Death to Carbohydrate Counting?

I nsulin therapy is an effective strategy for achieving glycemic control in patients with type 2 diabetes. Although often neglected, it is important to use an appropriate diet strategy to complement the insulin. Furthermore, a basic tenet of such therapy is that insulin dosage and administration should be appropriate to balance diet and physical activity in order to maintain normoglycemia. In this issue of Diabetes Care, Bergen-stal et al. (1) evaluated two strategies for determining the appropriate dosage of mealtime bolus insulin. A simple algorithm that adjusted bolus insulin dose based on weekly average of premeal glucose was compared with an algorithm based on mealtime carbohydrate counting. The authors demonstrated the equivalence of both the simple strategy and the more elaborate carbohydrate-counting strategy in achieving glycemic control; almost one-half the participants in both groups achieved an A1C Ͻ6.5%. Can patients with type 2 diabetes treated with basal:bolus insulin succeed without adding the complexity of carbohydrate counting? Carbohydrate counting has been around since the 1920s and became integral in managing patients with type 1 diabetes after the landmark findings of the Diabetes Control and Complications Trial (2). However, the efficacy of carbohydrate counting in type 2 diabetes is largely unknown. Potential barriers to carbohydrate counting include the time and effort required for patients to count the carbohydrate content at each meal, patient difficulties in understanding the strategy, and the availability of dietitians or appropriately trained health care providers to teach patients. The authors did not evaluate quality-of-life outcomes, and little is known about how carbohydrate counting affects quality of life. Prior studies have demonstrated that, when given a choice, patients opt to discontinue carbohydrate counting over other strategies (3). Further research is clearly needed on the optimization of carbohydrate counting in type 2 diabetes and also in assessment of the accuracy of patients' counting in the real world setting. It would appear that if similar levels of glycemic control can be achieved with few adverse events by using a simple algorithm , then the simple algorithm may be a better strategy for adjusting insulin. Additionally , the simple algorithm may be more feasible to teach patients within un-derserved settings where a dietitian may not be available. However, are there benefits to counting carbohydrates beyond glycemic control? In examining the study's secondary outcomes, there is an apparent trend for the carbohydrate-counting group to have less weight gain at the end of the …