Pediatric patients with Type 1 diabetes benefit from carbohydrate counting

The world of Type 1 diabetes care has been dramatically transformed in recent years by technologies such as continuous glucose monitoring and automated insulin pumps, but a new report underscores the importance of a decidedly low-tech method of glycemic control: counting carbohydrates.

A new review article examined more than a half-dozen studies of children and adolescents to see whether carbohydrate counting led to a meaningful benefit. The results showed that patients who counted carbohydrates had lower hemoglobin A1c (HbA1c) compared to those who did not. The report was published in the International Journal of Pediatrics.

The cornerstone of Type 1 diabetes therapy is insulin therapy, which replaces the pancreas’ insulin-producing role. But because carbohydrates are fully converted into glucose in the body, managing carbohydrate intake can also be a helpful strategy to maintain blood glucose control, explained co-author Tiago Ricardo Moreira, M.S., Ph.D., of Brazil’s Federal University of Vicosa, and colleagues.

“This approach offers a more flexible diet for people with diabetes by tailoring the insulin dosage to the amount of carbohydrates consumed,” they noted, adding that such strategies can also have long-term benefits by reducing the risk of complications from Type 1 diabetes.

Carbohydrate counting requires patients to monitor their blood glucose before and after meals, calculate how many carbohydrates they have consumed, and then adjust their insulin dose accordingly. Yet, the authors said carbohydrate counting remains "underutilized."

“This is due to several factors, such as the complexity of the process, insufficient training for both parents and healthcare providers, patient resistance (due to feeling overwhelmed by the number of calculations required at each meal), and lack of continuous support, which can discourage adherence to the method,” they said.

Given the apparent mismatch between the strategy’s utility and its utilization, the investigators wanted to gain a better understanding of its impact. They searched for studies published between 1993 and August 2024 in which carbohydrate counting was analyzed in children and adolescents with Type 1 diabetes. Moreira and colleagues found a total of seven studies that together involved 599 patients. Of those, 276 patients were members of study control groups, and 323 were part of intervention cohorts.

The studies used different intervention strategies, but they consistently showed that patients who used carbohydrate counseling had superior reductions in HbA1c. The studies reported carbohydrate counting-associated reductions in HbA1c ranging from -1.35% to -0.73% compared to controls. The final mean reduction among all of the studies was -0.94%.

Moreira and colleagues said the carbohydrate counting methods used in the studies ranged from basic methods in which patients calculated their own insulin doses with or without the help of digital tools to the use of automated bolus calculators, which do the calculations for patients. The studies also compared patients with experience counting carbohydrates to those without experience. A subgroup analysis suggested that patients who were experienced at using automated bolus calculators experienced the greatest reduction in HbA1c.

“Familiarity with the method likely results in fewer errors when calculating carbohydrate amounts, fewer deviations related to meals, and greater ease in applying the method in challenging situations, such as parties or festive occasions,” the authors said.

The investigators cautioned that there were important differences between the studies in their analysis. For instance, the studies did not uniformly collect the same data. Thus, they said certain factors, such as diabetes duration and insulin types, could not be compared across trials.

Even with those differences, though, Moreira and colleagues said the data suggest that patients experience better outcomes when they incorporate carbohydrate counting, particularly if they use automated bolus counting.