The Honeymoon Period in Type 1 Diabetes
We recently discussed the top 10 concerns related to a new diagnosis of type 1 diabetes. Following these concerns, families then often talk about the “honeymoon” period.
What is the honeymoon period? Most kids/teens/adults with new onset type 1 diabetes have experienced symptoms and signs due to the absolute lack of insulin, such as increased drinking, increased urination, and weight loss. These symptoms are due to the body’s inability to transport glucose into the cells through the loss of insulin production. Glucose builds up on the blood and an increased amount of fluid is consumed to allow for its elimination and the cycle is perpetuated. Due to the loss of the energy efficient glucose/insulin pathway, fat is metabolized for energy using a less efficient pathway with production of ketones, which leads to the possibility of diabetic ketoacidosis.
Keep in mind that in many children, teens, and adults with newly diagnosed diabetes, not all of the pancreatic islets have been destroyed. To exhibit symptoms of diabetes, approximately 80 percent of the pancreatic islets are either destroyed or non-functional. Therefore, 20 percent still may be remaining. After initiation of insulin, aerobic metabolism (the efficient energy pathway) is resumed and glucose may be transported into the cells and metabolized for energy. In anthropomorphic terms, the body “breaths a sigh of relief,” and normal metabolism can resume. After the body starts utilizing glucose and the high amounts of glucose bathing the islet cells in the pancreas (glucose toxicity) are decreased, the remaining islets may begin to recover the ability to produce insulin, resulting in the honeymoon period. This process does NOT occur in all patients and it sometimes takes several weeks to a month to start noting the production of the body’s own insulin (endogenous insulin).
How do you know that you have entered the honeymoon period? Generally, once insulin is started, one notes that over the course of days to weeks, blood sugars and the variability of the blood sugars have decreased. Blood sugars that were formerly in the 200-300 range now have decreased to near normal levels in the 100s and even 70-100 range. To prevent lows, your diabetes team will start to decrease the amount of injected insulin. Generally, however, you remain on some insulin to deter future destruction of those islet cells. There are research studies focused on prolonging the honeymoon period. The honeymoon period also allows for the islet cells to rest as injected insulin is working as an assist. It is unclear how long a honeymoon period may last; it could be several months to more than a year. It is different for each individual with type 1 diabetes.
The biggest question is how someone can prolong the honeymoon period. Clearly, the longer you prolong the honeymoon period, the longer you have control of blood sugars and the chance to delay potential, future complications related to high blood sugars. This is a huge question prompting much funding and research. Doctors and scientists do know that remaining on small amounts of insulin seems to prolong the honeymoon period (to decrease the “glucose toxicity” surrounding islet cells). Other suggestions include the initiation of a low carbohydrate diet. If one consumes low amounts of carbohydrate, less insulin will be required to enable glucose transport into the cells and theoretically cause less stress on the islet cells. Ironically, the low carbohydrate diet was the treatment of choice before the discovery of insulin to avoid the symptoms resulting from the inability of the islets to metabolize glucose. These children starved and looked extremely malnourished based on photographs included in past journal articles of the “founders” of insulin, Banting, Best, and Mcleod. I am aware of no studies that have positively demonstrated that a low carbohydrate diet alone will prolong the honeymoon period.
Most children, teens, and adults who present with new onset diabetes have often lost a significant amount of weight. Our treatment goals are for normalization of weight based on balanced nutritional guidelines. Our dietician usually recommends appropriate carbohydrate amounts based on age and or/weight to allow for much needed growth and development. Of course, in type 2 diabetes, weight loss might be appropriate with a different allotment of carbohydrates.
The honeymoon period and efforts at prolongation are the subjects of intensive research and discussion. At this point, I would suggest remaining on the minimal amount of insulin necessary to maintain stable blood sugars. You should also have a discussion with your diabetes team about research opportunities available.
Fran Cogen, M.D., C.D.E., is the director of the Childhood and Adolescent Diabetes Program at Children’s National Health System. She wrote about diabetes for HealthCentral.