with diabetes in special situations: a position statement report by Arabic Association for the Study of Diabetes and metabolism (AASD)

BACKGROUND

Diabetes is a significant global health concern. Regional factors play a crucial role in determining the appropriate diet for patients.

MAIN BODY

The Arabic Association for the Study of Diabetes and Metabolism has developed a position statement that addresses the dietary needs of patients in the context of low income and cultural dietary habits. This statement aims to explore the most suitable diet for Middle East and North Africa (MENA) region and provide guidance for physicians to overcome barriers in optimal care. While most dietary guidelines focus on uncomplicated diabetes, it's essential to recognize that diabetes often coexists with other common diseases in our region.

CONCLUSION

International guidelines cannot be directly applied to the Egypt and Arab countries due to cultural and dietary differences. Our position statement shares valuable insights into managing diabetes in special situations and diverse clinical settings within this region. These recommendations are flexible, considering personal, cultural, and traditional differences.

Low-carbohydrate diet in children and young people with type 1 diabetes: A randomized controlled trial with cross-over design

AIMS

We investigated whether a short period of tightly controlled low-carbohydrate diet (LCD) leads to higher time in range without increasing the associated risks in children and young people with diabetes (CYPwD).

METHODS

Thirty-five (CYPwD) were recruited into this randomized controlled cross-over study (20 female; 20 CSII; age 14.5 ± 2.9 years; HbA1c 48.9 ± 9.4 mmol/mol). The interventions were five and five weeks of ready-made food box deliveries of isocaloric diets in random order: either LCD (94.5 ± 4.7 g/day) or recommended carbohydrate diet (RCD) (191 ± 19.2 g/day). The outcomes were continuous glucose monitoring parameters, anthropometric, laboratory and quality of life (QoL) data.

RESULTS

Time in range was significantly higher in the LCD than in the RCD period (77.1 % vs. 73.8 %, P=0.008). Times in hyperglycemia and average glycaemia were significantly lower in the LCD. There was no difference between the diets in time in hypoglycemia or glycemic variability. The subjects' body weight and BMI were significantly lower during the LCD. There was no significant difference in the LDL-cholesterol levels. No significant differences were observed in the self-assessed QoL.

CONCLUSIONS

Short-term LCD led to an improvement of glycemic parameters without increasing time in hypoglycemia, disturbing the lipid profile or negatively affecting the quality of life of CYPwD.

Association between low-carbohydrate-diet score, glycemia and cardiovascular risk factors in adults with type 1 diabetes

BACKGROUND AND AIMS

Low-carbohydrate-diets (LCDs) are gaining popularity in individuals with type 1 diabetes (T1D). However, the impact of such diets on glycemia and cardiovascular risk factors is debated. This study aims to evaluate associations between low-carbohydrate intakes using LCD score with glycemia and cardiovascular risk factors (lipid profile) in adults with T1D or LADA in Québec, Canada.

METHODS AND RESULTS

This is a cross-sectional study using data collected in the BETTER registry (02/2019 and 04/2021) including self-reported 24-h dietary recalls to calculate LCD scores, waist circumference, level-2 and level-3 hypoglycemic episodes and measured biochemical data (HbA1c, LDL-cholesterol and non-HDL-cholesterol). Participants were divided into quartiles (Q) based on LCD scores. Two hundred eighty-five adults (aged 48.2 ± 15.0 years; T1D duration 25.9 ± 16.2 years) were included. Categorical variables underwent Chi-squared/Fisher's Exact tests, while continuous variables underwent ANOVA tests. Mean carbohydrate intake ranged from 31.2 ± 6.9% (Q1) to 56.5 ± 6.8% (Q4) of total daily energy. Compared to Q4, more people in Q1 reported HbA1c ≤ 7% [≤53.0 mmol/mol] (Q1: 53.4% vs. Q4: 29.4%; P = 0.011). The same results were found in the models adjusted for age, sex and T1D duration. A greater proportion of participants in Q1 never experienced level-3 hypoglycemia compared to Q3 (Q1: 60.0% vs. Q3: 31.0%; P = 0.004). There were no differences across quartiles for frequency of level-2 hypoglycemia events and lipid profile (LDL-cholesterol and non-HDL-cholesterol).

CONCLUSIONS

Low-carbohydrate intakes are associated with higher probabilities of reaching HbA1c target and of never having experienced level-3 hypoglycemia. No associations with level-2 hypoglycemia frequency, nor cardiovascular risk factors were observed.

Efficacy and Safety of Long-term Ketogenic Diet Therapy in a Patient With Type 1 Diabetes

Fewer than 1% of patients with type 1 diabetes achieve normal glycemic control (glycated hemoglobin [HbA1c] < 5.7%/ < 39 mmol/mol). Additionally, exogenous insulin administration often causes "iatrogenic hyperinsulinemia," leading to whole-body insulin resistance and increased risk of cardiovascular complications. We present data on the clinical efficacy and safety of a long-term (10-year) ketogenic diet (≤50 g carbohydrates/day) therapy in a patient with type 1 diabetes. The use of a ketogenic diet resulted in successful glycemic control, assessed by HbA1c (5.5%; 36.6 mmol/mol), continuous glucose monitoring median glucose (98 mg/dL; 5.4 mmol/L), and glucose time-in-range of 70 to 180 mg/dL (90%) without acute glycemic complications. In conjunction, there was a 43% decrease in daily insulin requirements. Low-density lipoprotein cholesterol increased, whereas small-dense low-density lipoprotein was in the normal range (<90 nmol/L). No adverse effects were observed on thyroid function, kidney function, or bone mineral density. This case report demonstrates that a long-term ketogenic diet in a person with type 1 diabetes has considerable therapeutic benefits.

