How many carbs can a diabetic have in a day?

Type 1 diabetes is considered as the most difficult to treat globally. Insulin is required and needs to be injected four or more times daily. And despite the knowledge on Type 1 diabetes and the availability of multiple devices and medications, it is still considered very difficult to manage the disease without low and high sugars.

Currently in India, it is estimated that there are approximately four lakh people, a majority of them children, affected with Type 1 diabetes. So, when administering insulin either via syringe or through affordable insulin pumps, there are chances that glucose will remain persistently high or when the parents are attempting to reduce it to acceptable levels, it can go below 70 mg/dL or even 54 mg/ dL, which can at times be life-threatening. Persistently high glucose levels, which are so common in Type 1 diabetes, after approximately 10-15 years, result in involvement of the kidney, heart, nerves, eye and so on. In children, Type 1 diabetes is also known to be one of the major reasons for cognitive impairment, mood swings and psychological disorders.

In a study carried out at Jothydev’s Diabetes Centre in Kerala, we found that with the use of simple technologies, integrated with a live conversation and communication with a team of experts, which consist of not only doctors but also dietitians, diabetes nurses, diabetes educators, pharmacists and phycologists, there was a significant reduction in the average glucose along with the benefits of negligible episode of hypoglycemia. Because whenever we attempt to treat Type 1 diabetes to reach acceptable glucose goals, the patients will always have a risk of hypoglycemia. It is estimated that the risk of serious hypoglycemia is as high as 40 – 50 per cent in general in Type 1 diabetes, one of the major reasons for limited lifespan which is observed globally.

But recently, the lifespan has improved a lot because of the use of technologies and emerging new knowledge in the management of the disease. And in this study, the patients as well as their parents were empowered; so, the responsibility of treating diabetes has been shifted by continuous counselling, training and education.

What is carb counting?

Carb counting means counting the number of grams of carbohydrate in a meal and matching that to your dose of insulin. For example, before a meal, you must account for each carbohydrate gram you eat and your insulin based on it. You can use what’s known as an insulin-to-carb ratio to calculate how much insulin you should take in order to manage your blood sugars after eating. You also have to factor in protein and the fat component in foods as they have a key role in satiety and how quickly the body absorbs carbohydrates.

Carbohydrate counting, though it has been known for several decades, is hardly practised in the management of diabetes. And this is dealt with by expert dietitians, where they will calculate the amount of carbohydrate, which is consumed in a particular diet, and depending upon the individual and the specifics of what he requires, will decide on the insulin to be administered; that is the rapidly acting insulin.

The amount of insulin which is required will differ from one patient to another. The quantity of carbohydrate in the diet is also customised.

Study shows need for multi-disciplinary therapy (MDT)

Though carb counting sounds very easy, it is a difficult tool to use. And in the study, there were two groups. Both were trained on carbohydrate counting. But one group tried to do it by themselves throughout the course of the study whereas the other group received constant education and support for each main meal and snacks they were consuming. They were interacting directly with professionally trained multi-disciplinary team members. And each patient had a dedicated WhatsApp group for communication in addition to routine telemedicine visits.

The patients were on different management tools; some of them were on injectable insulins, a couple of them were on insulin pens. And for glucose monitoring, some of them were using glucose meters. Others connected glucose meters via Bluetooth, communicating live to the hospital and a couple of others were using Continuous Glucose Monitoring devices. But uniformly those who were constantly getting trained and empowered showed a significant improvement in the outcomes.

There were a total of 50 patients with Type 1 diabetes between the ages of five and 35 years with an average diabetes duration of six months and all of them had uncontrolled diabetes at the time of enrollment in this study.

Need for sustained management support

Our assumption is that during hospital visits, patients might get trained in many aspects of management of diabetes, including carbohydrate counting. But training and teaching them during the hospital visits may not help them manage the disease on their own. They might require continuous support and training for at least three to six months so that the majority of them get empowered for self-management of the disease.

The quality of life in Type 1 diabetes patients is somewhat different from the rest of the population since disease management requires a high degree of patient involvement, i.e., frequent glucose monitoring, carbohydrate estimation, dose adjustment, insulin injection, planning of the meal, and therapeutic adjustments to physical activity and so on. In our study, we found that the MDT-assisted group had a more positive outlook on life according to the response to the questionnaire after the study.

How carb counting improves your social life

Subjects in both groups, 100 per cent of the control group and 91 per cent of the test group, worried about the future, and 100 per cent of both groups were able to maintain their friendships and social life. However, when it came to other factors, much less of the control group subjects replied positively to freedom to eat as they wish (36 per cent), enjoyment of food (36 per cent), physical activity (48 per cent), enjoying holidays or leisure activities (68 per cent), freedom to drink as they wish (72 per cent), while 100 per cent of the MDT-assisted group replied positively.

The difference was even more obvious when only 32 per cent of the control group were confident of their ability to estimate the insulin dose, which is crucial in Type 1 diabetes management, versus 100 per cent of the test group. Also, 100 per cent of the test group subjects reported self-confidence and motivation to achieve things, while only eight per cent of the control group were self-confident, and only 32 per cent reported motivation to achieve things.

It was found that continued assistance from an MDT of experts, along with technology-enabled education programs, permitted Type 1 diabetes patients to achieve glycaemic control through meticulous carbohydrate counting. Using carbohydrate counting and adjusting the insulin dose enable the patient to eat freely. Significantly lower HbA1c levels and fasting and post meal glycaemic levels, compared to the non-assisted group, were observed.

We observed that despite most patients finding it difficult to fully understand the concepts of meal planning and carbohydrate counting, it was possible to get good results with a little extra help from their healthcare teams. In the MDT-assisted patients, the extreme glycaemic variations often seen associated with Type 1 diabetes and its treatment were also found to be under control.

Carbohydrate counting remains a challenge for youth with Type 1 diabetes and their families, and errors in counting can have a clinical impact. Our data suggested that assistance from a multidisciplinary team of experts in diabetes management can improve carbohydrate counting, leading to improved glycaemic control and fewer diabetes-related complications. This enables the patients to be more in control of their dietary habits and physical activities, thereby lessening the burden of living with Type 1 diabetes.

It is a truth that in India more than 90- 95 per cent of the diabetes is not controlled, whether it is Type 1 or Type 2. This is not only depressing but it also increases the cost of treatment by more than five to 10-fold. We need to find reasons, and we need to evolve our own customised solutions to bring down the burden of diabetes- induced complications.