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Recommendations Summary

T1DM: Carbohydrate Management Strategies (2024)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    T1DM: Carbohydrate Management Strategies

    In children and adolescents living with type 1 diabetes, a registered dietitian nutritionists or international equivalent should suggest carbohydrate counting or carbohydrate estimation as a strategy to effectively dose insulin to optimize glycemic management. 

    Rating: Level 2(C)
    Conditional

    • Risks/Harms of Implementing This Recommendation

      There are few adverse events reported with MNT interventions provided by an RDN for children and adolescents with T1DM. However, hypoglycemia, hyperglycemia or weight gain may result if the RDN does not select or if the individuals with diabetes cannot implement the appropriate carbohydrate management strategy. Potential harms such as financial costs (Sheils 1999), time spent at clinic visits, psychological concerns and potential for anxiety related to MNT provided by RDNs are relatively minimal compared with the potential benefits of improved nutrition status and decreased disease progression. The cost-benefit ratio of MNT provided by the RDN is unlikely to be very high and if MNT is successful, the benefits may outweigh the financial costs. Coverage for services varies by state, payor, etc, and this can lead to varying out-of-pocket costs. These costs would be anticipated to be less than the cost of continuing the reduced access/low number of RDNs. Cost is minimal compared to potential benefits, especially considering the long-term cost of ill-health to government, hospitals, etc. Prevention of additional illness could create moderate savings.

    • Conditions of Application

      RDNs should work within interdisciplinary teams to promote the implementation of nutrition care. Interdisciplinary team protocols should include nutrition screening and referral to an RDN for individualized MNT. Incorporation of nutrition screening and referral to RDNs requires coordination of administrators, and organizational policies and procedures. Issues like feasibility of implementation, values of interventions, and equity issues should be considered while developing care plans for clients.

      The primary goal of implementing these recommendations is improving client outcomes while individualizing care to your client’s preferences and health status. Although the costs of MNT sessions and reimbursement vary, MNT is significantly associated with improved client outcomes. MNT can be considered cost-effective when considering the benefits of nutrition interventions on the onset and progression of comorbidities versus the cost of the interventions. The dietary recommendation can be implemented in numerous ways and hence is easy to incorporate into practice. This recommendation can be incorporated into ongoing counseling sessions and does not require any extra resources. However, there can be some barriers to providing care and the RDN should consider these when planning interventions for their clients. Issues like lack of insurance or higher out-of-pocket costs are more likely to impact the ability of certain demographics/groups to obtain care. Diabetes complications, both short and long-term, could be more frequent for those who have access problems, costing more for the individual, family, and the healthcare system as a whole. Limited services by RDNs in some areas (eg,  rural) can also be a barrier.

      The RDN should work with both children and adolescents with T1DM and their parents/caregivers, as they play a critical part in self-management in youth. The treatment plan should focus on normal growth and development of the individual along with dietary management. The RDNs should screen and assess the educational, psychological, emotional, behavioral, and access to food status of children and work with parents/caregivers to help implement the treatment plan.

    • Potential Costs Associated with Application

      The cost-benefit ratio of MNT provided by the RDN is unlikely to be very high and if MNT is successful, the benefits may outweigh the financial costs. Coverage for services varies by state, payor, etc, and this can lead to varying out-of-pocket costs. These costs would be anticipated to be less than the cost of continuing the reduced access/low number of RDNs. Cost is minimal compared to potential benefits, especially considering the long-term cost of ill-health to government, hospitals, etc. Prevention of additional illness could create moderate savings.

    • Recommendation Narrative

      Nine studies regarding carbohydrate management strategies in pediatric T1DM reported on glycemic outcomes, body mass index outcomes and/or quality of life (Campbell et al, 2014; Dalsgaard et al, 2014; Donzeau et al, 2020; Enander et al, 2012; Goksen et al, 2014; Kostopoulou et al, 2020; Rabbone et al, 2014; Sauder et al, 2020; Spiegel et al, 2012).

      Glycemic Outcomes

      Four randomized controlled trials (Donzeau 2020, Enander 2012; Goksen 2014, Spiegel 2012) studied the effectiveness of carbohydrate counting as a strategy to manage glycemia in pediatric individuals with T1DM. There was considerable heterogeneity among the comparator group or control group in the included studies. The comparator or control groups were mostly the exchange method (fixed amount of carbohydrate per meal) or plate exchange methods, and traditional diet approaches or dietary education. All these studies had low risk of bias for all domains of bias. In a meta-analysis of four randomized controlled trials, carbohydrate counting as a strategy to manage glycemia decreased HbA1c by a mean (95% CI) of -0.241% (-0.475, -0.007)(I2=0).  Donzeau 2020 reported that advanced carbohydrate counting using insulin-to-carb ratios intervention was associated with 0.22% lower A1C after one year (P < .05), compared to traditional dietary education using fixed amounts of carbohydrates and insulin with exchange lists, and Goksen 2014 reported that the group using carbohydrate counting using insulin-to-carbohydrate ratios had significantly lower mean A1C levels (P = .010) than the group using traditional exchange-based meal plans. Whereas Enander 2012 reported no significant differences in A1C within or between groups after one year of either carbohydrate counting with a regular insulin pump, carbohydrate counting with a cozmo pump, or plate exchange methods (Enander 2012) and Spiegel 2012 reported A1C decreased in both carbohydrate counting nutrition education intervention or control group with a handout, but the results were not statistically significant (Spiegel 2012).

      These findings from randomized controlled trials are aligned with the findings of one non-randomized study (Kostopoulou 2020) and four cohort studies (Campbell 2014, Dalsgaard 2014, Rabbone 2014,  Sauder 2020). Kostopoulou 2020 reported a statistically significant reduction in A1C when subjects followed Period B (proper prandial insulin dosing based on the amount of carbohydrates contained in each meal) for four months compared to Period A (standard insulin dosing per meal) for four months (P < .001). Four cohort studies (class B evidence, Campbell 2014, Dalsgaard 2014, Rabbone 2014,  Sauder 2020) report similar results. Campbell 2014 reported that subjects with excellent glycemic targets (A1C <7%) were more likely to use meal-specific insulin:carbohydrate ratios (P < .001) than those with poor glycemic targets (A1C ≥9%) (Campbell 2014). Dalsgaard 2014 reported a significant difference in the percentage of adequacy of A1C (P = .000) after one year of Carbohydrate Counting/Carb Exchange Lists (CCHO, adhering to total amount of CHO at each meal) and no significant changes during one year of Traditional Diet/Caloric Exchange Lists (TD, each food exchange had 15 g CHO) (Dalsgaard 2014). Rabbone 2014 reported that when comparing patients using or not using carbohydrate counting, regardless of the automated bolus calculator, a significantly lower A1C was observed at all study points. Lastly, in Sauder 2020, A1C was lower among those who started tracking calories (−0.4%, P < .05) or often counted carbohydrates (−0.8%, P < .001) compared to those with less use (Sauder 2020). The evidence on this topic is characterized by a few well controlled experimental studies, small sample sizes, and heterogeneity in interventions and comparator groups. The certainty of evidence was very low quality.

      Hence, to summarize, in children and adolescents with T1DM, low quality evidence suggests that carbohydrate counting (using insulin-to-carbohydrate ratio) can be an effective strategy to help reduce and provide continued maintenance of A1C goals. Small improvements in quality of life scores and overall confidence in prescribed dietary advice compared to other carbohydrate management strategies like carbohydrate consistency, plate method or exchange lists/food lists/carbohydrate choices were identified.

    • Recommendation Strength Rationale

      The certainty of evidence was very low quality

    • Minority Opinions

      None.