Severe growth retardation during carbohydrate restriction in type 1 diabetes mellitus: A case report

Carbohydrate restriction is not typically recommended for children with type 1 diabetes mellitus (T1DM) because of concerns regarding growth retardation, ketoacidosis, severe hypoglycemia, and dyslipidemia. There is no consensus regarding the effects of carbohydrate restriction on the growth of children with T1DM. However, some previously reported cases of T1DM exhibited growth retardation during carbohydrate restriction, whereas others showed no obvious impairment. A female child with T1DM exhibited severe height growth velocity impairment during carbohydrate restriction in early childhood. Her height standard deviation score (SDS) was 1.12 at the initial T1DM diagnosis (2 yr and 11 mo of age) and -1.33 at 4 yr and 8 mo of age. Her height velocity was only 1.7 cm/yr (SDS -7.02). Discontinuing carbohydrate restriction substantially improved her height growth velocity. Implementing a carbohydrate-restricted diet in children with T1DM can negatively affect height growth velocity.

A very low carbohydrate diet for minimising blood glucose excursions during ultra-endurance open-water swimming in type 1 diabetes: a case report

Carbohydrate-restricted diets are used by people with type 1 diabetes (T1D) to help manage their condition. However, the impact of this strategy on blood glucose responses to exercise is unknown. This study describes the nutritional strategies of an athlete with T1D, who follows a very low carbohydrate diet to manage her condition during an ultra-endurance open-water swimming event. The athlete completed the 19.7 km distance in 6 h 43 min. She experienced minimal disruptions to glycaemia, reduced need for supplemental carbohydrate, and no episodes of symptomatic hypoglycaemia. This case report will hopefully encourage further experimental studies that inform and expand current clinical practice guidelines.

Sensor-Based Glucose Metrics during Different Diet Compositions in Type 1 Diabetes-A Randomized One-Week Crossover Trial

By reducing carbohydrate intake, people with type 1 diabetes may reduce fluctuations in blood glucose, but the evidence in this area is sparse. The aim of this study was to investigate glucose metrics during a one-week low-carbohydrate-high-fat (HF) and a low-carbohydrate-high-protein (HP) diet compared with an isocaloric high-carbohydrate (HC) diet. In a randomized, three-period cross-over study, twelve adults with insulin-pump-treated type 1 diabetes followed an HC (energy provided by carbohydrate: 48%, fat: 33%, protein: 19%), HF (19%, 62%, 19%), and an HP (19%, 57%, 24%) diet for one week. Glucose values were obtained during intervention periods using a Dexcom G6 continuous glucose monitoring system. Participant characteristics were: 33% females, median (range) age 50 (22-70) years, diabetes duration 25 (11-52) years, HbA1c 7.3 (5.5-8.3)% (57 (37-67) mmol/mol), and BMI 27.3 (21.3-35.9) kg/m2. Glycemic variability was lower with HF (30.5 ± 6.2%) and HP (30.0 ± 5.5%) compared with HC (34.5 ± 4.1%) (PHF-HC = 0.009, PHP-HC = 0.003). There was no difference between groups in mean glucose (HF: 8.7 ± 1.1, HP: 8.2 ± 1.0, HC: 8.7 ± 1.0 mmol/L, POverall = 0.08). Time > 10.0 mmol/L was lower with HP (22.3 ± 11.8%) compared with HF (29.4 ± 12.1%) and HC (29.5 ± 13.4%) (PHF-HP = 0.037, PHC-HP = 0.037). In conclusion, a one-week HF and, specifically, an HP diet improved glucose metrics compared with an isocaloric HC diet.

Low-Carbohydrate Diets in Children and Adolescents With or at Risk for Diabetes

Carbohydrate restriction is increasingly popular as a weight loss strategy and for achieving better glycemic control in people with diabetes, including type 1 and type 2 diabetes. However, evidence to support low-carbohydrate diets in youth (children and adolescents 2-18 years of age) with obesity or diabetes is limited. There are no guidelines for restricting dietary carbohydrate consumption to reduce risk for diabetes or improve diabetes outcomes in youth. Thus, there is a need to provide practical recommendations for pediatricians regarding the use of low-carbohydrate diets in patients who elect to follow these diets, including those with type 1 diabetes and for patients with obesity, prediabetes, and type 2 diabetes. This clinical report will: Provide background on current dietary patterns in youth, describe how moderate-, low-, and very low-carbohydrate diets differ, and review safety concerns associated with the use of these dietary patternsReview the physiologic rationale for carbohydrate reduction in youth with type 1 diabetes and for youth with obesity, prediabetes, and type 2 diabetesReview the evidence for low-carbohydrate diets in the management of youth with type 1 diabetesReview the evidence for low-carbohydrate diets in the management of youth with obesity, prediabetes, and type 2 diabetesProvide practical information for pediatricians counseling families and youth on carbohydrate recommendations for type 1 diabetes and for obesity, prediabetes, and type 2 diabetes.

Diet and Glycemic Index in Children with Type 1 Diabetes

In children with type 1 diabetes, a healthy lifestyle is important to control postprandial glycemia and to avoid hyperglycemic peaks that worsen the inflammatory state of vessels and tissues. Glycemic index and glycemic load are two important indexes which assess the quality and quantity of foods consumed during meals. The main macronutrients of the diet have a different effect on postprandial blood glucose levels, so it is important that diabetic children consume foods which determine a slower and steadier glycemic peak. In this review, we present the results of the most recent studies carried out in the pediatric population with T1D, whose aim was to analyze the effects of low-glycemic-index foods on glycemic control. The results are promising and demonstrate that diets promoting low-glycemic-index foods guarantee a greater glycemic stability with a reduction in postprandial hyperglycemic peaks. However, one of the main limitations is represented by the poor adherence of children to a healthy diet. In order to obtain satisfactory results, a possibility might be to ensure a balanced intake of low-, moderate- and high-glycemic-index foods, preferring those with a low glycemic index and limiting the consumption of the high- and moderate-glycemic-index types.

Ketogenic Diet in Children and Adolescents: the Effects on Growth and Nutritional Status

The ketogenic diet is known to be a possible adjuvant treatment in several medical conditions, such as in patients with severe or drug-resistant forms of epilepsy. Its use has recently been increasing among adolescents and young adults due to its supposed weight-loss effect, mediated by lipolysis and lowered insulin levels. However, there are still no precise indications on the possible use of ketogenic diets in pediatric age for weight loss. This approach has also recently been proposed for other types of disorder such as inherited metabolic disorders, Prader-Willi syndrome, and some specific types of cancers. Due to its unbalanced ratio of lipids, carbohydrates and proteins, a clinical evaluation of possible side effects with a strict evaluation of growth and nutritional status is essential in all patients following a long-term restrictive diet such as the ketogenic one. The prophylactic use of micronutrients supplementation should be considered before starting any ketogenic diet. Lastly, while there is sufficient literature on possible short-term side effects of ketogenic diets, their possible long-term impact on growth and nutritional status is not yet fully understood, especially when started in pediatric age.

