Managing Type 1 Diabetes with Diet:
Beyond Carbohydrate Counting


Monitoring carbohydrate is a necessary strategy for managing type 1 diabetes, but this strategy doesn’t really target the underlying roots of the condition and recent research questions its effectiveness for achieving glycemic control.  There is so much more that may be achieved (better blood sugar control, lowered HbA1C, preservation of insulin producing cells, reduced insulin dosage) with more aggressive nutrition intervention that targets the whole system and underlying roots of the condition, instead of just the symptoms.

How many of you with type 1 diabetes or parents of children with type 1 diabetes have been told that you/your child could eat anything – just cover it with insulin? That there was nothing you could do with diet to manage this condition?  That you just needed to count your carbohydrates (with no emphasis on the different types of carbohydrates) and adjust your insulin dosage accordingly? 

The standard diet information for managing type 1 diabetes that is given to patients and their families is significantly lacking.  I think this is due to the usual conventional medical approach that uses a strict evidence-based medicine approach without balancing it with clinical reasoning, experience and analytical thinking as well as the focus on treating symptoms.  Granted there is limited research on type 1 diabetic children and diet, but before the discovery of insulin, diabetics were advised to consume only 20% (or lower) of their total calories as carbohydrate since we know that glycemic control in diabetic subjects is greatly influenced by dietary carbohydrate content.   We’ll see where the research ultimately takes us, but in my view there’s a lot more evidence and reasoning out there to convey beyond just counting carbohydrates since we do know that tighter glycemic control in type 1 diabetics results in better outcomes.

 

Managing Type 1 Diabetes with Diet: Ketogenic, Paleo, Other?

Ketogenic diet

The ketogenic diet (a high fat, adequate protein, very low carbohydrate (20-30 g/day) diet) has shown great efficacy in managing seizures in epileptic children (there’s even one case report that I know of successfully using this diet over 15 months in a child with both epilepsy and type 1 diabetes).  Impaired growth, dyslipidemia and other side effects have been reported, however, a recent prominent study of epileptic children reported that the short-term side effects of following a ketogenic diet (usually for about 2 years total) were not associated with negative outcomes over the long-term.   I think caution should be used when thinking about this diet in type 1 diabetic children without epilepsy.  This isn’t a life long diet for epileptic children (as it would be for type 1 diabetics) and its hard to say if the risks would outway the benefits at this point. 

There are proponents such as, Dr. Richard Bernstein, who is a type 1 diabetic himself, of the ketogenic type diet for diabetics (30 g/day carbohydrate, no limits on protein or fat).  There are many case reports of improved lipids and diabetic control in adults with type 1 diabetes using this type of diet.  To my knowledge, except for one chart review of 30 patients, there are no other studies using this type of diet in type 1 diabetics.  Adults may consider this an option for managing type 1 diabetes with diet (under proper medical supervision due to possiblities of hypoglycemia, ketoacidosis, other critical situations and possible nutritional deficiencies).

Paleo diet

The “paleo” approach is really a type of low carbohydrate diet. There are some pluses to the “paleo” diet approach as, generally, it is focused on whole foods, eliminates processed foods, refined sugars and is lower in total carbohydrates than the standard diet.  There are so many versions of the “paleo” diet, and because of this, I believe that it may promote some imbalances - especially for those that focus on the meat-eating aspects of the diet.  If the high animal protein component is not properly balanced with alkaline foods this can promote acidity (not healthy long term, especially for someone with diabetes).  In addition, the high animal protein focused “paleo” approach may promote an imbalanced fat intake – higher saturated/unhealthy omega-6 fats versus healthier monounsaturated and polyunsaturated fats.  Since there is evidence that the type of fat you consume is important for health, I think this an important point especially for diabetics who are at risk for other health conditions such as, cardiovascular disease.  In general, saturated fat is not "bad", but a high intake of animal protein (especially of processed meats, factory farmed animals, red meats) is not necessarily good and saturated fat shouldn’t be a major fat source. 

