A Foe for Type 1 Diabetes
Posted May 14, 2018 4:05 p.m. EDT
Like many children, Andrew Hightower, 13, likes pizza, sandwiches and dessert.
But Andrew has Type 1 diabetes, and six years ago, to control his blood sugar levels, his parents put him on a low-carbohydrate, high-protein diet. His mother makes him recipes with diabetic-friendly ingredients that won’t spike his blood sugar, such as pizza with a low-carb, almond-flour crust and homemade bread with walnut flour instead of white flour.
Andrew’s diet requires careful planning — he often takes his own meals to school. But he and his parents say it makes it easier to manage his condition, and since he started the diet, his blood sugar control has markedly improved and he has had no complications requiring hospital visits.
“I do this so that I can be healthy,” said Andrew, who lives with his parents in Jacksonville, Florida, adding that he will keep following the diet “when I eventually move out and go to college.”
Most diabetes experts do not recommend low-carb diets for people with Type 1 diabetes, especially children. Some worry that restricting carbs can lead to dangerously low blood sugar levels, a condition known as hypoglycemia, and potentially stunt growth. But a new study published in the journal Pediatrics suggests otherwise.
It found that children and adults with Type 1 diabetes who followed a very low-carb, high-protein diet for an average of just over two years — combined with the diabetes drug insulin at smaller doses than typically required on a normal diet — had “exceptional” blood sugar control. They had low rates of major complications, and children who followed it for years did not show any signs of impaired growth.
The study found that the participants’ average hemoglobin A1C, a long-term barometer of blood sugar levels, fell to just 5.67 percent. An A1C under 5.7 is considered normal, and it is well below the threshold for diabetes, which is 6.5 percent.
“Their blood sugar control seemed almost too good to be true,” said Belinda Lennerz, the study’s lead author and a pediatric endocrinology instructor at Boston Children’s Hospital and Harvard Medical School. “It’s nothing we typically see in the clinic for Type 1 diabetes.”
The new study comes with an important caveat. It was an observational study, not a randomized trial with a control group. The researchers recruited 316 people, 130 of them children whose parents gave consent, from a Facebook group dedicated to low-carb diets for diabetes, called TypeOneGrit. “Perhaps the surprise is that for this large number of patients,” a very low-carb diet “is much safer than many experts would have suggested,” said David M. Harlan of the University of Massachusetts medical school, who was not involved in the study. “This paper,” Harlan added, “should reopen the discussion about whether this is something we should be offering our patients as a therapeutic approach.”
The paper’s authors cautioned that the findings should not lead patients to alter their diabetes management without consulting their doctors, and that large clinical trials will be needed to see whether this approach should be used more widely.
“We think the findings point the way to a potentially exciting new treatment option,” said Dr. David Ludwig, a co-author of the study and a pediatric endocrinologist at Boston Children’s Hospital who has written popular books about low-carb diets. “However, because our study was observational, the results should not, by themselves, justify a change in diabetes management.”
About 1.25 million Americans have Type 1 diabetes, which occurs when the pancreas does not produce enough insulin to regulate blood sugar levels. Managing the condition requires administering insulin throughout the day, especially when consuming meals high in carbs, which raise blood sugar more than other nutrients. Over time, chronically elevated blood sugar can lead to nerve and kidney damage and cardiovascular disease.
The standard approach for people with Type 1 diabetes is to match carb intake with insulin. But the argument for restricting carbs is that it keeps blood sugar more stable and requires less insulin, resulting in fewer highs and lows. The approach has not been widely studied or embraced for Type 1 diabetes, but some patients swear by it.
TypeOneGrit has about 3,000 members on Facebook who ascribe to a program devised by Dr. Richard Bernstein, an 84-year-old physician with Type 1 diabetes. His book, “Dr. Bernstein’s Diabetes Solution,” recommends limiting daily carb intake to about 30 grams, the amount in a sweet potato or about four or five cups of cooked broccoli. Bernstein recommends foods such as nonstarchy vegetables, seafood, nuts, meat, yogurt, tofu and recipes made with almond flour, sugar substitutes and other low-glycemic ingredients. His plan emphasizes protein intake, which he says is especially important for growing children.
The most striking finding of the new report was that A1C levels, on average, fell from 7.15 percent, in the diabetic range, to 5.67 percent, which is normal. The rate of diabetes-related hospitalizations also fell, from 8 percent before the diet to 2 percent after, including fewer hospitalizations for hypoglycemic seizures. Those following the diet had increased LDL cholesterol, most likely from consuming more saturated fat, which some experts said was potentially concerning and deserved further study. But other heart disease risk factors appeared favorable: They had high HDL cholesterol, the protective kind, and low triglycerides, a type of fat in the blood linked to heart disease.
Dr. Joyce Lee, a diabetes expert at the University of Michigan who was not involved in the study, said that the findings were impressive and merited further follow-up, and that patients who wanted to explore a low-carb approach might do so while being monitored by their health care team. But she also noted that the patients in the new study were a “highly motivated” group, and that it would be difficult for many people to adopt the restrictive regimen they followed.
“The reality is that it’s really hard to do low-carb, given our cultural norms,” said Lee, a professor of pediatrics at the University of Michigan.
In an interview, Bernstein, a co-author on the paper, said it demonstrates what he sees in his practice: that there are diabetics on his regimen “who are walking around with normal blood sugars and they are happy about it, healthy, and growing if they are kids.”
Derek Raulerson, 46, a human resources manager in Alabama, agrees. Both he and his son, Connor, 13, have Type 1 diabetes. Raulerson said he struggled for years to control his blood sugar. But six years ago, he gave up juice, bread, potatoes and other simple carbs, and made protein and nonstarchy vegetables the focus of his meals. Since going low-carb, he said, he has lost weight, cut in half the amount of insulin he uses daily, and watched his A1C fall from the diabetic range to normal levels. “I have normalized, steady blood sugars now,” he said. “I am no longer on the roller coaster.”