Therapeutic Nutrition in Type 1 Diabetes; A Guide for Health Care Professionals.
PLEASE NOTE. The content of the Healthcare Professional Pack provides information that might be of use to someone with Type 1 Diabetes who is looking to transition to a therapeutic nutrition approach to their condition. It is intended to facilitate discussion between the patient and clinician and not to either provide advice or get in the way of the clinician to patient relationship.
“People with Type 1 Diabetes should have the right to normal blood glucose” – Dr. Richard Bernstein, pioneer of a lower-carb approach in Type 1 Diabetes.
This HCP pack has information to provide healthcare professionals with an overview of a low carbohydrate approach to Type 1 Diabetes. It details the benefits, principles, and practice of a therapeutic nutritional approach to the condition.
For many people, reducing carbohydrates in the diet is the beginning of a journey towards improved glycaemic control, increased day to day safety, and improved quality of life.
The pack provides the rationale, evidence, and practical information needed to work with people with Type 1 diabetes to help them achieve their goals. There is a wealth of dietary information on the types of food that would be ideal for someone with Type1 looking to restrict the carbohydrate in their diet. There are no recipe calendars or fixed regimens, but there is an abundance of recipes that set out to provide examples of recipes and food choices that someone with Type 1 will find helpful when shopping and in the preparation of food. The emphasis is on a practical approach to food preparation and selection that will suit those with time pressure and financial pressure. There are plenty of hints and tips on being opportunistic to get the best value out of a shopping trip.
This course has been produced around both personal and professional observation of the needs of people with Type 1 who are interested in a low carb lifestyle. Data collected elsewhere has shown that the concerns of people with Type 1 diabetes are not necessarily aligned with those of the clinician. Type 1s were predominantly concerned with mental health and lifestyle issues compared with biological markers that clinicians usually are more used to.
Not all people are at the same stage in their journey to achieve this aim straight away, and therefore the setting of goals that are in alignment with the individual’s hopes is essential, as with any change process. A simple way to do this is to use the GRIN model: Find out what Goals the patient has concerning their diabetes management at present; what Resources can be utilised to help them achieve that goal; a practical and realistic way of making changes in small Increments if needed; and finally, making arrangements for following up, emphasising the positives, reassessing progress and reviewing the goal (Noticing ).
A RATIONAL ALTERNATIVE TO CONVENTIONAL DIETARY MANAGEMENT
The principle behind therapeutic nutrition in Type 1 Diabetes is simple:
‘reducing carbohydrates in the diet will lead to an improvement in glycaemic control.’
This has proven to be the case in published studies that are included in this pack.
INCREASED SAFETY: The Law of Small Numbers
Improved glycaemic control leads to increased safety from a reduction in diabetes emergencies. Nielsen found 5x fewer hypoglycaemic episodes on a relatively modest carbohydrate intake of 75g per day. https://www.ncbi.nlm.nih.gov/pubmed/16454166.
Ludwig commented on the remarkably low incidence of diabetic ketoacidosis on a ketogenic diet of 35g carbohydrates per day. http://pediatrics.aappublications.org/content/141/6/e20173349
The reduced insulin doses at each meal buffer the errors in the estimation of carbohydrate counting and insulin dosing, which are common in Type 1 Diabetes. There is smoothing out of blood glucose excursions and less likelihood of hyperglycaemia and hypoglycaemia.
The time spent in normoglycemia is increased, and this should lead to a reduction of complications in the future. It is not unreasonable to expect near normal glycaemic control if the patient decides on a very low carbohydrate diet. Daily insulin volumes are typically reduced in people with type diabetes by anecdotally around 50%.
As little as possible, but as much as needed.
The principle here is not to reduce insulin for its own sake but to aim for insulin volumes as low as possible but as much as needed. As with any Type 1 management strategy, insulin volumes needed will alter according to variables other than diet—stress, infection, etc., etc.
Time spent in a glucose range where there is a reduction in peaks and troughs is increasingly being seen as beneficial. Markers such as Coefficient of Variation or similar might be used alongside HbA1c as a predictor of complications in the future. The increasing application of continuous glucose monitoring is enabling research in this area.
Sunghwan Suh and Jae Hyeon Kim Glycaemic Variability: How Do We Measure It and Why Is It Important?
So, it makes sense to safely manage carbohydrate reduction in a condition where the ability to metabolise carbohydrate is absent without an injection of insulin. We know in practice how difficult it is to balance dietary carbohydrates with insulin.