There is one long-term study in adult type 1 diabetics linking a low carbohydrate diet (15-20% of total calories, protein 30% of total calories, fat 50-55% of total calories) with improvements in glycemic control, lipids and reduced insulin dosages.  Of note, the researchers excluded starchy vegetables, pasta, rice, cereals and most bread except for “dense” bread  (think whole foods based, sprouted grain, higher fiber). No refined sugars or other high glycemic impact carbohydrates were allowed (a very low glycemic load diet).  No episodes of severe hypoglycemia were reported. With appropriate modifications, certain aspects of the “paleo” diet approach (mostly as a lower carbohydrate, low glycemic load diet with a whole foods emphasis) may be a good option for managing type 1 diabetes. (*If you are a diabetic with impaired renal function a high protein diet is not for you as it is will overburden your kidneys).

 

Managing Type 1 Diabetes with Diet: A Family’s Amazing Success Story

Have you ever heard of a type 1 diabetic who doesn’t require insulin?  It may be hard for some of you to believe (it was for me too!), but Gabriel and Nathan Roman, now 11 and 15 years old, have never required insulin and their parents report of others that have gotten off of insulin, decreased their insulin dosage, no longer have autoantibodies or dramatically improved their blood sugar control and HbA1C results.

Although this sounds too good to be true, through a lot of hard work and aggressive nutrition and lifestyle intervention (what they call the “diabetic-alkaline lifestyle”) their two type 1 diabetic boys have never required insulin.   Although these are only two case studies, they report excellent results going on 5 years and have reportedly helped many other type 1 diabetics and their families improve blood sugar management.  Hopefully, some research will come out of their work.

I think Dan and Sally Roman, parents of Nathan and Gabriel, are way ahead of their time.   They appear to have done their homework (Sally is also a Registered Nurse), understand that their “lifestyle”, while reversing how the diabetes is “expressed” (ie. beta cell preservation and insulin production, near normal blood sugars), is not a cure, acknowledge that not everyone is going to have the same results as their sons have had and appear open to new research and insights on the subject that may lend itself to necessary modifications.

Here are the basics of their low glycemic load, diabetic-alkaline lifestyle for managing type 1 diabetes (this is taken from a recent article written by Dan Roman):

“Low glycemic foods: The diabetic-alkaline life­style’s focus is on foods that are alkalizing to the body and extremely low in glycemic impact: We eat lots of raw, green, leafy vegetables (no starchy root vegetables), and low-glycemic alkalizing fruits such as lemons, limes, tomatoes, and plenty of avocados. Low glycemic nuts, nut flours, and nut butters such as almonds, walnuts (in moderation) and pecans are abundant in this lifestyle. We also incorporate plentiful amounts of healthy seeds into our diet, such as sunflower, pumpkin, hemp, flax, and chia seeds. (All nuts and seeds used are raw, unprocessed, and unsalted.)

Fats and Oils: Healthy fats and oils are critical to success as they provide an alternative fuel supply to carbohydrates. Among the best oils are almond, avocado, cold-pressed extra virgin olive, and coconut. Off limits are margarines, vegetable oils, trans fats, and saturated fats from factory-farmed meats. After a period of time, six months to a year to give the bowels a rest, some occasional wild-caught salmon or grass-fed meat can be beneficial for some people.

Supplements: We also include a few supplements to balance their nutrition and support our boys’ metabolisms. We strongly recommend being under the care of a qualified doctor to determine which supplements should be considered. Each case is different. Our main focus is firmly on the foods, but we believe some supplements are helpful. Fish oil rich in EPA and DHA, as well as cinnamon bark, vitamin D3, niacinamide, B complex including B12, and chlorophyll would be good supplements for your doctor to consider.

Allergenic Foods: The usual food suspects are avoided. First and foremost we eliminated sugar, high-fructose corn syrup and its derivatives, artificial sweeteners, and sugar alcohols. Both gluten and dairy are strongly associated with a higher risk of developing Type 1 diabetes, so we exclude these antigen-producing foods. Processed meats and factory-farmed meats are also avoided.”

Here’s a nutritional analysis of their diet for managing type 1 diabetes (2 weeks): Note the % of total calories from carbohydrate, protein and total and specific fats as well as the total grams of fiber per day.


The Bottom Line: What to Do?

