STUDI LITERATUR: PENGARUH PERHITUNGAN KARBOHIDRAT

TERHADAP HbA1C, BMI, DAN LDL PADA PASIEN DIABETES

MELLITUS TIPE 1

Effect of Carbohydrate Counting on HbA1C, BMI, and LDL in Type 1

Diabetes Mellitus Patients: Literature Review

Hanifa Kurniawatia, Nur Rahmanb,c, Rany Adelinaa*

a
Undergraduate Program in Applied Nutrition and Dietetics, Department of Nutrition, Politeknik Kesehatan
Kementerian Kesehatan Malang, Indonesia
b
Dietitian Professional Education Study Program, Department of Nutrition, Politeknik Kesehatan
Kementerian Kesehatan Malang, Indonesia
c
Center of excellence for local-based material science and technology for non-communicable diseases,
Politeknik Kesehatan Kementerian Kesehatan Malang, Indonesia

*Penulis korespondensi
Email: rany_adelina@poltekkes-malang.ac.id

ABSTRACT
Proper management of type 1 diabetes mellitus can maintain the optimal quality of life of patients.
Carbohydrate counting is a method of nutritional intervention that is more flexible and has been widely used
by patients with diabetes mellitus as glycemic control. This study aims to investigate the effect of the
carbohydrate counting method on HbA1c, BMI, and LDL in patients with type 1 diabetes mellitus. Systemic
Mapping Study (Scoping Study) was used in this study as a literature study. The included criteria were met
in a total of 10 types of literature, most of which were cross-sectional studies, randomized control tests, and
pilot studies with a large sample of more than 35 students. Nine out of ten studies showed a decrease in
HbA1c with the method carbohydrate counting, while the remaining one study reported an increase in
HbA1c with the method carbohydrate counting. Four of the seven studies showed a lower mean BMI with
the method carbohydrate counting, two studies reported no significant difference in BMI between the
intervention group and the control group, and one remaining study reported an increase in BMI with the
method carbohydrate counting. Four of the five studies showed a lower mean LDL by method carbohydrate
counting, and the remaining one study reported an increase in LDL by method carbohydrate counting. The
results of the literature review show that the method carbohydrate counting can reduce the concentration
of HbA1c, BMI, and LDL in patients with type 1 diabetes mellitus.

Keywords: HbA1c, BMI, LDL, carbohydrate counting, Type 1 Diabetes Mellitus

INTRODUCTION Gizi Indonesia, 2019). Indonesia is on the 6th

rank in the world, with 103 million adults
Insulin-dependent diabetes (IDDM) is the suffering from diabetes mellitus
older name for Type I Diabetes Mellitus (International Diabetes Federation, 2017).
(DM). This situation arises as a result of T According to the findings of Riskesdas
cell-mediated autoimmune destruction of (2018), the prevalence of diabetes mellitus in
pancreatic cells, resulting in an inability to Indonesia increases from 1.5 percent in 2013
produce insulin (absolute deficiency) (Pakar to 2 percent in 2018 (Kemenkes RI, 2019).

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Journal of Food Technology and Nutrition
Vol 21 (2): 94-102, 2022