Lipid-lowering therapies and cardiovascular risk-stratification strategies in adults with type 1 diabetes

PURPOSE OF REVIEW

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of mortality in adults with type 1 diabetes (T1D). Although dyslipidaemia is a modifiable and prevalent risk factor in individuals with T1D, determining when to initiate lipid-lowering therapy for primary prevention of ASCVD can be challenging. In this article, recommendations for lipid-lowering therapy from updated clinical guidelines over the last 5 years, additional risk-stratification methods, hypertriglyceridaemia management and potential barriers to optimal care in adults with T1D are discussed.

RECENT FINDINGS

Low-density lipoprotein cholesterol (LDL-C) is the primary target for lipid-lowering. However, international guidelines recommend differing approaches to ASCVD risk-stratification, lipid-lowering, and LDL-C goals in individuals with diabetes, predominantly reflecting evidence from studies in type 2 diabetes. Despite guideline recommendations, several studies have demonstrated that statins are underused, and LDL-C goals are not attained by many individuals with T1D. Additional risk-stratification methods including T1D-specific ASCVD risk calculators, coronary artery calcium scoring, and lipoprotein(a) may provide additional information to define when to initiate lipid-lowering therapy.

SUMMARY

Clinical trial evidence for lipid-lowering therapies in T1D is lacking, and further studies are needed to inform best practice. Optimization and harmonization of ASCVD risk-stratification and lipid management in individuals with T1D is required.

Experiences and Attitudes of Parents Reducing Carbohydrate Intake in the Management of Their Child’s Type 1 Diabetes: A Qualitative Study

Reducing carbohydrate (CHO) intake is being used as an approach to manage type 1 diabetes (T1D) in children. This study aimed to investigate the experiences and attitudes of parents of children with T1D who are reducing CHO intake to help manage blood glucose levels (BGLs). Semi-structured interviews were conducted with the parents of children with T1D for >1 year who reported implementing a low CHO approach to manage BGLs. Data were analysed using a constant comparative analysis approach. Participants (n = 14) were parents of children (6.6 ± 2.0 years) with T1D in Western Australia. All parents reported different methods of CHO restriction and all perceived that benefits outweighed challenges. Parents reported feeling less worried, had improved sleep and felt their child was safer when using a low CHO approach due to more stable BGLs. Reported challenges included: increased cost and time spent preparing food; perceived judgement from others; and child dissatisfaction with restricted food choices. Parents reported accessing information and support through social media networks. Parents reported a desire for more research into this approach. Understanding the promoters and barriers for this dietary approach may inform strategies to better engage and support families with approaches that align with current evidence while considering their concerns around safety and hyperglycaemia.

The Impact of a Low-Carbohydrate Diet on Micronutrient Intake and Status in Adolescents with Type 1 Diabetes

Objective: The aim of this study was to evaluate the macronutrient and micronutrient intake and status in youth with type 1 diabetes mellitus (T1DM) following the consumption of a low-carbohydrate diet (LCD). Research Methods and Procedures: In a prospective intervention clinical trial, adolescents with T1DM using a continuous glucose monitoring device were enrolled. Following a cooking workshop, each participant received a personalized diet regime based on LCD (50–80 g carbohydrate/day). A Food Frequency Questionnaire was administered, and laboratory tests were taken before and 6 months following the intervention. Twenty participants were enrolled. Results: The median age was 17 years (15; 19), and the median diabetes duration was 10 years (8; 12). During the six-months intervention, carbohydrate intake decreased from 266 g (204; 316) to 87 g (68; 95) (p = 0.004). Energy intake, the energy percent from ultra-processed food, and fiber intake decreased (p = 0.001, p = 0.024, and p < 0.0001, respectively). These changes were accompanied by declines in BMI z-score (p = 0.019) and waist-circumference percentile (p = 0.007). Improvement was observed in the median HbA1c from 8.1% (7.5; 9.4) to 7.7% (6.9; 8.2) (p = 0.021). Significant declines below the DRI were shown in median intake levels of iron, calcium, vitamin B1, and folate. Conclusions: The LCD lowered ultra-processed food consumption, BMI z-scores and the indices of central obesity. However, LCDs require close nutritional monitoring due to the possibility of nutrient deficiencies.

A perspective on treating type 1 diabetes mellitus before insulin is needed

Type 1 diabetes mellitus (T1DM) is a progressive autoimmune disease that starts long before a clinical diagnosis is made. The American Diabetes Association recognizes three stages: stage 1 (normoglycaemic and positive for autoantibodies to β-cell antigens); stage 2 (asymptomatic with dysglycaemia); and stage 3, which is defined by glucose levels consistent with the definition of diabetes mellitus. This Perspective focuses on the management of the proportion of individuals with early stage 3 T1DM who do not immediately require insulin; a stage we propose should be termed stage 3a. To date, this period of non-insulin-dependent T1DM has been largely unrecognized. Importantly, it represents a window of opportunity for intervention, as remaining at this stage might delay the need for insulin by months or years. Extending the insulin-free period and/or avoiding unnecessary insulin therapy are important goals, as there is no risk of hypoglycaemia during this period and the adherence burden on patients of glycaemic monitoring and daily adjustments for diet and exercise is substantially reduced. Recognizing the pressing need for guidance on adequate management of children and adults with stage 3a T1DM, we present our perspective on the subject, which needs to be tested in formal and adequately powered clinical trials.

Weight management in young adults with type 1 diabetes: The advancing care for type 1 diabetes and obesity network sequential multiple assignment randomized trial pilot results

AIMS

Co-management of weight and glycaemia is critical yet challenging in type 1 diabetes (T1D). We evaluated the effect of a hypocaloric low carbohydrate, hypocaloric moderate low fat, and Mediterranean diet without calorie restriction on weight and glycaemia in young adults with T1D and overweight or obesity.