When managing type 1 diabetes with diet, I would tend to favor a diet providing moderate quality protein, lower carbohydrate/low glycemic load, high fiber and higher in fat (quality fats in proper percentages).  As I keep emphasizing, there is no one diet that fits everyone, but I think Dan and Sally Roman’s diet is a great template to start with and then modify and personalize as needed (under proper medical supervision).  In an email conversation I had with Dan Roman he mentioned that he considers this diet “mildly ketogenic” (nutritional ketosis – different than ketoacidosis), which is something to monitor, but its not anywhere near the realm of the standard very low carbohydrate, ketogenic type diet (20-30 g/day) at 196 grams of carbohydrate/day with about 75 grams not from fiber.   

Learn about them and their Health-e-Solutions Lifestyle for Type 1 Diabetes.  They offer information for managing and optimizing  type 1 diabetes with diet, healthy recipes for children with type 1 diabetes (that kids actually like!), home study courses, workshops, and other practical resources.  Subscribe to their newsletter to get a better feel for their philosophy and the science they look at - see if it connects with you.

*Sidebar: All of this is easier said than done, especially if you’ve been taught and managed your type 1 diabetes only by carbohydrate counting.  I understand this in some manner due to watching my brother and sister-in-law put in alot of hard work on a daily basis with their type 1 diabetic son.  There is no magic diet for managing type 1 diabetes that works for everyone.  Sysy Morales, an adult type 1 diabetic, recently interviewed Dan and Sally Roman about their diabetic-alkaline diet and lifestyle for managing type 1 diabetes and I thought her introduction and concluding statements really spoke in a way that only someone that has personally dealt with this condition can:

“… I was as confused and shocked as you when I first heard of this. I ask that you please keep an open mind as you read this.  No one has to feel compelled to do as they have done, however to say what they are doing is a lie or a scam, without having infinite knowledge about type 1 diabetes or what they’re doing is exercising ignorance and I know we can all rise above that. It benefits us all to learn more about what they’ve done and to think about how this information could be used by our diabetes researchers…

 …If you’re feeling a pang of jealousy as I had initially, understand this is due to the amount of suffering we have endured at the hands of type 1 diabetes… This doesn’t mean anyone judges anyone for not being willing to try it or sacrifice certain foods. It’s a personal decision that should be respected. However, having access to information and opportunity is something we all deserve. The chance to decide for ourselves how we go about tackling our diabetes is essential.”


This is a general discussion about managing type 1 diabetes with diet - a very complex condition.  Check out my references and links for more information (both on this page and “diabetes and diet” page – see below link).  I hope this page has given you some new information about managing type 1 diabetes with diet as well as resources that will lead you down a path of better health and vitality.


Home > Diabetes and Diet > Managing Type 1 Diabetes with Diet


10/2013

Some references: Lipski, E. Digestive wellness, 2012;   Sildorf, SM et al. Remission without insulin therapy on gluten free diet in a 6 year old boy with type 1 diabetes mellitus. BMJ Case Report. 2012: doi: 10.1136/bcr.02.2012.5878;    Patel, A et al. Long-term outcomes of children treated with the ketogenic diet in the past. Epilepsia, 2010; 51: 1277-1282.;   Nielson, JV et al. Low carbohydrate diet in type 1 diabetes, long term improvement and adherence: a clinical audit. Diabetology and Metabolic Syndrome 2012;4:23: doi:10.1186/1758-5996-4-23.;   O’Neill, D. et al. The Effects of a Low-Carbohydrate Regimen on Glycemic Control and Serum Lipids in Diabetes Mellitus. Metabolic Syndrome and Related Disorders. December 2003, 1(4): 291-298. doi:10.1089/1540419031361345.;   Crouse, J. et al. Glycemic Index, Glycemic Load, and Blood Glucose Outcomes in Adolescents With Type 1 Diabetes Mellitus. ICAN: Infant, Child, & Adolescent Nutrition. 2013: doi: 10.1177/1941406413498414.;  The efficacy of carbohydrate counting in type 1 diabetes: a systemic review and meta-analysis;   Natural Medicines Comprehensive Database

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