There is no such thing as a healthy carb in a keto lifestyle.
There’s little room for even ‘Healthy Whole Grains*’ on a Very-Low Carb Diet in Type 1 Diabetes. Here’s why.
We often hear that carbohydrate counting and insulin bolus to cover the carbs frees-up people to enable them to eat what they like. It does indeed seem a tantalizing idea. Before modern insulins, life was difficult for people with diabetes and there was also a lot that was poorly understood. Blood glucose monitoring at the time was not routine, and the fat-heart hypothesis had not gained full momentum. The diet was different.
But in reality, the freedom to inject and eat what we want is a near-impossible challenge for the vast majority of people. It is optimistic in the extreme to expect precise choreography of the timing of insulin injections and carbohydrate counting.
For the majority of the time in the majority of people, the enormous quantities of carbs we are currently consuming are damaging not only the health of most of the non- diabetes population. They are making the progression to complications in Type 1 diabetes almost inevitable.
Let’s take a look at the current state of the art. The recently reported REPOSE trial in 2017 looked at combining intensive glucose monitoring with a guideline diet of 55 to 60% carbs (250-300g of carbs a day). This trial included the added luxury of a DAFNE education (Dose Adjustment For Normal Eating), which is a named educational intervention in Type 1 NICE guidelines.
These patients were used to study whether multiple insulin injections or an insulin pump were the best strategies. As you can see, it was an impressive trial. But, the analysis of results showed that the NICE guideline target for Hba1c of 48 millimoles per mole (6.5%) was rarely met. It occurred in just 3.3% of those in the trial. In other words, 97% of the trial participants did not achieve the guideline target.
Recent data from the National Diabetes Audit for England and Wales has found that the average HbA1c, which is a measure of longer-term ( 3 months approx) control) is 70 mmol/mol with pens and 65 mmol/mol with a pump.
The non-diabetic HbA1c is 33-42mmol/mol. The observation from the audit was that these figures have not changed for the last three years of the audit. So, one has to assume that this is the best that can be achieved with the current management strategy which is to count carbohydrates and inject the appropriate amount of insulin. The current dietary recommendation is for 55% of energy to come from carbohydrates. To be brutal, these numbers are worrying.
A paper presented at the European Association for the Study of Diabetes in 2020 estimated that for every year that a person had an HbA1c above 58 mmol/mol they lost 100 days of life. Every year. That means 70% of the Type 1 population in England and Wales, and no doubt the same worldwide.
However one massages these figures they are not good. Because there is an alternative diet that can vastly improve control compared to the current one, it is disappointing that the information is not yet widely available, Keto diets will not suit everyone but the knowledge that they exist should be provided.
Eating carbohydrates is not necessary for Type 1 diabetes management. The body can produce ample glucose for its needs from the metabolism of glycolytic intermediates or converting triglyceride and protein to glucose. So, carbohydrates can safely be replaced by fat and protein that are much less likely to cause swings in glucose. Hence there is potential to reduce long-term complications.
There is no need to add extra carbohydrates to a Type 1 diabetes diet. There are carbohydrates in very low-carb diets that cannot be avoided, for example, in leafy vegetables. But basing a diet on carbs as a necessary macro-nutrient is not needed. Of course, there are exceptions. The obvious one is hypo management when glucose is required. But because Type 1 is a condition of near absence or total absence of insulin, complicating management by deliberately adding the only macro-nutrient the body cannot metabolise will only make control challenging to achieve. Of course, it is still necessary to count carbs. They are nearly impossible to avoid in practice. However, when eaten at levels much lower than the guideline amounts, actually managing those carbs with small doses of insulin becomes so much easier.
‘Healthy’ carbohydrate implies that healthy carbohydrates contain nutrients, especially vitamins that complement a healthy diet. Unrefined carbohydrates indeed provide nutrients. But there are no nutrients specific to carbs that cannot be sourced from other foods. The other often-stated information about ‘healthy’ carbohydrates is that they are starchy and fibrous, so they delay glucose absorption and make diabetes control easier. But in practice, knowing that starch is nothing more than glucose molecules linked in a chain, it seems an ultimately futile attempt to limit the rate of absorption of glucose effectively. The glucose will be absorbed at some point, and the patient will have to inject insulin to cover it. Even so-called resistant starches are digested by some people.
Other macronutrients, both fat, and protein, can easily replace the shortfall of energy that removing carbohydrates from the diet causes. And they can easily replace the micronutrients. There are no micronutrients unique to carbohydrates.
Protein and fat are both at least as nutritionally dense and energy-dense as carbohydrates. In the case of fat, it is twice as energy-dense. And there is much anecdotal and increasing research evidence that this approach of low carb in Type 1 diabetes eating is superior to the current high carbohydrate recommendation. The report on the Type1 Grit Facebook community showed that 97% of T1 were achieving 48mmol/mol or less HbA1c on a 38g average carb per day diet over 2.2 years. And that is ongoing. People with Type 1 diabetes need access to this information to be able to assess their personal risk management strategy. Do people with Type1 have to wait ten years until the research catches up? Or should we evaluate the health risks based on what we know and make our own minds up? It’s ultimately up to the individual, but they do need all the information.
*this is a marketing term