CDC epidemiological research in 2011 According to Fu et al. (2016)'s systematic

shows that around 1 million individuals are review and meta-analysis, carbohydrate
living with type 1 diabetes mellitus in counting is reducing HbA1c levels
America. Type 1 diabetes mellitus has a significantly (P<0.05) in comparison to other
lower incidence in Asia than in the United diabetes diet approaches or regular diabetes
States. Indonesian data shows that 720 diet teaching. According to Gokosmanoglu &
pediatric Type 1 DM cases occurs in 2011 Onmez (2018), a statistical analysis is
(Pakar Gizi Indonesia, 2019). revealing a substantial reduction in HbA1c
Type 1 diabetes mellitus is incurable, but levels and LDL cholesterol (P<0.05) between
with proper glycemic control, it is possible to the intervention group (carbohydrate
maximize the patient’s quality of life. counting method) and the control group in
Glycated hemoglobin (HbA1c) is a marker of the intervention group (carbohydrate
glycemic control in diabetics (Soebagijo Adi counting method). According to Body Mass
Soelistijo et al., 2015). HbA1c reflects the Index (BMI), despite consuming a flexible
long-term average glycemia over the and tight glycemic control diet, the patient's
previous 2-3 months (American Diabetes weight does not increase significantly
Association, 2010). Controlling the body (P>0.05).
mass index (BMI) and lipid profile, as part of So according to the explanation above,
comprehensive patient management, can the aim of this study is investigating the effect
also help patients with type 1 diabetes of the carbohydrate counting method on
mellitus achieve optimal quality of life HbA1c, BMI, and LDL in patients with type 1
(Soebagijo Adi Soelistijo et al., 2015). diabetes mellitus.
Losing weight improves blood glucose
control by increasing glucose uptake by cells
MATERIALS AND METHOD
(Octaviana Wulandari & Martini, 2012).
According to Wulandari and Adelina (2020), Method
blood glucose levels and HbA1c levels The systematic Mapping Study (Scoping
increased, but not significantly, in subjects Survey) approach was used as a literature
with obese BMI and central obesity. Low- study in this research, which investigates the
density lipoprotein (LDL) is the primary influence of glycemic control (HbA1c), BMI,
cholesterol carrier in the blood. According to and LDL carbohydrate counts on patients
Arifin et al. (2019), an increase in blood with type 1 diabetes mellitus. During the
glucose levels is directly proportional to an investigation, scientists conducted a
increase in total cholesterol, LDL cholesterol, research publication, published online using
and triglyceride levels. the keywords "Carbohydrate Counting",
The management of type 1 diabetes "Diabetes Mellitus Type 1" with PubMed and
mellitus includes the administration of the Scholars' search engines.
insulin, diet, training, and education also According to the keywords sorted by the
home surveillance as support. It is vital to parameters, an article or journal was found.
highlight that the composition of carbs in the Articles or journals published in English in the
needed energy must be proportional to that recent ten years, with a cross-sectional study
of insulin-use units in individuals with type 1 design, randomized control trial, or pilot
diabetes mellitus (Melfazen et al., 2012). study, had been selected as inclusion
This is because insulin injection does not go criteria. The final findings of journals that
with adequate intake causes hypoglycemia might be studied according to preset criteria
problems, which are normally present in are seven, with three from Google Scholar
individuals with type 1 diabetes mellitus with and seven from Pubmed. The results of data
insulin treatment, insulin (Pakar Gizi searches utilizing the prism flow chart
Indonesia, 2019). The carbohydrate counting method were documented in the following
technique is also an alternative option. section, as shown in Figure 1.

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Figure 1. Prism Flow Chart Search Results in Literature Review

Full-text data (research publication) was detailed characteristics of respondents from

utilized to evaluate a project's quality or eligible studies.
viability (inclusion and exclusion criteria).
The name of the author, year of publication, The Research's Characteristics
country, title, technique (study design, Between 2010 and 2020, ten studies with
sample size, intervention, and analysis), a a total of 513 people were published.
summary of results, and database were all Children and adolescents were involved in
included in the tabular presentation of the four of the research, while adults were
results of the literature review. involved in the other six. There were 10
studies in total, one of which compared the
RESULTS AND DISCUSSION adherent and non-adherent groups to the
carbohydrate counting approach. The
Respondent Characteristics
carbohydrate counting method was
The participants in this study were all
compared to various diabetic diet
individuals with type 1 diabetes mellitus who
approaches in eight trials, and the
were on insulin therapy and lived in all parts
carbohydrate counting applications were
of the country. The bulk of the study's
compared to the normal DM diet method
participants were over 35 years old, with an
without application in one study. All studies
average age of 10-41 years. The majority of
reported changes in HbA1c concentrations,
respondents (56 percent) were female, and
seven studies reported changes in BMI and
the average length of diabetes mellitus
diagnosis was 2-22 years. Table 1 shows the

