This is information for primarily people with type 1 diabetes. It has been written to address the common areas of conflict in clinical settings in the hope of improving the consultation experience for the clinician and the person with Type 1
A diabetes annual review is an opportunity to discuss results, management options, and mental health/lifestyle issues.
The current NICE guideline NG17 is an authoritative resource for monitoring and managing Type 1 diabetes.
Clinicians will be familiar with the tests, examinations and measurements needed for an annual review, which is not part of this course.
An area of difficulty is the dietary guidelines which do not align with a ketogenic diet. There are a few statements that allow a patient to be supported on a keto diet. ( see below). However, the reality is that many patients do not get support in this area and, worse, are given inaccurate advice, which leads to conflict and an unsatisfactory consultation.
This short document will explore issues that lead to conflict and suggest evidence that might help to provide a solution.
Survey
A recent survey of subscribers to www.type1keto.com was carried out. The respondents were experienced in managing a keto lifestyle. There were 18 respondents who are a helpful focus group to report on the experience of a ketogenic expert patient in clinical settings. The results of this small survey correlated well with a larger, more general survey of 140 respondents from the same site.
Questions
The survey asked the following questions:
- If your clinician is supportive, what was it about the consultation that helped you to realise this? i.e., did they recommend keto, did they approve when you told them, and made suggestions about resources and how they might help you?
- If your clinician is unsupportive, what are the reasons for their concerns as you understood them?
- Have you ever been told that keto is a fad diet, unsustainable or nutritionally incomplete?
- Have you ever been told, or think you were told, that a keto diet is a risk factor for DKA?
- Have you ever been told that a normal HbA1c on a keto diet must mean you have a lot of hypos? And if so, has your ability to drive safely been questioned?
Responses
40% of clinicians were judged supportive or tolerant.
11% were supportive of low carb only.
49% were not supportive of keto diets.
The main concerns of clinicians in this sample were:
- Risk of hypoglycaemia 25%
- The belief that carbohydrates are an essential macronutrient 19%
- Stroke risk 12.5%
- The diet is unsustainable or bland 19%
- Diabetic ketoacidosis risk 12.5%
- Cholesterol concerns 6%
- Adhering to NHS advice, 6%
There were equal numbers who thought the diet was a fad. So, 50% of clinicians took a negative view of keto, and 50% were positive.
It is, therefore, still the case that around half of clinicians in this sample were not comfortable with patients adopting a keto lifestyle despite the NICE guideline being supportive of patient choice. Few recommend it in the clinic.
It is also the case that apart from stroke risk and concerns about cholesterol which make up around 20% of concerns, 75% of concerns are not based on fact. The reasons for this are included in the course and summarised here.
The risk of hypoglycaemia 25%. The evidence does not bear this out. In one study, the risk was six times fewer,
https://ujms.net/index.php/ujms/article/view/6465, In another study, hypo frequency was reduced in nearly all cases.
A survey that was run online from the www.type1keto.com site found that 75% of the 140 respondents had 50% or fewer hypos.
The belief that carbohydrates are an essential macronutrient 19%
This is not accurate information. There is a tendency to steer patients to eat carbohydrates, partly because of the high volumes of insulin their patients take on a high carbohydrate diet. Carbohydrates will mitigate to some extent the dangers of high insulin volumes and resultant hypoglycaemic episodes if the insulin and carbohydrate calculations are inaccurate. Carbohydrates provide energy but have no nutrient value. Of course, whole grains and other natural, unrefined sources of carbohydrates will contain vitamins and fibre, but no nutrients are exclusive to carbohydrates that cannot be easily obtained from non-carbohydrate macronutrients. It isn’t easy to eat a zero-carbohydrate diet. Hypos are fewer in number on a keto diet but should be managed with carbohydrates such as pure glucose in the usual way.
Stroke risk 12.5%. Cholesterol concerns 6%
Based on lipid profiles, there is no long-term evidence for ketogenic diets and stroke risk. The evidence for lipid levels and stroke risk is based on a high carbohydrate fat-storing metabolism, and it is difficult to see how this can be extrapolated to a ketogenic fat-burning metabolism. However, proxy markers of reduced HbA1c, increased Time in Range, improved lipid profiles, and improved renal function (in Type 2 diabetes) https://pubmed.ncbi.nlm.nih.gov/34468402/ etc., suggests that long-term evidence will be favourable.
