The Society of Metabolic Health Practitioners (SMHP™) is proud to share its position on an innovative nutritional intervention for type 1 diabetes mellitus (T1DM): Therapeutic Carbohydrate Reduction (TCR). This consensus, reached after an extensive Delphi process involving experts in the field, represents a pivotal moment in advancing how we approach this challenging autoimmune condition.

Despite breakthroughs like hybrid closed-loop insulin systems and continuous glucose monitoring, individuals with T1DM still face high rates of complications and suboptimal outcomes. Only 21% of adults with T1DM in the U.S. achieve the American Diabetes Association (ADA) target A1C of <7.0%, and outcomes are even worse for children and adolescents. Insulin resistance in T1DM, an independent risk factor for complications, exacerbates the challenges.

The SMHP believes it’s time to re-evaluate traditional dietary guidance for T1DM and embrace TCR as a viable, evidence-based approach to improve glycemic control and quality of life.

Doug Reynolds, President of the SMHP, explains:
“This is a huge step forward in the quest for the SMHP to become the de facto source of information for nutritional and lifestyle therapies to support metabolic health. This came about predominantly as a result of the type 1 diabetes workshop and focus day that we had at our symposium in Boca Raton back in January this year.”

Why Therapeutic Carbohydrate Reduction?

TCR emphasizes a significant reduction in dietary carbohydrates to stabilize blood sugar levels, lower insulin requirements, and reduce glycemic variability. Unlike traditional high-carbohydrate approaches, TCR aligns insulin dosing with dietary intake in a way that minimizes the swings in blood sugar that are so difficult to manage with T1DM.

The SMHP’s position is grounded in mounting evidence. Studies show that even modest reductions in carbohydrate intake can improve glycemic outcomes, while very low-carbohydrate diets (VLCDs) have demonstrated the potential to achieve near-normal A1C levels. One observational study of over 300 participants adhering to a VLCD showed a remarkable mean A1C of 5.67% with low insulin requirements. These findings highlight the transformative potential of TCR when properly implemented.

Dr. Ian Lake, a general practitioner who has type 1 diabetes, explains:
“I have known for years that there is no suitable guideline diet for type 1 diabetes that fits my understanding of the metabolic profile of type 1 diabetes and my lived experience as someone with type 1 diabetes. Recommending a universal diet for a serious metabolic condition is helping no one. And, with no change in orthodox practice coming any time soon, it has been necessary to put our combined knowledge into a document that will set the new standard for type 1 diabetes care.”

Addressing Misconceptions About Safety

Critics often express concerns about risks like diabetic ketoacidosis (DKA) with TCR. However, research and clinical experience indicate that, with appropriate monitoring and insulin adjustment, TCR is not associated with an increased risk of DKA. On the contrary, TCR may reduce the frequency and duration of hypoglycemic episodes by lowering the overall insulin burden—a benefit observed in clinical reports and patient outcomes.

Beyond Blood Sugar: Tackling Double Diabetes

One of the more alarming trends in T1DM management is the rise of “double diabetes”—a condition where individuals with T1DM develop insulin resistance akin to type 2 diabetes. This phenomenon, driven by high insulin doses and poor dietary control, is now seen in up to 25% of people with T1DM. TCR offers a strategy to address this growing issue by improving insulin sensitivity and reducing the need for excessive exogenous insulin.

Dr. Tro Kalayjian, the first author, explains:
“The status quo is unacceptable. Patients with type 1 diabetes face insurmountable challenges, and implementing a low-carbohydrate diet shouldn’t be met with unnecessary resistance from dietitians or endocrinologists. All clinicians need to work proactively to educate and empower patients and families interested in implementing TCR.”

A Call for Systematic Change

The SMHP is urging healthcare professionals, researchers, and policymakers to prioritize TCR as a standard option for T1DM management. Key recommendations include:

• Expanding Research: Invest in randomized controlled trials to evaluate TCR’s efficacy and long-term safety in T1DM.
• Enhancing Education: Provide patients and families with accessible, accurate information about TCR as a dietary option.
• Supporting Clinicians: Develop guidelines and training programs to help clinicians integrate TCR into practice.
• Promoting Equity: Ensure that all individuals with T1DM have the opportunity to explore TCR with the support of a knowledgeable healthcare team.

Empowering Patients with Options

Every person with T1DM deserves access to treatment options that go beyond the status quo. TCR, as part of a comprehensive, individualized treatment plan, holds the promise of transforming lives by improving glycemic control, reducing complications, and enhancing quality of life. The SMHP is committed to championing this approach and fostering further research to refine its implementation.

Dr. Evelyn Bourdua-Roy explains:
“Every diabetic person deserves to know that therapeutic carbohydrate restriction is a safe and efficient option if they want to achieve normal blood sugar with minimal to no long-term complications, and that this approach is supported by science and by a growing number of experts.”

The message is clear: It’s time to embrace therapeutic carbohydrate reduction as a safe, effective, and empowering option for managing type 1 diabetes. Together, let’s rethink what’s possible in diabetes care.

Dr. Tro Kalayjian concludes:
“We desperately need more funding to not only conduct the necessary trials needed to change standards of care but also to push back against the current guidelines which demonize real-food, low-carb approaches. It is our hope that this paper will be the first of many position statements that strive to bring metabolic health to the forefront of every clinician’s mind and clinical practice. We need your help.”

“At the SMHP we are building a community,” says Doug Reynolds. “We are striving to bring all the practitioners who embrace this intervention, and all the patients who are benefiting from it, together under one roof. We encourage all practitioners, physicians, PAs, NPs, nurses, RDs and nutritionists, health coaches and all other Allied Healthcare Professionals to join as members and contribute to the work we do. Get accredited and lend legitimacy to your metabolic health practice. And to the members of the public and patients out there who want to support what we do (and to anyone who is able, really), please explore the opportunity to make a donation to our cause.”