By Marika Sboros
Type 1 diabetes is usually a terrifying diagnosis, more so for parents when doctors diagnose it in their children. A lifetime dependency on increasing use of insulin and other drugs looms large.
If diabetics don’t manage their condition properly, the spectre of life-threatening complications also looms large. These include kidney failure, blindness, limb amputation and premature death.
Now, US scientists offer type 1 diabetics a radically different approach to conventional treatment and management of type 1 diabetes. Their study just published in the journal, Pediatrics, suggests that a very low-carb, higher-protein (VLC) diet can achieve “exceptional” blood sugar control.
And it can do so by significantly reducing use of insulin and other drugs. Better still, it does so with “low rates of adverse events”. They suggest that current treatment protocols should change. Top global experts agree.
The researchers explicitly acknowledge limitations of their study. For starters, it is observational, not the “gold standard” randomised controlled trial (RCT) a control group. They studied 316 people, 130 of them children. Participants were drawn from the Facebook group TypeOneGrit devoted to low-carb diets for diabetes. The researchers reviewed participants’ medical records and contacted their medical providers.
Lead author of the study is Dr Belinda Lennerz, a paediatric endocrinologist at Harvard and Boston Children’s Hospital. Lennerz told Anahad O’Connor in the New York Times that results were “almost too good to be true”.
Participants’ blood sugar control was like “nothing we typically see in the clinic for type 1 diabetes”, she said.
He says that the biggest challenge facing people with any form of diabetes is controlling blood sugar around meals. That’s especially the case with type 1 diabetics.
After eating a high-carbohydrate meal, blood sugar rises (hyperglycaemia) rapidly for one to two hours. Insulin can control that rise but can also cause low blood sugar (hypoglycaemia) later.
It is these fluctuations in blood sugar levels that present a threat to diabetics, whether type 1 or 2, he says.
Despite the latest technologies for monitoring blood sugar and administering insulin, Ludwig says most people with type 1 diabetes have to face a kind of “Charybdis or Scylla” choice (between high and low blood sugar) after every meal.
That’s a reference to the idiom derived from Greek mythology of “having to choose between two evils”.
Monsters in check
Odysseus faced Scylla, a monster that lived on one side of a narrow channel of water. On the opposite side was her counterpart monster, Charybdis. The Pediatrics study shows that a low-carb diet could keep those monsters in check.
It’s also true, however, that many, if not most, medical doctors and dietitians these days deemphasize the importance of diet in type 1 diabetes, beyond “carbohydrate counting”. They have a particular aversion to VLC diets for children. A common belief is that restricting carbs is “dangerous” and can lead to low blood sugar levels and stunted growth.
The new study suggests the exact opposite.
Yet many doctors like to say that type 1 diabetes is not a lifestyle disease. They say that it is a chronic, autoimmune condition that occurs when the body’s immune system turns on itself. That much certainly is true.
The immune system attacks the insulin-producing beta cells of the pancreas, leaving little or no ability to produce insulin, a hormone that regulates blood sugar. Without insulin, sugar (glucose) and ketones (made from fat) build up in the blood and leads to what doctors call diabetic ketoacidosis. That can cause serious damage to organ systems and can be fatal.
But why the immune system suddenly turns on itself is a mystery that this study may unravel. One reason may very well be incorrect diet, in particular far too many carbs.
Ludwig got the idea for the study after meeting US orthopaedic surgeon Dr Carrie Diulus at a nutrition conference in 2016.
Type 1 diabetes ‘honeymoon’ period
Diulus is an orthopaedic surgeon with type 1 diabetes who has She posted before and after pictures of herself on Twitter after she made radical dietary changes.
She maintains normal HbA1c levels on a very-low-carbohydrate diet. HbA1c refers to glycated haemoglobin (A1c), which identifies average plasma glucose concentration. It is a marker of how well a patient controls blood sugar levels. It is a marker of how well a patient has been able to control blood sugar levels over the past two to three months.
As an endocrinologist, Ludwig has cared for people with diabetes for more than 20 years. During that time, he had never seen someone with T1DM and normal HgA1c after the initial “honeymoon period”.
And if he had, he would have expected that person to have an unrecognised hormone problem and frequent, severe hypoglycemia.
Diulus impressed him. She radiates health, vitality and wellbeing.
What’s more, Diulus told Ludwig that her diabetes control was the rule, not the exception, in a large social media community of children and adults following recommendations of Dr Richard Bernstein.
That turned out to be the TypeOneGrit Facebook page.
Being a researcher at heart – and at work, as it’s his day job – Ludwig felt compelled to delve deeper. He suggested to Diulus that they do a scientific survey of that community.
Right first step?
Ludwig describes the unexpectedly positive results as a phenomenon that most diabetes experts don’t believe exists. Thus, an observational study is “the right first step” to document it and prove its existence. He suggested the study to Lennerz, who he mentors. The rest is the groundbreaking nutrition science history. He documents it all on his blog.
Results showed that, as hypothesised, participants average HbA1c was 5.67 %. That’s in the normal range, says Ludwig. It is also well below the average values of 8.2% for patients with type 1 diabetes. Some participants even had values in the 4% range, which he calls “quite extraordinary”.