MATERIALS AND METHODS

We implemented a 9-month Sequential, Multiple Assignment, Randomized Trial pilot among adults aged 19-30 years with T1D for ≥1 year and body mass index 27-39.9 kg/m2 . Re-randomization occurred at 3 and 6 months if the assigned diet was not acceptable or not effective. We report results from the initial 3-month diet period and re-randomization statistics before shutdowns due to COVID-19 for primary [weight, haemoglobin A1c (HbA1c), percentage of time below range <70 mg/dl] and secondary outcomes [body fat percentage, percentage of time in range (70-180 mg/dl), and percentage of time below range <54 mg/dl]. Models adjusted for design, demographic and clinical covariates tested changes in outcomes and diet differences.

RESULTS

Adjusted weight and HbA1c (n = 38) changed by -2.7 kg (95% CI -3.8, -1.5, P < .0001) and -0.91 percentage points (95% CI -1.5, -0.30, P = .005), respectively, while adjusted body fat percentage remained stable, on average (P = .21). Hypoglycaemia indices remained unchanged following adjustment (n = 28, P > .05). Variability in all outcomes, including weight change, was considerable (57.9% were re-randomized primarily due to loss of <2% body weight). No outcomes varied by diet.

CONCLUSIONS

Three months of a diet, irrespective of macronutrient distribution or caloric restriction, resulted in weight loss while improving or maintaining HbA1c levels without increasing hypoglycaemia in adults with T1D.

Dietary patterns and cardiometabolic health: Clinical evidence and mechanism

For centuries, the search for nutritional interventions to underpin cardiovascular treatment and prevention guidelines has contributed to the rapid development of the field of dietary patterns and cardiometabolic disease (CMD). Numerous studies have demonstrated that healthy dietary patterns with emphasis on food-based recommendations are the gold standard for extending lifespan and reducing the risks of CMD and mortality. Healthy dietary patterns include various permutations of energy restriction, macronutrients, and food intake patterns such as calorie restriction, intermittent fasting, Mediterranean diet, plant-based diets, etc. Early implementation of healthy dietary patterns in patients with CMD is encouraged, but an understanding of the mechanisms by which these patterns trigger cardiometabolic benefits remains incomplete. Hence, this review examined several dietary patterns that may improve cardiometabolic health, including restrictive dietary patterns, regional dietary patterns, and diets based on controlled macronutrients and food groups, summarizing cutting-edge evidence and potential mechanisms for CMD prevention and treatment. Particularly, considering individual differences in responses to dietary composition and nutritional changes in organ tissue diversity, we highlighted the critical role of individual gut microbiota in the crosstalk between diet and CMD and recommend a more precise and dynamic nutritional strategy for CMD by developing dietary patterns based on individual gut microbiota profiles.

Dietary treatment of type 1 diabetes: Beyond carbohydrate counting to fight cardiovascular risk

AIMS

Type 1 diabetes (T1D) is tied to an increased risk of cardiovascular morbidity and mortality. Dietary treatment would be an elective therapeutic strategy to fight this risk. However, it is not known what the best dietary approach is. We revisited the currently available literature on the nutritional treatment of T1D in the light of their potential comprehensive effects on the management of cardio-metabolic risk factors (body weight, fasting and postprandial glucose and lipid metabolism).

DATA SYNTHESIS

Nutritional research in T1D is mainly focused on blood glucose control, with most of the trials aiming at evaluating the acute effects of nutrients on postprandial glycemic response. The effects of the quantity and quality of nutrients and some specific foods on other metabolic risk factors have been explored mainly in cross-sectional analysis. Very few well-designed nutritional trials evaluated the best dietary approach to comprehensively manage cardiovascular risk by targeting along with blood glucose control, overweight, fasting and postprandial dyslipidemia. Therefore, the current best practice guidance for the dietary management of cardiovascular risk in T1D is generally based on evidence from patients with type 2 diabetes.

CONCLUSIONS

Well-conducted nutritional trials specifically designed for T1D are needed to identify the best dietary treatment to fight cardiovascular risk in these patients.

Study protocol: a randomised controlled proof-of-concept real-world study - does maximising time in range using hybrid closed loop insulin delivery and a low carbohydrate diet restore the glucagon response to hypoglycaemia in adults with type 1 diabetes?

INTRODUCTION

People with type 1 diabetes (T1D) develop an impaired glucagon response to hypoglycaemia within 5 years of diagnosis, increasing their risk of severe hypoglycaemia. It is not known whether eliminating hypoglycaemia and hyperglycaemia allows recovery of this glucagon response. Hybrid closed loop (HCL) technologies improve glycaemic time in range (TIR). However, post-prandial glycaemic excursions are still evident. Consuming a low carbohydrate diet (LCD) may minimise these excursions.

METHODS AND ANALYSIS

This feasibility study will assess if maximising TIR (glucose ≥3.9 mmol/L≤10 mmol/L) using HCL systems plus an LCD (defined here as <130 g carbohydrate/day) for >8 months, restores the glucagon response to insulin-induced hypoglycaemia. Adults (n=24) with T1D (C-peptide <200 pmol/L), naïve to continuous glucose monitoring (CGM) and HCL systems, will be recruited and randomised to: group 1 (non-HCL) to continue their standard diabetes care with intermittent blinded CGM; or group 2 (HCL-LCD) to use the HCL system and follow a LCD. Baseline data on diet and glycaemia will be collected from all participants. The HCL-LCD group will then enter a 2-week run-in to acclimatise to their devices. Throughout, the HCL-LCD group will have their glucose closely monitored and adjusted aiming for glycaemic TIR >70%. Participants will have their glucagon response to hypoglycaemia measured at the beginning and 8 months later at the study end using a stepped hyperinsulinaemic hypoglycaemic clamp, in combination with the stable isotopes 6,6-²H₂-glucose (D2-glucose) and 1,1,2,3,3-²H₅-glycerol (D5-glycerol) to assess glucose and glycerol kinetics. The impact of hypoglycaemia on symptoms and cognitive function will be assessed during each clamp study. The primary outcome is the difference in the glucagon response to hypoglycaemia between and within groups at baseline versus study end.

