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ADA: Relooking at Carb Counting in T1D

Jun 26, 2013
The evidence for counting carbs is not substantial….

Kirstine Bell, a PhD candidate at the University of Sydney, reported in a review and meta-analysis of six randomized, controlled trials, carbohydrate counting slightly improved glycemic control with a mean drop in glycated hemoglobin (HbA1c) of -0.3%, but it wasn’t significant (P=0.185).

"There’s limited evidence to recommend carbohydrate counting over other dietary interventions for improving glucose control in type 1 diabetes," Bell said. "And it’s concerning that there are only six studies that could be identified when this is such an integral element of diabetes management in type 1 diabetes. It affects the management of millions of people around the world."

Carbohydrate counting is the best known method for matching insulin dosing to meals, and is the recommended dietary strategy for achieving glycemic control in type 1 diabetes, though that recommendation has been largely based on expert consensus, Bell said.

To assess the state of the literature, she and colleagues conducted a review and meta-analysis of carbohydrate counting trials in adults and children with type 1 diabetes. They ultimately included six studies with a total of 563 adults and 104 children conducted between January 1980 and April 2012.

Overall, there were five adult studies and one pediatric trail that included children, ages 8 to 13. Five trials had a parallel group design while one involved a cross-over. All trials lasted at least 3 months and compared carbohydrate counting with usual care, which consisted of either general nutrition advice or low dietary glycemic index (GI) advice.

For their analysis, Bell and colleagues set the primary outcome of change in HbA1c, and secondary outcomes included hypoglycemia, insulin dose, weight change, fasting plasma glucose, and quality of life.

Researchers found a decrease in mean HbA1c with carbohydrate counting compared with usual care (-0.3%), but it wasn’t significant (P=0.185). They were unable to conduct an analysis of secondary outcomes because of the low number of studies and inconsistencies in their reporting metrics.

They did, however, find a trend toward reduced risk of hypoglycemia and improved quality of life with carbohydrate counting. On the other hand, there were no changes in insulin dosing, weight, or fasting plasma glucose.

Bell cautioned that the efficacy of carbohydrate counting may be limited by patients’ ability and commitment to managing their diet. Studies have shown that greater accuracy and precision in carbohydrate counting have been associated with greater declines in HbA1c, she said.

She concluded that her study suggests the evidence to recommend carbohydrate counting as standard therapy in type 1 diabetes glycemic management is limited, and more work needs to be done. However, she acknowledged that carbohydrate counting is so routine in practice, finding a control group would be challenging.

"It’s still the best known method for matching insulin to meals," she concluded, "but our study highlights the need for further research."

Practice Pearls:

  • The standard practice of counting carbohydrates to better manage postprandial glycemic control in type 1 diabetes may not have substantial evidence behind it.
  • This study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Bell K, et al "The efficacy of carbohydrate counting in type 1 diabetes: A systematic review and meta-analysis" ADA 2013; Abstract 164-OR.