Reassuringly too, participants reported low rates of complications, such as the diabetic ketoacidosis and severely low blood sugar. They also found no evidence for adverse effect on growth among children. Overall, cardiovascular risk factors were “excellent”, Ludwig says.
Click here to read: ‘Cure’ for type 2 diabetes? A doctor’s personal journey
With admirable restraint, Ludwig says that these findings “suggest that a low-carb diet might help prevent the long-term complications of diabetes”. Researchers need to explore this possibility in high-quality RCTs, he says.
That’s already happening. The Sweden-based Dietary Science Foundation is helping to fund a study that has received ethical approval and will start soon. Uppsala University Hospital will participate.
Ludwig also says that most study participants were satisfied with this approach. They easily accepted the idea of life-long restriction of many high-carb staples of the modern SAD (standard America, Western) diet.
However, their embrace of this unconventional diet brought a substantial minority into conflict with their diabetes care providers. Some lectured patients about the “dangers” of restricting carbohydrate in diabetes, he says. This led some parents to hide the low-carb diet from their child’s doctor for fear of accusations of child abuse.
Ludwig says that this distrust, more than any diet, represents the real danger. It could set the stage for a “catastrophic event”. That’s if patients don’t seek professional help at times of need. And if they make diabetes management decisions beyond their competencies.
He hopes that greater awareness of the low-carb diet for type 1 diabetes, will bridge misunderstanding between patients and providers.
Ironically, there is nothing new about the premise on which this research is built. VLC diets were first-line treatment for type 1 diabetes before insulin came onto the scene. Some doctors, Bernstein among them, felt it was worth keeping up.
Bernstein developed type 1 diabetes at the of 12 and was having complications by his 30s. He became a doctor to learn better how to treat his own disease. His research led him to decide that the proper treatment was a low carb diet. This clashed with conventional medical “wisdom” at the time (the 1990s). It included treating patients with insulin and a diet high in carbs
Leading US type1 diabetes expert Dr Jake Kushner has welcomed the study. Kushner is associate professor of pediatrics at Baylor College of Medicine.
Kushner declares himself “simply thrilled” to see the Pediatrics paper and calls it a “landmark work”. It could “radically alter standard health care for people with type 1 diabetes by introducing low-carbohydrate nutrition as a core element of care”, he says.
Impossible is possible
Till now, many experts believed that this was impossible, Kushner says. But hundreds of people have been able to follow Bernstein’s methods, he says. Crucially, they have been able to enjoy “far better glucose control than with typical standard-of-care”.
Paradoxically, those who followed Bernstein’s low-carb methods also had dramatically reduced risk of life-threatening low blood sugar episodes, Kushner says. In addition, there were no other obvious negative sequelae for the patients.
Of course, as with all great research findings, Kushner says that the study brings up “far more questions than it answers”.
It remains possible, for example, that the study patients might have self-selected for their ability to follow Bernstein’s protocol for type 1 diabetes care. To this end, he wants to see a government entity or philanthropic source fund a prospective RCT. (Ludwig and Lennerz are presently seeking funding for just such a study.)
Kushner also wants to know precisely which nutritional strategy doctors can most easily and safely apply to populations of people with type 1 diabetes.
Pros and cons
In addition, Kushner wants to understand the relative pros and cons of low-carb nutrition (and various other nutritional strategies) for a given type 1 diabetic patient population. This is as it relates to life-threatening complications (hypoglycemia, diabetic ketoacidosis), microvascular complications (diabetic retinopathy, diabetic nephropathy, etc), macrovascular complications (cardiovascular disease, stroke, etc), and overall survival.
“We must understand the potential psychological impact of low carb strategies in patients with type 1 diabetes,” Kushner says.
He agrees, though, that diabetes professionals and advocates continue to make claims about the negative impact of following a “restrictive” diet. He also knows of many other experienced diabetes professionals who passionately argue that avoiding carbohydrates represents a “terrible burden” that would add to the difficulty of living with diabetes.
Kushner joins growing numbers of endocrinologists who “strongly suspect” that low-carb nutrition is beneficial for diabetes-related burdens. But in the end, “we will need solid evidence to sort out these opposing hypotheses”.
“We must learn much more in order to fully understand which nutritional strategy is most easily and safely applied. That will people with type 1 diabetes to live long, healthy lives.”
Award-winning British NHS GP Dr David Unwin endorses the sentiments. The NHS has given Unwin an award for saving upwards of £40,000 annually in insulin that he did not have to prescribe in his practice.
He finds the Pediatrics study “interesting”. Unwin has noticed more people with Type 1 diabetes experimenting with this approach, having found it on the internet. Those he has spoken to report significant weight loss and reducing their insulin usage by up to 50%.
When asked, though, the thing they most appreciated was having fewer hypos (low blood sugar bouts), Unwin says.
The cost is not eating high-carb foods such as cereals, ice cream, cakes and biscuits. This choice may surprise many non-diabetics, Unwin says.
“But perhaps that is because we fail to understand some of the difficulties of living with type 1 diabetes?”
Unwin has memorably said: “Telling diabetics to eat carbohydrates moderately just leaves them moderately poisoned.”
That raises the question why any self-respecting diabetes care provider would voluntarily want to do that?