About the Author(s)


Tro Kalayjian Email symbol
Department of Medicine, Greenwich Hospital/Yale New Haven Health, Greenwich, Connecticut, United States

Beth J. McNally symbol
Private Practice Nutritionist, Kingston, Ontario, Canada

Matthew W. Calkins symbol
Department of Family Medicine, Atrium One Health, Rural Hall, United States

Mark T. Cucuzzella symbol
Department of Family Medicine, West Virginia University, Morgantown, West Virginia, United States

Robert Cywes symbol
Private Practice Doctor, Jupiter, Florida, United States

Hayden Dikeman symbol
Department of Biology, Emory University, Atlanta, Georgia, United States

David T. Dikeman symbol
Department of Biology, Baylor University, Waco, Texas, United States

Evelyne Bourdua-Roy symbol
Private Practice Doctor, Quebec, Canada

Sarah M. Rice symbol
Private Research and editing, Cape Town, South Africa

Ian Lake symbol
Private Practice Doctor, Gloucester, United Kingdom

Laura A. Buchanan symbol
Department of Telemedicine, Toward Health, Tappan, New York State, United States

Douglas B. Reynolds symbol
Society of Metabolic Health Practitioners, San Diego, California, United States

Mirian Kalamian symbol
Private Practice Nutritionist, Hamilton, Montana, United States

Eric C. Westman symbol
Department of Medicine, Duke University Health System, Durham, North Carolina, United States

Citation


Kalayjian T, McNally BJ, Calkins MW, et al. The SMHP™ position statement on therapeutic carbohydrate reduction for type 1 diabetes. J. metab. health. 2024;7(1), a100. https://doi.org/10.4102/jmh.v7i1.100

Consensus Statements

The SMHP™ position statement on therapeutic carbohydrate reduction for type 1 diabetes

Tro Kalayjian, Beth J. McNally, Matthew W. Calkins, Mark T. Cucuzzella, Robert Cywes, Hayden Dikeman, David T. Dikeman, Evelyne Bourdua-Roy, Sarah M. Rice, Ian Lake, Laura A. Buchanan, Douglas B. Reynolds, Mirian Kalamian, Eric C. Westman

Received: 17 Aug. 2024; Accepted: 18 Nov. 2024; Published: 30 Nov. 2024

Copyright: © 2024. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

This article presents the position of the Society of Metabolic Health Practitioners (SMHP) regarding therapeutic carbohydrate reduction (TCR) nutrition interventions for type 1 diabetes mellitus (T1DM). A modified Delphi methodology was used to arrive at a consensus consisting of several focus groups, multiple rounds, and an anonymous survey. The field of endocrinology has seen many new advances for the treatment of T1DM including hybrid closed-loop insulin delivery systems and continuous glucose monitors for better glycaemic control, monoclonal antibodies to delay the onset of disease and increased access to paediatric endocrinologists, among many other noteworthy achievements. Despite these advancements, standard of care approaches to T1DM result in higher than acceptable morbidity and mortality, with a high prevalence of microvascular and macrovascular complications. Insulin resistance in type 1 diabetes is an independent risk factor for adverse outcomes even in well controlled type 1 diabetes. In 2021, only 21% of adults with T1DM in the United States achieved the American Diabetes Association’s (ADA’s) target haemoglobin A1C goal of < 7.0%, while data in the paediatric and adolescent population have demonstrated worse glycaemic control. Supported by observational and interventional evidence, the SMHP advocates for the reevaluation of the prevailing nutritional therapy for T1DM with more broad consideration for TCR. The SMHP recommends open access and clinical support for TCR nutrition interventions for individuals with T1DM of all ages and calls upon the medical community to help foster more attention and research on TCR for T1DM.

Keywords: Type 1 diabetes mellitus; therapeutic carbohydrate reduction; low-carbohydrate diet; ketogenic diet; very low-carbohydrate diet; glycaemic control; double diabetes; insulin resistance.

Introduction

Type 1 diabetes mellitus (T1DM) is an autoimmune condition with no known prevention or cure and is characterised by the inability to produce insulin via loss of pancreatic beta cell function. Lifelong insulin replacement therapy is necessary, with the treatment goal of keeping blood glucose levels as close to a healthy range as possible to prevent severe hypoglycaemia and hyperglycaemia, thereby minimising the risk of diabetes complications.

