Nutrition and Type 1 Diabetes: Do Carbohydrates Matter?
I recently had the opportunity to contribute to an upcoming text from the American Diabetes Association on nutrition therapy in diabetes care. Specifically, I was tasked with reviewing and rewriting a chapter on nutrition recommendations for adults with type 1 diabetes and insulin-requiring type 2.
In my excitement for its upcoming publication, I’d like to share a preview of some key findings on carbohydrates. Is carbohydrate counting still relevant today? Does the type of carbohydrate make a difference? And how do approaches like low-carb or keto eating fit in? My hope is that this sneak peek sparks curiosity and inspires you to consider adding this valuable resource to your professional library once it’s released.
The Evidence Review Process
While it might be tempting to cherry-pick “the best” studies on nutrition and type 1 diabetes, I actually followed a systematic review process. It’s as dry as it sounds, but a critical step for developing evidence-based guidelines we can trust.
I started by asking a simple but important question: What nutrition therapy strategies work best for adults with type 1 diabetes?
I searched several major medical databases (PubMed, EMBASE, and others) using predefined search terms. I removed lower-quality studies, such as those with too few participants, unclear methods, or short durations, as well as studies that didn’t fit my target population (adults in outpatient settings).
I also factored in existing guidelines, including the 2025 ADA Standards of Care and the Academy of Nutrition and Dietetics’ 2020–2023 evidence review, along with a few other systematic reviews and meta-analyses that evaluated broader groups of studies.
All this to say, the recommendations in this chapter were built on the strongest available evidence, while also acknowledging that more high-quality research is still needed.
Carb Counting: Still Relevant or Outdated?
As many automated insulin pumps move away from traditional carbohydrate counting and toward more general meal announcements, patients often wonder: Is carbohydrate counting still relevant for diabetes management?
👍 The short answer is yes. Carbohydrate counting remains a core strategy for managing type 1 diabetes and insulin-requiring type 2 diabetes. Carbohydrate intake and insulin are the primary drivers of post-meal glucose levels, and matching insulin to carbohydrate intake is a key principle of care. This practice is not going away anytime soon.
That said, carbohydrate counting doesn’t need to look the same for everyone. There are different “levels” of carb counting, from basic awareness of carb-containing foods, to estimating portions, to structured insulin-to-carbohydrate ratios used for precise mealtime dosing.
It’s also important to recognize the limitations: estimating carbs in mixed meals is difficult, human error is common, and outcomes depend heavily on individual skill and consistency. Setting realistic expectations helps make carb counting more sustainable and effective in real-world practice.
Does the "Quality" of Carbohydrate Matter?
After discussing how much carbohydrate to eat, the next question is often about quality. Does it matter if carbs are complex, high in fiber, or lower on the glycemic index? Is brown rice better than white? Should we count net carbs?
👍 The short answer is yes. The source and type of carbohydrate play an important role in glucose control and long-term health. As for “net carb counting,” the jury is still out.
High-quality carbs, like whole grains, fruits, vegetables, legumes, and other fiber-rich foods, provide nutrients and support more stable glycemia. In contrast, refined carbs and added sugars are linked with greater glucose variability and poorer outcomes.
The consensus is not “carbs or no carbs,” but rather:
- Match insulin to carbohydrate intake for glycemic management; and
- Prioritize high-quality, fiber-rich carbs to improve outcomes and reduce complications.
Should I Recommend a Low-Carb Approach?
Over the years, I’ve seen that many people living with type 1 diabetes find it easier to reduce or even limit carbohydrate intake rather than deal with carb counting or seeking out higher-quality carbohydrate sources. In fact, before the discovery of insulin more than 100 years ago, eliminating carbohydrates was the only treatment option available.
More recently, however, nutrition therapy guidelines have advised caution with very-low-carb or ketogenic eating patterns due to the increased risk of diabetic ketoacidosis (DKA). So where do the guidelines stand today?
🤔 The reality is that there is no one-size-fits-all carbohydrate target, and there is also no universally agreed-upon definition of high, low, or very-low carbohydrate eating patterns.
While a keto eating pattern can improve glucose management and reduce insulin needs in type 1 diabetes, it’s not universally recommended due to safety concerns and limited evidence. For now, it remains an option only for carefully selected individuals who have strong clinical support and close monitoring.
Want to Learn More?
Keep an eye out for this updated resource! While I don’t yet have the exact publication or launch date, I’m hopeful this publication will be available in the ADA digital bookstore by the end of the year.
In the meantime, you can subscribe to stay up to date with evidence-based insights in diabetes care and nutrition. Sign up below to receive exclusive updates, resources, and professional perspectives—delivered straight to your inbox.
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