Sarah Rice BSc. (Hons), MCOptom (UK), MHP, NNP
November is Diabetes Awareness Month, and while new TCR research in type 2 diabetes is published almost every month, data on type 1 diabetes remain relatively rare in academic publications. Recent months have seen an upward trend in publications on TCR in type 1 diabetes, giving much-needed attention to this area.
Type 1 diabetes more often affects a younger population. It is an autoimmune condition that attacks the beta cells of the pancreas and dramatically reduces insulin production. This insulin deficiency leads to hyperglycemia and other symptoms that require insulin self-medication in order to normalize the physiology. Before the discovery of insulin, this condition was always fatal, marking this discovery as a pivotal moment in the treatment of type 1 diabetes. Initially, insulin was given in conjunction with recommendations to adopt a low-carbohydrate approach, but over time over time, a more liberal approach gained favor—using carb counting and insulin dosing (1). Despite advances in medical technology over time, not only is the prevalence of type 1 diabetes increasing, but the majority of those diagnosed fail to meet the blood glucose goals set by the various medical institutions (2). A low-carbohydrate dietary approach reduces the amount of mealtime insulin dose (basal insulin is still required) and has been shown to improve glycemic control.
One population expected to see a significant increase in the development of this condition is the under 15 age group. Two recent papers investigated the use of a low-carbohydrate diet for children and young people compared to other approaches and found it to be safe and effective.
Levran et al. compared a low-carbohydrate (LCD) and a Mediterranean diet (MedD) for 6 months. LCD results were comparable to MedD but showed more time in the range and lower insulin doses for improved glycemic control. As higher insulin doses are associated with an increased risk of insulin resistance in the patient with type 1 diabetes, these are important findings (2).
Neumann et al. deliveries of randomized calories in a lower carb food box (note, not very low carb) of about 95 g/day or a recommended carbohydrate diet of about 200 g/day. The LCD group showed significantly higher time in range, with less time spent with elevated blood glucose and a lower average blood glucose (3).
In both studies, the LCD groups reported no adverse events. Overall, the results suggest that a low-carbohydrate approach is feasible and may provide additional benefits to people with type 1 diabetes.
A new systematic review by Paul et al. examines the effectiveness of the low-carbohydrate approach as presented in the literature and also reports on the lived experiences of adults with type 1 diabetes. Examination of lived experiences included consideration of enablers (motivators and benefits) and barriers (limited information and implementation challenges). Overall, the review could not make a definitive statement about the low-carbohydrate approach for efficacy in improving HbA1c, but reported that a reduction in HbA1c of ≥0.5% was associated with reduced bolus insulin and weight and improved quality of life ( 4). Not everyone has found a low-carb approach easy to implement, so appropriate support through health professionals experienced in this approach could be important to success.
Type 1 diabetes is a challenging condition that requires daily management, where decisions have both immediate and long-term consequences. It is thought that 40-60% of people with type 1 diabetes experience ‘diabetes distress’ as a result of this burden. A case study from Winje et al. reports of a person with significant symptoms of diabetes distress who met diagnostic criteria for phobia (fear of hypoglycemia and insulin) and depression. The clinical team discussed the benefits of a ketogenic diet as a reasonable solution to reduce insulin requirements and provided detailed information to ensure the safe implementation of this approach (see paper for details). Within 2 weeks, a steady decrease in blood glucose concentrations and an improved mood began to relieve diabetes symptoms:
“In an extremely short period of time, I noticed significant improvements. With each passing day, I felt myself regaining my vitality” (5).
These data highlight the need for more research and education on the role of TCR for the management of type 1 diabetes in order to ensure appropriate informed consent and support for this approach within an individualized treatment plan.
The Metabolism section of Nutrition Network’s reference resource has an extensive list where you can read more about implementing therapeutic carbohydrate restriction (TCR) for type 1 diabetes.
The Nutrition Network offers educational modules where you can learn more about TCR for diabetes management for both clinicians and patients.
1. Wood M, Ebe K, Bando H. Prolonged honeymoon period in patients with type I diabetes (T1D) on a low-carbohydrate diet (LCD). Asp Biomed Clin Case Rep [Internet]. October 24, 2023 [cited 2023 Nov 20];6(3):248–53. Available from: https://asploro.com/prolonged-honeymoon-period-in-type-i-diabetes-t1d-patients-on-low-carbohydrate-diet-lcd/
2. Levran N, Levek N, Gruber N, Afek A, Monsonego-Ornan E, Pinhas-Hamiel O. Low-carbohydrate diet proven effective and safe for youth with type 1 diabetes: A randomized trial. Acta Paediatr. October 16, 2024;
3. Neuman V, Plachy L, Drnkova L, Pruhova S, Kolouskova S, Obermannova B, et al. Low-carbohydrate diet in children and youth with type 1 diabetes: A randomized controlled trial with a cross-over design. Diabetes Research and Clinical Practice [Internet]. November 1, 2024 [cited 2024 Sep 10];217:111844. Available from: https://www.sciencedirect.com/science/article/pii/S016882272400754X
4. Paul J, Jani R, Thorning S, Obucina M, Davoren P, Knight-Agarwal C. Low-carbohydrate diets, glycemic control, enablers and barriers in the management of type 1 diabetes: a mixed methods systematic review. Diabetes & Metabolic Syndrome [Internet]. November 2, 2024 [cited 2024 Nov 4];16:261. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11531154/
5. Winje E, Lake I, Dankel SN. Case report: Ketogenic diet alleviated anxiety and depression associated with management of insulin-dependent diabetes. Forward Nutr [Internet]. October 30, 2024 [cited 2024 Oct 30]11. Available from:
