Reconsidering the Definition of Type 1 Diabetes: World Diabetes Day 2020

On the occasion of World Diabetes Day 2020, I propose we reconsider the official definition of Type 1 diabetes, which says almost nothing about carbohydrate intolerance.

If you live with diabetes and you pay attention to your health, you know that perhaps the single unavoidable fact of your condition is that your body cannot handle carbohydrates normally, and that you need to be critically aware of your carbohydrate consumption. This fact should be part of all of the most basic explanations and descriptions of the disease. But it isn’t.

Go ahead and look at the explanations of Type 1 diabetes from respected sources like the Mayo Clinic and the CDC. You won’t find a word that indicates the extreme importance that carbohydrate intolerance plays in the day-to-day life of a person with diabetes. Oh, you might find a few references to a “healthy, balanced diet,” but this only serves to suggest that people with diabetes have exactly the same nutritional needs as everyone else. They do not. Carbohydrate intolerance needs to be considered as the most decisive factor in the design of any diabetic diet.

The truth is that we used to know that people with Type 1 diabetes had to eat differently. A couple generations ago, newly diagnosed patients were usually taught to limit sugar intake, to eat consistently, and to limit carbs to a moderate amount. Type 1 diabetes wasn’t easy back then—slower insulins and paltry blood glucose monitoring made managing blood sugar a very challenging task. It was understood that eating with consistency and restraint would make it easier to dose insulin accurately, and to avoid hypoglycemic events.

Nowadays, many patients are still encouraged to eat carbohydrates throughout the day to ward off hypoglycemia, advice that has arguably become obsolete due to advances in insulin quality and blood sugar monitoring. More strikingly, the recommended amounts of carbohydrates have increased. This began in the 1980’s, when the US government put grains at the bottom of the food pyramid. Today the official dietary guidelines recommend that Americans eat 45-65% of their calories in the form of carbohydrate. This recommendation is bad enough for healthy adults, and a major driver of the epidemics of Type 2 diabetes and obesity. For patients with the impaired carbohydrate tolerance characteristic of Type 1 diabetes, it is potentially disastrous.

Diabetes outcomes are getting worse, not better, and this is despite all of our rapidly improving management technology. This decline is caused by the recent rise of a new idea: that insulin “cures” carbohydrate intolerance and that therefore people with diabetes can eat whatever they wish. This is a fiction. Even our most advanced insulins are extremely inexact tools. If you have Type 1 diabetes, you know that the more carbohydrates you eat, the more insulin you need to take, both of which cause unpredictable and extreme blood sugar swings.

The idea of carbohydrate intolerance shouldn’t be in the least bit controversial. After all, doctors have used the oral glucose tolerance test (OGTT) to reliably diagnose diabetes for almost a century, and the phrase “impaired glucose tolerance” is currently used as a technical term for pre-diabetes. The problem is that these phrases are mostly buried deep within the medical literature. Carbohydrate intolerance is almost never given the emphasis it deserves.

World Diabetes Day is celebrated annually on November 14, in honor of the birth of Sir Frederick Banting, one of the co-discoverers of insulin in 1921. Banting’s remarkable story is more relevant than ever today, as we continue to weep for the ongoing insulin pricing crisis in America—and await the development of a coronavirus vaccine. Banting and his collaborators sold their patent on insulin for exactly $1, declining the chance of immense wealth in order to share it with as many patients as quickly as possible.

Banting’s spirit is still alive in the medical community. I know so many doctors, nurses and other professionals who truly live to help their patients. But too often they are inadvertently failing them by giving them dietary advice that is unhelpful or even harmful. The medical establishment needs to recognize that carbohydrate intolerance is an essential element of Type 1 diabetes.

Dr. Mariela Glandt

Dr. Mariela Glandt, trained as an internist at Harvard and an endocrinologist at Columbia University, has almost two decades experience in the treatment of diabetes. Four years ago she discovered the growing low carb movement and changed her approach to the treatment of diabetes.  She is the founder and director of Glandt Center for Diabetes Care in Tel Aviv which specializes in optimization of diabetes care through use of a very low carbohydrate diets.  Dr. Glandt is involved in clinical trials, actively publishes articles in medical journals, lectures in Israel and abroad, and teaches medical residents at Bronx Hospital in NY.   She is also the co-founder of Eatsane which makes low carb food products with no artificial sweeteners.