ETHICS AND DISSEMINATION

Ethical (20/SS/0117)/institutional review board (2021/0001) approval has been obtained. The study will be disseminated by peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04614168.

Partial Remission of Diabetes in a Young Adult While Testing Positive for Several Islet Cell Autoantibodies: A Case Report, Literature Review, and Patient Perspective

Type 1 diabetes is a chronic disease characterized by abnormal metabolism and hyperglycemia due to insulin deficiency. There is a rapid decline in insulin production due to autoimmune destruction of the pancreatic beta cells. Partial remission (honeymoon phase) of type 1 diabetes is common in children and young adults with newly diagnosed type 1 diabetes. There is temporary restoration of beta cell function such that little or no exogenous insulin is required. Stopping insulin therapy soon after an emergency admission requiring intravenous insulin and subsequent subcutaneous insulin therapy can be frightening for both patient and healthcare provider. Affected patients require education and support during this period. This report describes a case of a 28-year-old man who presented to the emergency department with features of type 1 diabetes and diabetic ketoacidosis. He was treated with intravenous fluids and intravenous insulin and discharged on a subcutaneous insulin regimen. Despite testing positive for several types of islet cell autoantibodies, the patient was able to stop insulin therapy within three months of diagnosis. The patient maintained a self-initiated low-carbohydrate diet, regular weight-reducing exercise, and normal glucose levels without the need for insulin therapy. The honeymoon phase of type 1 diabetes, latent autoimmune diabetes, and ketosis-prone type 2 diabetes are discussed as important differential diagnoses.

Assessing the Nutrient Status of Low Carbohydrate, High-Fat (LCHF) Meal Plans in Children: A Hypothetical Case Study Design

There is well-established evidence for low-carbohydrate, high-fat (LCHF) diets in the management of chronic health conditions in adults. The natural next step is to understand the potential risks and benefits of LCHF diets for children, where they may have useful applications for general health and a variety of chronic health conditions. It is vital that any diet delivers sufficient micronutrients and energy to ensure health, wellbeing, and growth. This descriptive study assesses the nutrient and energy status of LCHF sample meal plans for children. We designed four meal plans for hypothetical weight-stable male and female children (11 years) and adolescents (16 years). Carbohydrates were limited to ≤80 g, protein was set at 15–25% of the total energy, and fat supplied the remaining calories. Using FoodWorks dietary analysis software, data were assessed against the national Australian/New Zealand nutrient reference value (NRV) thresholds for children and adolescents. All meal plans exceeded the minimum NRV thresholds for all micronutrients; protein slightly exceeded the AMDR recommendations by up to three percentage points. This study demonstrates that LCHF meal plans can be energy-, protein-, and micronutrient-replete for children and adolescents. As with any dietary approach, well-formulated meals and careful planning are key to achieving the optimal nutrient status.

Growth and development in type 1 diabetes

PURPOSE OF REVIEW

The purpose of this review is to summarize the current literature on the subject of linear growth in children and adolescents with or at risk for type 1 diabetes mellitus (T1DM).

RECENT FINDINGS

Poor glycemic control in T1DM is associated with growth hormone resistance, and improving glycemic control can improve linear growth. Newer reports suggest that the increasingly popular very low carbohydrate diets, may reduce linear growth velocity.

SUMMARY

Linear growth during childhood is a complex process regulated influenced by genetic, hormonal, nutritional and environmental factors. Linear growth may be impaired in children with T1DM, correlating with poor metabolic control; an extreme example is Mauriac syndrome. This decrement in linear growth appears to be driven in part by a reduction in growth hormone responsiveness, leading to low insulin-like growth factor-1 (IGF-1) levels. Improving glycemic control can lead to improved IGF-1 levels and linear growth. Other factors associated with poor linear growth in T1DM include celiac disease and dietary alterations, with early reports suggesting that very low carbohydrate diets, if not carefully managed, may increase risk of attenuated linear growth. This review examines the latest data regarding the associations between T1DM and linear growth in children.

'Old Is Gold': How Traditional Indian Dietary Practices Can Support Pediatric Diabetes Management

Nutrition is crucial for maintaining normal growth, development, and glycemic control in young people with diabetes (PwD). Undue restrictions cause nutrient deficiencies as well as poor adherence to meal plans. Widespread availability of low-cost, ultra-processed, and hyperpalatable food is further damaging. Most families struggle to find ways to provide nutritious, yet attractive, food with a low glycemic index (GI). India is one of the oldest continuous civilizations with a rich and diverse cultural and culinary heritage. Traditional dietary practices, including the centuries-old 'Thali' (meaning plate) concept, emphasize combinations (grains, lentils, vegetables, dairy, spices, prebiotics and probiotics, and fats) of local, seasonal, and predominantly plant-based ingredients. These practices ensure that all of the necessary food groups are provided and fit well with current evidence-based recommendations, including the International Society for Pediatric and Adolescent Diabetes (ISPAD) 2018 Guidelines. Techniques for the preparation, cooking, and preservation of food further impact the GI and nutrient availability. These practices benefit nutrient density, diet diversity, and palatability and thus improve adherence to meal plans and glycemic control. This narrative review describes the ancient wisdom, food composition, and culinary practices from across India which are still valuable today. These may be of benefit worldwide to improve glycemic control as well as quality of life, especially in PwD.

Low-Carbohydrate Diet among Children with Type 1 Diabetes: A Multi-Center Study

AIMS/HYPOTHESIS

The proportion of children with type 1 diabetes (T1D) who have experience with low-carbohydrate diet (LCD) is unknown. Our goal was to map the frequency of LCD among children with T1D and to describe their clinical and laboratory data.

METHODS

Caregivers of 1040 children with T1D from three centers were addressed with a structured questionnaire regarding the children's carbohydrate intake and experience with LCD (daily energy intake from carbohydrates below 26% of age-recommended values). The subjects currently on LCD were compared to a group of non-LCD respondents matched to age, T1D duration, sex, type and center of treatment.

RESULTS

A total of 624/1040 (60%) of the subjects completed the survey. A total of 242/624 (39%) subjects reported experience with voluntary carbohydrate restriction with 36/624 (5.8%) subjects currently following the LCD. The LCD group had similar HbA1c (45 vs. 49.5, p = 0.11), lower average glycemia (7.0 vs. 7.9, p = 0.02), higher time in range (74 vs. 67%, p = 0.02), lower time in hyperglycemia >10 mmol/L (17 vs. 20%, p = 0.04), tendency to more time in hypoglycemia <3.9 mmol/L(8 vs. 5%, p = 0.05) and lower systolic blood pressure percentile (43 vs. 74, p = 0.03). The groups did not differ in their lipid profile nor in current body height, weight or BMI. The LCD was mostly initiated by the parents or the subjects themselves and only 39% of the families consulted their decision with the diabetologist.

CONCLUSIONS/INTERPRETATION

Low carbohydrate diet is not scarce in children with T1D and is associated with modestly better disease control. At the same time, caution should be applied as it showed a tendency toward more frequent hypoglycemia.

Effect of Nutritional Habits on the Glycemic Response to Different Carbohydrate Diet in Children with Type 1 Diabetes Mellitus

Unhealthy eating habits are associated with obesity, metabolic syndrome, and increased insulin resistance in young patients with type 1 diabetes mellitus (T1DM), and may impact the possible benefit from dietary interventions on glycaemic control. This study determines how nutritional patterns influence the quality of dietary intervention with a 30% or 50% carbohydrate diet in terms of glycaemic control measured with continuous glucose monitoring (CGM). Eating habits were obtained with a frequency-of-consumption questionnaire (FFQ-6) before the diet assessment. Altogether, we collected CGM and FFQ-6 data from 30 children (16 boys and 14 girls aged 10-17 years) with T1DM subjected to two consecutive 3-day nutritional plans. From these, 23 patients met the CGM data quality criteria for further analysis. Furthermore, high accuracy achieved in training (95.65%) and V-fold cross-validation (81.67%) suggest a significant impact of food habits in response to introduced nutritional changes. Patients who consumed more vegetables or grains (>4 times per day), more wheat products (>once per day), fewer fats (<1.5 times per day), and ranked fruit juice as the most common selection in the drinks category achieved glycaemic control more often after the introduction of a 30% carbohydrate diet, as opposed to those with different dietary patterns, whose glycaemic control was negatively impacted after switching to this diet. Additionally, the 50% carbohydrate diet was safe for all patients in the context of glycaemic control.

Carbohydrate restriction for diabetes: rediscovering centuries-old wisdom

Carbohydrate restriction, used since the 1700s to prolong survival in people with diabetes, fell out of favor after the discovery of insulin. Despite costly pharmacological and technological developments in the last few decades, current therapies do not achieve optimal outcomes, and most people with diabetes remain at high risk for micro- and macrovascular complications. Recently, low-carbohydrate diets have regained popularity, with preliminary evidence of benefit for body weight, postprandial hyperglycemia, hyperinsulinemia, and other cardiometabolic risk factors in type 2 diabetes and, with more limited data, in type 1 diabetes. High-quality, long-term trials are needed to assess safety concerns and determine whether this old dietary approach might help people with diabetes attain clinical targets more effectively, and at a lower cost, than conventional treatment.

Physical Activity, Dietary Patterns, and Glycemic Management in Active Individuals with Type 1 Diabetes: An Online Survey

Individuals with type 1 diabetes (T1D) are able to balance their blood glucose levels while engaging in a wide variety of physical activities and sports. However, insulin use forces them to contend with many daily training and performance challenges involved with fine-tuning medication dosing, physical activity levels, and dietary patterns to optimize their participation and performance. The aim of this study was to ascertain which variables related to the diabetes management of physically active individuals with T1D have the greatest impact on overall blood glucose levels (reported as A1C) in a real-world setting. A total of 220 individuals with T1D completed an online survey to self-report information about their glycemic management, physical activity patterns, carbohydrate and dietary intake, use of diabetes technologies, and other variables that impact diabetes management and health. In analyzing many variables affecting glycemic management, the primary significant finding was that A1C values in lower, recommended ranges (<7%) were significantly predicted by a very-low carbohydrate intake dietary pattern, whereas the use of continuous glucose monitoring (CGM) devices had the greatest predictive ability when A1C was above recommended (≥7%). Various aspects of physical activity participation (including type, weekly time, frequency, and intensity) were not significantly associated with A1C for participants in this survey. In conclusion, when individuals with T1D are already physically active, dietary changes and more frequent monitoring of glucose may be most capable of further enhancing glycemic management.

The beneficial short-term effects of a high-protein/low-carbohydrate diet on glycaemic control assessed by continuous glucose monitoring in patients with type 1 diabetes

AIM

To compare the effects of three different but isocaloric dietary patterns, high-protein/low-carbohydrate (HPD) with 20% of calories as carbohydrates, Mediterranean/low glycaemic index (MED) with 40% carbohydrates, and a reference diet (REF) with 50% carbohydrates, in patients with type 1 diabetes (T1D).

MATERIALS AND METHODS

In a randomized crossover study, 15 patients with T1D were assigned to the three dietary patterns for three separate weeks, with 7-day washout periods in between. Continuous glucose monitoring was applied during the intervention periods. The primary outcome was glycaemic control, as measured by the percentage of time patients spent within the euglycaemic range (TIR_{70-140   mg/dl} ). Other key glycaemic metrics were also investigated as secondary outcomes.

RESULTS

TIR_70-140 was not statistically different between HPD, MED and REF (p = .105). Pairwise analysis revealed a statistically significant difference between HPD and REF at the .05 level, which was not retained after applying Bonferroni correction (54.87% ± 14.11% vs. 48.33% ± 13.72%; p = .018). During the HPD period, 11 out of 15 participants spent more time within TIR_70-140 compared with either the REF or MED. The HPD performed significantly better than the REF in terms of TIR_70-180 (74.33% ± 12.85% vs. 67.53% ± 12.73%; p = .012), glycaemic variability (coefficient of variation: 36.18% ± 9.30% vs. 41.48% ± 8.69%; p = .016) and time spent in the hypoglycaemic range (TBR_{70   mg/dl} ; median: 12, IQR: 16 vs. median: 14, IQR: 20; p = .007), whereas no statistically significant differences were observed between MED and HPD or REF.