The caveats around these markers should be offset against the short-term gains of improved well-being, vision, and mental clarity, reduced hypos( below), possible weight loss and reduction in the soft side effects The current situation from the National Diabetes Audit for England and Wales is that the mean HbA1c is 70mmol/mol on pens and 65mmol/mol on pumps. At a level of 58mmol/mol, which 70% of T1D are above, one loses 100 days of life every year that HbA1c is at or above this level. https://www.easd.org/virtualmeeting/home.html#!resources/estimating-life-years-lost-to-diabetes-outcomes-from-analysis-of-national-diabetes-audit-and-office-of-national-statistics-data-england-88c5df0d-653c-448b-8f4e-697f3e5be1df The figures have not changed for the past three audits.
It can be argued that the risk management situation favours glucose control over lipid numbers, where the proven benefits are much less impressive. Gain 100days of life per year, or reduce heart attack risk by 1.2% over 5 years? ( based on high carbohydrate diets in statin therapy). It is likely but unproven that good glycaemic control will greatly reduce heart attack risk. For example, in the Norfolk EPIC trial, when the number of heart attacks was analysed in the normal nondiabetic range for HbA1c (33-42mmol/mol) 75% of all of the heart attacks occurred in those people who were in the top 20% of HbA1c values. HbA1c is an independent risk factor for heart disease.
The diet is unsustainable or bland 19%
The keto diet is not unsustainable. There is evidence that some people take a look at this diet and decide it is not for them. Many people use this diet for rapid weight loss without medical indication. Like all other diets, the keto diet is as sustainable as any other if the person is motivated. There is a relaxed attitude to glucose targets at present. A high percentage of people with Type 1 diabetes are not reaching the target recommended for reducing complications. The fact that there has been little movement in the percentage of people achieving the target over successive National Diabetes Audit reports would suggest that either current dietary strategies are not achieving success or that clinicians are pragmatic about the patient’s potential for good control and balance the pursuit of good glucose control on high carb diets with quality of life. The situation might change if patients are provided with information about alternatives to high-carbohydrate diets.
The keto diet is far from bland, and there are literally thousands of recipes on websites specialising in keto diets showing that imaginative and varied meals can make up a keto diet.
Food and eating is a very emotive topic. There is evidence that carbohydrates have addiction-like properties, and some clinicians will inevitably have their own personal issues with carbohydrates and possibly refined sugars. Trigger words such as ‘boring’,’ bland’, ‘everyone needs a treat’, ‘faddy’, etc., are subjective and give an insight into the message being conveyed. Clinicians are aware of the need to avoid personal bias in consultations.
Diabetic ketoacidosis risk 12.5%
There is no evidence of this. Indeed, a person on a keto diet is still at risk of DKA, but this is not in any way exacerbated by the diet. Peripheral insulin is an issue in DKA, but this is common to all types of dietary management of Type 1 diabetes. All evidence to date shows no increased incidence of DKA for those on a keto diet. Sufficient insulin regulates ketosis if someone chooses a ketogenic diet.
This graph of ketone levels taken twice daily by 8 people running 100 miles over five days with zero calories and therefore in deep nutritional ketosis, shows clearly that the two people in that group with Type 1 diabetes are indistinguishable from those who did not have the condition. These two people certainly had no increased risk.
Adhering to NHS advice, 6%
This is a valid position to take, and it is true that keto diets are not actively promoted for type 1 diabetes. However, increasing national guidelines now recognise that keto diets improve glycaemic control even if they hold back from endorsing them. The latest NICE guideline NG17 specifically excluded low carb research database from its evidence. Appendix C section 1.2.2.
The best course of action is to find one of the growing numbers of clinicians who will support your lifestyle choice.
There is little point in engaging in argument, but early on in the guidelines, it does say in Section 1.2.4
View each adult with type 1 diabetes as an individual rather than as a member of any cultural, economic or health-affected group (also see recommendations 1.4.5 and 1.4.14 about cultural preferences in the section on dietary advice). [2004, amended 2015]
Section 1.2.5
Jointly agree on an individual care plan with the adult with type 1 diabetes. Review this plan annually and amend it as needed, taking into account changes in the person’s wishes, circumstances and medical findings. [2004, amended 2015].
https://www.nice.org.uk/guidance/ng17/chapter/Recommendations
There is a clinician focussed course available through the website.