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Journal of Food Technology and Nutrition
Vol 21 (2): 94-102, 2022

five studies reported changes in LDL (Low-

Density Lipoprotein). The research duration
Table 1. Characteristics of Respondents
Gender Male/Female (n) 245/286
Age (years) 10-41
Duration of DM (years) 2-22

Table 2. Characteristics of Studies that Meet Inclusion Criteria

Author/Year Country Methods Summary of Results
(Bayram, 2020) Turkey - Design: cross-sectional study Mean levels The HbA1c of the
- Sample: 53 children and adherent group was significantly
adolescents with type 1 diabetes (P<0.05) lower than the non-
mellitus adherent group with the
- Intervention: method training carbohydrate counting method.
carbohydrate counting Adherence also affected the
- Control: Non-adherent group with decrease in mean LDL cholesterol,
carbohydrate counting and BMI but not significant
(P>0.05)
- Analysis: Shapiro-Wilk test and
Mann-Whitney test
(Alfonsi et al., Canada - Design: Pilot randomized control The intervention of carbohydrate
2020) trial counting method with application
- Sample: 44 adolescents with of image identification resulted in
type 1 diabetes mellitus significantly lower HbA1c values
- Intervention: application (P = 0.03) compared to the control
Carbohydrate counting using group.
image recognition
- Control: Method standard DM
diet without application
- Analysis: independent t-tests and
the chi-squared test
(Gokosmanoglu Turkey - Sample: 40 adults with type 1 Statistical analysis showed a
& Onmez, diabetes mellitus decrease in hemoglobin levels
2018) - Intervention: Flexible insulin A1c, and LDL cholesterol was
dosing using the method significant (P<0.05) between the
carbohydrate counting intervention group and the control
- Control: Standard dose insulin group. While the BMI showed no
without the carbohydrate significant difference between the
counting method intervention group and the control
group (P> 0.05). However,
- Analysis: Pearson correlation,
patients generally did not gain
independent paired t-test, and
weight despite flexible eating, and
Wilcoxon test strict glycemic control
(Gökşen et al., Turkey - Sample: 84 children and The mean HbA1c value at the end
2014) adolescents with type 1 diabetes of the second year was
mellitus significantly (P<0.05) lower in the
- Variable: method Carbohydrate group carbohydrate counting. The
counting on metabolic control of mean value of BMI and LDL
patients with type 1 diabetes cholesterol was lower in the
mellitus method group carbohydrate
- Analysis: Chi-square test, Mann- counting but not significant
(P>0.05).
Whitney U- test, and ANOVA test

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Table 2. Characteristics of Studies that Meet Inclusion Criteria (Cont.)

Author/Year Country - Methods Summary of Results
(Son et al., Turkey - Sample: 37 adults with type 1 In the group carbohydrate
2014) diabetes mellitus counting, there was an
- Intervention: Method insignificant decrease in HbA1c
carbohydrate counting levels at 6 months of treatment
- Control: standard DM diet compared to the study baseline (P
- Analysis: chi-squared test and > 0.05). In the carbohydrate
Mann-Whitney U test counting group, a statistically
insignificant increase was
detected in the LDL cholesterol
ratio at the end of 6 months
(Hayes et al., Australia - Design: Pilot study After the intervention, there was a
2012) - Sample: 38 adolescents with significant decrease in the mean
type 1 diabetes mellitus BMI (P<0.05), but a significant
- Intervention: Carbohydrate increase in HbA1c concentration
counting with insulin adjustment (P<0,05).
for flexible diet (1 unit/15g ratio)
- Control: before receiving the
intervention
- Analysis: Mann-Whitney U test,
Chi-squared test, and Paired t-
test
(Trento et al., Italy - Design: Randomized control trial HbA1c concentrations in the
2011) - Sample: 56 adults with type 1 intervention group were significant
diabetes mellitus (P< 0.05) lower than the control
- Intervention: Carbohydrate group. The mean BMI had no
counting educational program significant difference (P>0.05)
- Control: standard DM diet when compared to the control
education group. However, the comparison
- Analysis: Independent t-tests and of BMI values in the carbohydrate
counting group before and after
the chi-squared test
the intervention showed a
decrease but not significant.
(Laurenzi et al., Italy - Design: Randomized control trial HbA1c levels were significantly
2011) - Sample: 56 adults with type 1 (P<0.05) lower in the intervention
diabetes mellitus group than in the control group.
- Intervention: Education program There was a significant decrease
on carbohydrate counting in BMI (P<0.05) in the intervention
method group compared to control
- Control: estimating pre-meal subjects
insulin dose in the usual
empirical way
- Analysis: x2 test, unpaired, two-
tailed t-test, or Mann –Whitney
two-sample statistic

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Journal of Food Technology and Nutrition
Vol 21 (2): 94-102, 2022

Table 2. Characteristics of Studies that Meet Inclusion Criteria (Cont.)

Author/Year Country - Methods Summary of Results
(Dias et al., Brazil - Sample: 32 adults with type 1 A significant decrease in HbA1c
2010) diabetes mellitus concentration (P<0.05) was
- Intervention: dietary method with observed from baseline to
carbohydrate counting evaluation three months after the
- Control: before receiving intervention. After the intervention
intervention there was an increase in BMI but
- Analysis: Paired t-test not significant (P>0.05). A
decrease in LDL was observed
from baseline to evaluation three
months after the intervention but
was not significant (P>0.05).
(Scavone et al., Italy - Design: a pilot study After the intervention, there was a
2010) - Sample: 73 adults with type 1 significant decrease in HbA1c
diabetes mellitus concentration (P<0.05).
- Intervention: education
Carbohydrate counting
- Control: usual care
- Analysis: chi-square test or
Fisher's exact test

of the ten studies was a minimum of 3 proportional to the insulin utilized units in
months. Detailed characteristics of the patients with type 1 and 2 diabetes mellitus
eligible studies were presented in Table 2. who were getting intense insulin therapy
(Multiple Daily Insulins = MDI) (Melfazen et
HbA1c levels in patients with Type 1 al., 2012). The carbohydrate counting
Diabetes Mellitus approach could be used as an alternative.
Data on HbA1c concentrations were The carbohydrate counting procedure
provided by all studies, which included a total highlights the number of carbs used
of 513 participants. Nine out of ten studies compared with the carbohydrate type (Pakar
found that the carbohydrate counting method Gizi Indonesia, 2019).
resulted in lower HbA1c concentrations than According to Fu et al. (2016), a
the control group. Hayes et al. (2012) systematic review and meta-analysis found
reported an increase in the concentration of that carbohydrate counting resulted in a
HbA1c following the intervention of the substantial (P<0.05) reduction in HbA1c
carbohydrate counting method with insulin concentrations when compared to alternative
adjustment for a flexible diet (1 unit/15g diabetes diet approaches or regular diabetes
ratio). diet teaching. According to Bishop et al.
Insulin production or utilization had (2009), dinners with the right carbohydrate
impaired DM sufferers. Carbohydrate intake measurement utilizing the carbohydrate
was one of the main nutrients to be evaluated counting method had a significantly lower
for insulin in DM (Lindawati et al., 2019). HbA1c concentration (P<0.05) than those
Carbohydrates in the body become glucose with overestimated and underestimated
the fastest, reaching 100% within 1 hour carbohydrate estimates. Spiegel et al.
(Pakar Gizi Indonesia, 2019). Excess (2012) found that the carbohydrate counting
carbohydrate intake can build glucose and education group had a lower HbA1c
produce hyperglycemia in the body concentration, although it was not
(Lindawati et al., 2019). The composition of statistically significant (P>0.05).
carbohydrates in energy required ought to be