The standard management of T1DM involves patient-guided titration of exogenous insulin to carbohydrate intake, with some consideration for diet, infection, and exercise. Patients may find that other factors affect diabetes management, like stress levels and sleep quality. Due to these variables, patients with T1DM often experience fluctuating blood glucose levels and an increasing prevalence of insulin resistance with the duration of disease.1,2 Most patients with T1DM initially manage their blood glucose with multiple daily insulin injections, including both basal and bolus formulations, with a target haemoglobin A1C goal of 7.0%. However, data from 2021 suggest that only 21% of adults achieve this goal.3 In the US, roughly 65% of patients with T1DM will transition to an insulin pump for the management of glycaemia.4 Insulin pumps can be manually programmed, but increasingly, patients are adopting hybrid closed-loop insulin pump systems, where the insulin dosing is, in part, managed through an algorithm. In all modalities, effectively managing blood glucose requires a constant, rigorous cycle of monitoring and promptly addressing any detected hypoglycaemia or hyperglycaemia. Failure to execute this process correctly can result in severe hypoglycaemia or hyperglycaemia, with subsequent acute and long-term complications, diminished quality of life, and a shortened lifespan. The burden of disease in patients with T1DM relates to the constant need for the self-management of daily glucose monitoring, insulin administration, equipment upkeep, and the management of potential complications. These burdens may have psychosocial impacts on mental health and finances, often exacerbated by comorbid anxiety, depression, and stress.5,6

Early access to high-quality medical care can improve overall health outcomes and enhance the quality of life for patients with T1DM. The SMHP believes that early access to medical care should also include clinical support for medical nutrition therapy (MNT) that includes therapeutic carbohydrate reduction (TCR). Furthermore, the SMHP recommends that TCR should be a widely accepted and broadly supported MNT for patients with T1DM and that all healthcare professionals respect patient autonomy with regards to dietary choices, particularly in those patients seeking to implement TCR for T1DM. A framework for implementation is outside the scope of this article but we recommend other sources describing TCR implementation strategies for type 1 diabetes.7,8,9 Our consensus was achieved using a modified Delphi approach.

Methods

The Delphi method is a recognised process for consensus studies, designed to arrive at a reliable consensus of opinion among a group of experts. In the classic form, this is achieved via a series of anonymous questionnaires, feedback, iterations, and multiple rounds utilising response statistics.10 Our approach used a modified Delphi technique, which differs by including direct interaction among panel members that may be via discussions, multiple rounds, or online platforms while retaining an anonymous component.11

Expert panel

The authors reflect a diverse group of individuals selected from physicians, scientists, nutritionists, and patient advocates with a background and experience in both metabolic health and type 1 diabetes. The final panel included 15 individuals, which is in line with recommendations for this approach.10 All authors gave consent for their participation, which was entirely voluntary.

Study design

Each author had direct contact with the main researcher (TK) to maintain communication about the study process and facilitate good response rates. Focus groups and rounds were conducted between July 2023 and July 2024 to collate research and clinical information until agreement was reached.

The authors were split up into 4 focus groups, with representation from the SMHP board (TK) attending each focus group. The resultant draft document was circulated in several rounds with each focus group for proofing and editing, culminating in a formal agreement on the final draft.

To conclude, an online anonymous survey was compiled where 17 key points were taken from the final draft and submitted for a position comment (agree or disagree), with an option to give feedback for review. Consensus was reached using predefined criteria, as follows:

  • An 80% survey response rate is required
  • Consensus declared at 70% agreement (of those who responded)
  • Two similar suggestions for a change or addition warrant a re-evaluation of the statement point.

The SMHP board approved the final version of the document.