CONCLUSIONS

Compared with REF and MED, an HPD plan may have a positive impact on glycaemic control in patients with T1D. During the HPD, patients spent a shorter time in hypoglycaemia and exhibited lower glycaemic variability.

Impact of Fat Intake on Blood Glucose Control and Cardiovascular Risk Factors in Children and Adolescents with Type 1 Diabetes

Nutrition therapy is a cornerstone of type 1 diabetes (T1D) management. Glycemic control is affected by diet composition, which can contribute to the development of diabetes complications. However, the specific role of macronutrients is still debated, particularly fat intake. This review aims at assessing the relationship between fat intake and glycemic control, cardiovascular risk factors, inflammation, and microbiota, in children and adolescents with T1D. High fat meals are followed by delayed and prolonged hyperglycemia and higher glycated hemoglobin A1c levels have been frequently reported in individuals with T1D consuming high amounts of fat. High fat intake has also been associated with increased cardiovascular risk, which is higher in people with diabetes than in healthy subjects. Finally, high fat meals lead to postprandial pro-inflammatory responses through different mechanisms, including gut microbiota modifications. Different fatty acids were proposed to have a specific role in metabolic regulation, however, further investigation is still necessary. In conclusion, available evidence suggests that a high fat intake should be avoided by children and adolescents with T1D, who should be encouraged to adhere to a healthy and balanced diet, as suggested by ISPAD and ADA recommendations. This nutritional choice might be beneficial for reducing cardiovascular risk and inflammation.

Medical management of children with type 1 diabetes on low-carbohydrate or ketogenic diets

OBJECTIVES

Low-carbohydrate and ketogenic diets are becoming increasingly popular choices for people with type 1 diabetes (T1D) aiming to achieve optimal glycemic control. A carbohydrate-restricted diet in children has been associated with negative health effects including poor linear growth and inadequate bone mineralization. Guidelines for monitoring children and adolescents choosing to follow a carbohydrate-restricted diet do not exist. We aimed to create a clinical protocol outlining how to clinically and biochemically follow patients choosing a carbohydrate-restricted diet with the goal of medical safety.

METHODS

An interdisciplinary committee was formed and reviewed current consensus guidelines for pediatric patients on carbohydrate-restricted diets for epilepsy and metabolic disorders. A literature search was done to determine management strategies for children with T1D on a low-carbohydrate or ketogenic diet. Key health parameters that require monitoring were identified: growth, glycemic control, bone health, cardiometabolic health, and nutritional status. These health outcomes were used to develop a protocol for monitoring children on carbohydrate-restricted diets.

RESULTS

A one-page protocol for medical providers and educational materials for families interested in following a low-carbohydrate or ketogenic diet were developed and successfully implemented into clinical care.

CONCLUSION

Implementing a protocol for children on carbohydrate-restricted diets in clinic allows medical providers to ensure medical safety while being open to discussing a family's dietary preferences. Following children in the protocol over time will lead to informed clinical guidelines for patients with T1D who choose to follow a carbohydrate-restricted diet.

The Low-Carbohydrate Diet: Short-Term Metabolic Efficacy Versus Longer-Term Limitations

Background: Diets have been a central component of lifestyle modification for decades. The Low-Carbohydrate Diet (LCD), originally conceived as a treatment strategy for intractable epilepsy (due to its association with ketogenesis), became popular in the 1970s and since then has risen to prominence as a weight loss strategy. Objective: To explore the efficacy, limitations and potential safety concerns of the LCD. Data Sources: We performed a narrative review, based on relevant articles written in English from a Pubmed search, using the terms ‘low carbohydrate diet and metabolic health’. Results: Evidence supports the efficacy of the LCD in the short-term (up to 6-months) for reduction in fat mass and remission of Type 2 Diabetes Mellitus (T2D). However, the longer-term efficacy of the LCD is disappointing, with diminishment of weight loss potential and metabolic benefits of the LCD beyond 6-months of its adoption. Furthermore, practical limitations of the LCD include the associated restriction of food choices that restrict the acceptability of the LCD for the individual, particularly over the longer term. There are also safety concerns of the LCD that stem from nutritional imbalances (with a relative excess of dietary fat and protein intake with associated dyslipidaemia and increased risk of insulin resistance and T2D development) and ketotic effects. Finally, the LCD often results in a reduction in dietary fibre intake, with potentially serious adverse consequences for overall health and the gut microbiota. Conclusions: Although widely adopted, the LCD usually has short-lived metabolic benefits, with limited efficacy and practicality over the longer term. Dietary modification needs tailoring to the individual, with careful a priori assessments of food preferences to ensure acceptability and adherence over the longer term, with avoidance of dietary imbalances and optimization of dietary fibre intake (primarily from plant-based fruit and vegetables), and with a posteriori assessments of the highly individual responses to the LCD. Finally, we need to change our view of diets from simply an excipient for weight loss to an essential component of a healthy lifestyle.

Low-carb Diet in Hospitalized Late Pubertal Type 1 Diabetic Girls: A Short-Term CGM Study

OBJECTIVE

We conducted the present study to observe potential short-term benefits or risks of low-carb diet (LCD).

METHODS

This is a prospective randomized cross-over study. Type 1 diabetic girls were hospitalized in ternary groups for 7 days and each group randomly started with LCD or regular diet. Continuous glucose monitoring (CGM) was performed between 0 and 168 h.

RESULTS

Twenty-eight subjects completed the study. Total energy, protein, and fat consumption were high (P < 0.001); carbohydrate consumption and rapidly acting insulin dose were low (P < 0.001 and P = 0.002, respectively) during LCD. Morning postprandial, noon postprandial, and evening preprandial capillary blood sugar levels were lower during LCD (P = 0.013, 0.018, and 0.048, respectively).

CONCLUSION

LCD may have the advantage of better glycemic control despite lower insulin dose which is a favorable outcome with regard to weight control and atherosclerosis prevention. No adverse events were observed.