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Patients with Type 1 Diabetes Mellitus diabetes mellitus were studied in five of the
and their Body Mass Index (BMI) 10 studies, which included a total of 246
Seven out of ten studies with a total of participants. Dias et al. (2010), Gökşen et al.
396 individuals provided information on (2014), Gokosmanoglu & Onmez (2018),
changes in BMI in type 1 diabetic patients. and Bayram (2020) all found that the
Four of the seven investigations conducted carbohydrate counting method reduced
by Laurenzi et al. (2011), Hayes et al. (2012), mean LDL relative to the control group in four
Gökşen et al. (2014), and Bayram, (2020) of the five investigations. One other study
found that the carbohydrate counting method Son et al. (2014) found that patients with type
resulted in a lower average BMI than the 1 diabetes mellitus had an increase in LDL,
control group. Trento et al. (2011) and although it was not statistically significant.
Gokosmanoglu & Onmez (2018) found no Low-density lipoprotein (LDL) is often
significant difference in BMI between the referred to as bad cholesterol because it can
intervention and control groups, but the stick to blood vessels. If there is a lot of LDL
average patient weight did not increase in the blood, it causes the accumulation of
when the carbohydrate counting method was fatty deposits (plaque) in the arteries, so that
used. Dias et al. (2010) reported an increase blood flow narrows. The higher the HbA1c
in BMI in type 1 diabetes mellitus patients, level, the higher the LDL level. The worse the
but it was not statistically significant. glycemic control in people with diabetes
Obesity causes a reduced number of mellitus, the more severe the plaque buildup
insulin receptors that can work in cells in (Damara & Ariwibowo, 2021). The
skeletal muscle and fat tissue, this can lead triglyceride and cholesterol level increases
to insulin resistance. Obesity causes the were strongly linked to a rise in the blood
response of pancreatic beta cells to an level, as stated in Daboul (2011). Blood
increase in blood glucose to decrease, glucose had shown its significance in
besides that insulin receptors on cells boosting blood fat levels according to
throughout the body, including muscles, are research by Arifin et al. (2019). Blood
reduced in number and activity (less glucose increases were directly related to
sensitive) (Junaidi dkk, 2021). Weight loss total cholesterol, LDL, and triglyceride levels
improved blood glucose control through increase. The incidence of dyslipidemia
increasing glucose absorption by cells could therefore be suppressed by the
(Octaviana Wulandari & Martini, 2012). management of the growth of glucose levels
According to Wulandari and Adelina's (2020) in the blood. The glycemic control (blood
study, blood glucose levels and HbA1c levels glucose levels and HbA1c) in patients with
increased in participants with obese BMI and diabetes mellitus could be used for the
central obesity, but not significantly. dietary measurement of carbs.
According to Spiegel et al. (2012), using the
carbohydrate counting method on compliant CONCLUSION
patients helped reduce overeating by Based on the results of the study of
reducing frequent hypoglycemia, resulting in literature can be concluded that using the
weight loss. According to Fu et al. (2016)'s method of carbohydrate counting as
comprehensive review and meta-analysis nutritional interventions can reduce the
study, carbohydrate counting did not reduce concentration of HbA1c, BMI, and LDL
mean BMI considerably (P>0.05) when patients with type 1 diabetes mellitus. The
compared to other diabetic diet approaches method is carbohydrate counting expected to
or regular diabetes diet teaching. be used as a nutritional intervention in
patients with type 1 diabetes mellitus, to
Low-Density Lipoprotein (LDL) in Type 1 achieve optimal quality of life with control of
Diabetes Mellitus Patients glycemic control (HbA1c), BMI, and LDL
The variations in Low-Density (Low-Density Lipoprotein) remained within
Lipoprotein (LDL) in individuals with type 1 normal limits.

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Vol 21 (2): 94-102, 2022

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