Results and discussion

Current standard of care medical nutritional therapy intervention for managing T1DM

Current standard treatment approaches have resulted in unsatisfactory real-world clinical results with elevated haemoglobin A1C and unacceptable rates of complications. A 2018 study revealed concerning trends: women diagnosed with T1DM before age 10 faced a lifespan nearly 18 years shorter than their counterparts without diabetes, while men in similar situations lost almost 14 years of life.12 Moreover, cardiovascular disease, already the leading cause of death in patients without T1DM, is more prevalent among those with T1DM. Recent data from Sweden indicate a significantly elevated risk of cardiovascular mortality in patients with T1DM, with up to a tenfold increase according to glycaemic control status and age.13 Taken together, these real-world results suggest that the current standards are resulting in suboptimal diabetes control with regards to mortality, macrovascular complications, cardiovascular, and mental health outcomes.14

Critical to the well-being of individuals with T1DM is the integration of individualised, diabetes-focused medical nutritional therapy alongside an insulin dosing regimen.15 Although the ADA guidelines recommend reducing total carbohydrate and sugar intake using a variety of eating patterns, all dietary patterns presented, with the exception of a low-carbohydrate approach, still include starches, legumes, and grains. The inclusion of these dietary paradigms by the ADA implies counting carbohydrates and insulin bolusing is optimal when there are no randomised interventional trials showing this is the optimal approach.15

A 2014 study demonstrated that despite two years of instruction in carbohydrate counting, haemoglobin A1C levels remained high at 7.9%.16 A 2014 meta-analysis found that standard carbohydrate counting led to only a marginal haemoglobin A1C reduction of 0.3%, equating to an average blood glucose improvement of 10 mg/dL (0.6 mmol/L).17 For context, the difference between normal blood glucose levels and the average blood glucose level attained by a child with T1DM using carbohydrate counting is approximately 100 mg/dL (5.5 mmol/L). A large diabetes registry of 12,035 adults with T1DM demonstrated only 23% of subjects had a haemoglobin A1C < 7%, while 44.5% had a haemoglobin A1C of 7–9%, and 32.5% had a haemoglobin A1C > 9%.18 International comparisons, such as the 2021 Australian National Diabetes Audit, indicate a median haemoglobin A1C of 8.2% for people with T1DM, well above a healthy target (< 5.7%) and the Australian target for those with diabetes of ≤ 7.0%.19 Some of the challenges of using a high-carbohydrate diet could be explained by the difficulty of managing blood sugar levels in the setting of rapidly and slowly absorbed carbohydrate intake.

Uncontrolled glycaemia leads to poor outcomes

The data in Figure 1 reflect random blood glucose levels in the healthy range and are prospectively associated with an increased risk of retinopathy, peripheral neuropathy, diabetic nephropathy, peripheral arterial disease, and myocardial infarction. These data illustrate the probability of diabetes complications increasing at non-normal haemoglobin A1C levels in the mid-5% range.20 Additionally, these data demonstrated that the odds of myocardial infarction increased with increased glycaemia. Recent data suggests that both glycaemia and glycaemic variability are associated with an increase in mortality in critical illness and associated with an increase in cardiovascular mortality in the chronic conditions of obesity and prediabetes.21,22

FIGURE 1: Micro- and macrovascular complication rates rise as blood glucose levels rise from normal.

Emerging evidence indicates that TCR may offer a promising opportunity for enhancing glycaemic control. Studies in people with type 2 diabetes have shown a direct correlation between carbohydrate intake and glycaemia,23 suggesting that reducing carbohydrates is crucial for achieving better glycaemic outcomes in this population. The interplay between carbohydrate intake, glycaemia, and the onset of diabetes complications underscores the potential significance of TCR as a therapeutic option in T1DM.

Another somewhat under-recognised but vitally important complication of high glycaemic eating and the resulting higher insulin doses is a condition called ‘double diabetes’. This is a condition where insulin resistance and its sequelae of obesity and cardiometabolic complications occur. The prevalence is now around 25% in patients with T1DM,24 and is trending upward.25

Therapeutic carbohydrate reduction nutritional therapy for type 1 diabetes

The SMHP advocates for open access and clinical support for TCR for individuals with T1DM of all ages. A description of TCR will be provided, followed by an overview of the evidence and data available to demonstrate how TCR has therapeutic potential as an effective clinical intervention in T1DM.

