Hong Lin Evelyn Tan
Department of Medicine, John Hunter Hospital, Newcastle, NSW


Starvation therapy in Type 1 Diabetes Mellitus (T1DM): fad or fab?

Hong Lin Evelyn Tan1, Judy Luu
1 Department of Medicine, John Hunter Hospital, Newcastle, NSW.

Introduction: Prior to the discovery of insulin, Type 1 diabetes (T1DM) was managed with “starvation diets”.  We report the case of a 22 year-old student with T1DM who was maintained on no insulin for 16 months after commencing a carbohydrate free diet mimicking a “starvation diet”. 

Case history: Mr KH, a philosophy student, was diagnosed with T1DM in July 2014 after presenting with a blood glucose level of 22.5mmol/L and diabetic ketoacidosis (pH 7.18).  His HbA1c at diagnosis was 12.1% and anti-GAD and islet cell antibodies were positive.  Through his own research, he initiated a low fat and carbohydrate free diet; insulin was gradually reduced and ceased completely four months later due to recurrent hypoglycaemia.  Despite complete cessation of insulin he was able to maintain near normal glucose levels on a carbohydrate free diet for the next 16 months.  There were no episodes of ketoacidosis.  Mr KH monitored fasting capillary ketone levels every two days as well as blood glucose levels on multiple occasions per day.  His HbA1c averaged 5.0% (31 mmol/mol) during this period off insulin.  He recommenced insulin therapy in February 2016.

Discussion: Prior to the discovery of insulin in 1922, severe caloric restriction was perceived as the only means of prolonging life for those diagnosed with T1DM.  This treatment was abandoned with the advent of insulin therapy and is no longer recommended due to the risk of malnutrition and euglycemic ketoacidosis.  However, it is advocated for obese patients with type 2 diabetes where very low calorie diets have been shown to result in weight loss and improvement in insulin resistance. We review historical evidence for starvation therapy, compare it to current dietary evidence for the management of T1DM and reflect on the changing landscape of patient autonomy in medical decision making.