As a pediatric diabetologist, my primary concerns in regard to patients with diabetes are:
- Appropriate growth and development
- Excellent quality of life
- Adequate control of both hyper and hypoglycemia
These goals, however, are not always in the same order at all times. Sometimes I am more concerned about quality of life than I am concerned about the hb A1c, even with the knowledge that tight glycemic control will hopefully prevent diabetes micro and macro complications in the future. At other times I am very concerned with growth and development and therefore tight control of diabetes is most important. As difficult enough as it is for the healthcare team managing diabetes, juggling these three issues, it is even more difficult for the family as each day brings new challenges. So, upon reading one of the diabetes self-management journals (Franzisker, S., Carbohydrate Restriction-Another option for Diabetes Management, Diabetes Self Management, March/April, 2014, p20-25) this week, the topic of low carbohydrate diet and blood sugar management was discussed once again.
The topic of low carbohydrate diet as a means to control blood glucose is not new; indeed Dr. Richard Bernstein (who has type 1 diabetes) has written in detail about his method of diabetes management leading to tight control and low hb A1c’s. Conceptually, a low carbohydrate diet leading to lower blood sugars makes outstanding sense. Indeed, the management of diabetes before the discovery of insulin relied on NO or limited carbohydrate diets (even alcohol-based) to enable survival of those who were unable to produce insulin. It made sense that the individuals that produced some insulin, those with type 2 diabetes, had greater survival.
My conundrum: how does a healthcare provide (especially a pediatric provider) accomplish all three goals with a low carbohydrate diet? There is much controversy in this regard among all the different specialties that care for people with diabetes. The pediatric dieticians, as well as care providers, are very much concerned with having enough carbohydrates in the diet for growth and development and perhaps even more importantly, quality of life concerns.
Quite simply, it is very difficult to stick to a low carbohydrate diet for long periods of time
I am aware that many adult endocrinologists and particularly cardiologists are strongly recommending low carbohydrate diets for their adult patients with type 2 diabetes. This makes sense; but once again, adherence is a major factor. In regard to type 1 diabetes management for our children and adolescents, the low carbohydrate diet is much more controversial. It is hard enough as it is to restrict carbs in terms of carbohydrate prescriptions, let alone asking a child to vastly restrict carbohydrates for the foreseeable future. There are additional concerns with children and adolescents aside from the obvious growth and development issue. There are also concerns around fitting in with peers and concerns about being "different." This is even more of a concern with adolescents whose developmental task is risk taking and defiance against rules. Although there are adolescents who would be willing to adhere to a low carbohydrate diet, most would find it extremely difficult which would then lead to more disappointment and feelings of failure in an already difficult situation.
What about those children and adolescents with celiac disease (gluten in tolerance)? My understanding is that many gluten-free products actually are more carbohydrate laden, which would increase the difficulty of adhering to both a gluten-free and low carbohydrate diet!
So what can we conclude?
- It would be very difficult to ask a child or adolescent with type 1 diabetes to adhere to a low carbohydrate diet. Instead, I suggest that the family do their very best to try to maintain enough carbohydrates in the diet to allow for growth and development by obtaining a carbohydrate prescription from their dietician.
- Quality of life is extremely important for everyone! If the child/adolescent is miserable trying to adhere to a low carbohydrate diet, attempts at glycemic control will be thwarted- eventually. I would even suggest that the child/adolescent try to engage in the same activities, food, or otherwise in an attempt to be like their peers. By doing so, however, they need to be able to hone their diabetes self-care skills by frequent blood glucose monitoring, carbohydrate counting and appropriate insulin administration with diligence and skill. This is not an easy task.
- For children/adolescents/ adults with type 2 diabetes, a very different scenario emerges. Weight loss, in association with diet and exercise, is essential! However, once again, for children and adolescents, adherence to a low carbohydrate diet is extremely difficult. Thus, efforts to perhaps decrease the amount of carbohydrates in the diet would be extremely prudent under the guidance of a dietician who understands the need to balance both medical outcomes with psychosocial needs.