Nutrition and Exercise Performance in Adults With Type 1 Diabetes

The best nutritional practices for exercise and sports performance are largely activity specific. The presence of type 1 diabetes undeniably bestows additional factors to consider to manage exercise and ensure adequate nutrients and fuels are available for optimal performance. Whether participating in sports or physical activity on a recreational basis or striving to achieve a high level of athletic performance, individuals with type 1 diabetes must pay attention to their nutritional and dietary patterns, including intake of macronutrients, micronutrients, fluids and supplements, such as caffeine to maintain metabolic and glycemic balance. Performance aside, nutritional recommendations may also differ on an individual basis relative to exercise, glycemic management and body weight goals. Balancing all these dietary factors can be challenging for individuals with type 1 diabetes, and many related aspects have yet to be fully researched in this population.

Ketogenic Diet as a Normal Way of Eating in Adults With Type 1 and Type 2 Diabetes: A Qualitative Study

OBJECTIVES

There are currently no recommendations on following the ketogenic diet (KD) in the context of diabetes and, therefore, health-care professionals may not be comfortable in supporting this dietary regimen. In this qualitative study, we aim to understand the perspective of patients with diabetes when following the KD, particularly with regard to reasons for starting the diet, motivators, support systems, sources of information and challenges.

METHODS

Adults diagnosed with type 1 or type 2 diabetes who followed a KD for ≥3 months were recruited for inclusion in this study. Semistructured interviews were conducted, audio recorded and transcribed. Themes were analyzed using concept mapping until theme saturation was achieved.

RESULTS

Participants were 54.5 (standard deviation 10.1) years old, on average, and had been following the KD for 6 to 19 (median 5) months; 43% were male and 79% had type 2 diabetes. The main motivation to start the diet was to improve blood glucose control or to reduce/stop taking diabetes medications, followed by weight loss and diabetes reversal. Participants reported benefits of the diet, such as improved glycemic control, weight loss and satiety, which appeared to strongly prevail over challenges, such as lack of support from health-care professionals and lack of information sources. Most participants considered the KD as a normalized way of eating that they would continue for the rest of their lives.

CONCLUSIONS

A wide range of reported benefits, either expected or that emerged, strongly motivated individuals to follow the KD despite the lack of safety information and/or support. Further studies are needed to establish guidelines that health-care professionals can use to provide direction for individuals with diabetes who wish to follow the KD.

Cardiac ketone body metabolism

The ketone bodies, d-β-hydroxybutyrate and acetoacetate, are soluble 4-carbon compounds derived principally from fatty acids, that can be metabolised by many oxidative tissues, including heart, in carbohydrate-depleted conditions as glucose-sparing energy substrates. They also have important signalling functions, acting through G-protein coupled receptors and histone deacetylases to regulate metabolism and gene expression including that associated with anti-oxidant activity. Their concentration, and hence availability, increases in diabetes mellitus and heart failure. Whilst known to be substrates for ATP production, especially in starvation, their role(s) in the heart, and in heart disease, is uncertain. Recent evidence, reviewed here, indicates that increased ketone body metabolism is a feature of heart failure, and is accompanied by other changes in substrate selection. Whether the change in myocardial ketone body metabolism is adaptive or maladaptive is unknown, but it offers the possibility of using exogenous ketones to treat the failing heart.

Palaeolithic Diet in Diabesity and Endocrinopathies - A Vegan's Perspective

Introduction: The Palaeolithic diet is designed to resemble that of human hunter-gatherer ancestors thousands to millions of years ago. This review summarises the evidence and clinical application of this diet in various disorders. An empiric vegan variant of it has been provided, keeping in mind vegan food habits. Review of the literature: different types of Palaeolithic diets in vogue include the 80/20, the autoimmune, the lacto, the Palaeolithic vegan and the Palaeolithic ketogenic. We have developed an Indian variant of the Palaeolithic vegan diet, which excludes all animal-based foods. The Palaeolithic diet typically has low carbohydrate and lean protein of 30–35% daily caloric intake in addition to a fibre diet from non-cereal, plant-based sources, up to 45–100 g daily. In different observational studies, beneficial effects on metabolic syndrome, blood pressure, glucose tolerance, insulin secretion, lipid profiles and cardiovascular risk factors have been documented with the Palaeolithic diet. Short-term randomised controlled trials have documented weight loss, and improved glycaemia and adipo-cytokine profiles. Few concerns of micronutrient deficiency (e.g. calcium) have been raised. Conclusion: Initial data are encouraging with regard to the use of the Palaeolithic diet in managing diabesity. There is an urgent need for large randomised controlled trials to evaluate the role of the Palaeolithic diet with different anti-diabetes medications for glycaemic control and the reversal of type 2 diabetes.

Low versus high carbohydrate diet in type 1 diabetes: A 12-week randomized open-label crossover study

AIMS

To compare the effects of a low carbohydrate diet (LCD < 100 g carbohydrate/d) and a high carbohydrate diet (HCD > 250 g carbohydrate/d) on glycaemic control and cardiovascular risk factors in adults with type 1 diabetes.

MATERIALS AND METHODS

In a randomized crossover study with two 12-week intervention arms separated by a 12-week washout, 14 participants using sensor-augmented insulin pumps were included. Individual meal plans meeting the carbohydrate criteria were made for each study participant. Actual carbohydrate intake was entered into the insulin pumps throughout the study.

RESULTS

Ten participants completed the study. Daily carbohydrate intake during the two intervention periods was (mean ± standard deviation) 98 ± 11 g and 246 ± 34 g, respectively. Time spent in the range 3.9-10.0 mmol/L (primary outcome) did not differ between groups (LCD 68.6 ± 8.9% vs. HCD 65.3 ± 6.5%, P = 0.316). However, time spent <3.9 mmol/L was less (1.9 vs. 3.6%, P < 0.001) and glycaemic variability (assessed by coefficient of variation) was lower (32.7 vs. 37.5%, P = 0.013) during LCD. No events of severe hypoglycaemia were reported. Participants lost 2.0 ± 2.1 kg during LCD and gained 2.6 ± 1.8 kg during HCD (P = 0.001). No other cardiovascular risk factors, including fasting levels of lipids and inflammatory markers, were significantly affected.

CONCLUSIONS

Compared with an intake of 250 g of carbohydrate per day, restriction of carbohydrate intake to 100 g per day in adults with type 1 diabetes reduced time spent in hypoglycaemia, glycaemic variability and weight with no effect on cardiovascular risk factors.