TCR eating patterns are gaining popularity with individuals with T1D, particularly as the ADA has advised that a variety of eating patterns are acceptable for the management of diabetes and that ‘evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for people with diabetes. Therefore, macronutrient distribution should be based on an individualised assessment of current eating patterns, preferences, and metabolic goals.’15

Defining therapeutic carbohydrate reduction

TCR encompasses dietary interventions measured in absolute amounts (grams/day) that fall below 130 grams of dietary carbohydrate per day for specific conditions where TCR has been shown to offer therapeutic benefits.26

In the research literature, TCR is often described as follows:

  • Low-carbohydrate diet (LCD): less than 130 grams of carbohydrates (total) per day
  • Very low-carbohydrate diet (VLCD): 50 grams of carbohydrates (total) or less per day.

Other protocols of TCR have also been described for T1DM, including TCR regimens with less than 30g of total carbohydrates per day.9

As a way of eating that can comprise whole, nutrient-dense foods, TCR eating patterns can align with the ADA’s nutrition therapy consensus recommendations that eating patterns should:

  • emphasise non-starchy vegetables
  • minimise added sugars and refined grains
  • choose whole foods over highly processed foods to the extent possible.27

TCR can be tailored to an individual’s preferences, values, and health goals. Various ways of eating may fall under the umbrella of TCR, including Mediterranean, Atkins, Palaeolithic, vegetarian, vegan, and carnivore dietary approaches. A variety of foods can be selected for TCR meals and snacks, including: meat, fish, eggs, leafy greens, above-ground vegetables, some fruits, and healthy fats such as olive oil, avocado, dairy products, and butter. The use of a continuous glucose monitor, or manual monitoring, can be useful in providing feedback on food choices and glycaemic variability and is recommended to help guide the process.27

Note that this dietary approach for T1DM does not replicate the 4:1 or 3:1 classic ketogenic diets, which are often used therapeutically for individuals with epilepsy.28 TCR nutrition therapies for T1DM prioritise dietary protein and include adequate healthy dietary fats for energy. Adequate amounts of dietary protein help meet growth, repair, and development as well as vitamin and mineral requirements. Dietary fat is used to meet energy as well as essential fatty acid and micronutrient needs. Prandial insulin dosing for TCR meals considers all macronutrients, and using exogenous insulin to cover protein in meals is particularly important when using TCR for T1DM.

Therapeutic carbohydrate reduction: therapeutic potential in T1DM

For T1DM, TCR has therapeutic potential as an effective clinical intervention.

Improved glycaemia

The ADA’s consensus recommendations on eating patterns address the importance of reducing overall carbohydrate intake among individuals with diabetes; highlighting this dietary approach demonstrates ‘the most evidence for improving glycaemia’.15 While directed towards type 2 diabetes and prediabetes, evidence suggests that reducing overall carbohydrate intake can also positively impact individuals with T1DM in managing glycaemia.29 An analysis conducted by Lennerz et al (2021) reviewed 24 studies with varying degrees of TCR, which revealed that the degree of carbohydrate reduction associates with haemoglobin A1C in T1DM suggesting that VLCD may have the greatest impact on glycaemia (see Table 1).30

TABLE 1: Reports on reduced-carbohydrate diets in people with T1DM adapted from Lennerz et al., 2021.30

Emerging data suggest that adopting TCR eating patterns can lead to improved and even optimal glycaemic control in T1DM. One study in particular demonstrated ‘exceptional glycaemic control’ and yielded promising results.31 In this observational study, over 300 subjects with T1DM voluntarily adhered to a VLCD, resulting in exceptional glycaemic control and low adverse event rates.31 Their mean haemoglobin A1c was 5.67%, with a mean daily insulin dose of 0.4 U/kg, and an average diet duration of 2.2 years ± 3.9 years. These findings underscore the effectiveness of a very low-carbohydrate (VLC) TCR eating pattern not only for improving glycaemia but also for achieving normoglycaemia in T1DM management, warranting further exploration and consideration among clinicians and patients. Despite the voluntary nature of the participants’ decision to follow a VLC TCR approach, suggesting they may have been highly motivated individuals who self-selected this therapy, the study reveals the possibility of attaining normoglycaemia in T1DM through TCR. Clinicians are encouraged to acknowledge and offer support to individuals and families who choose TCR as part of their diabetes management.

On the ketogenic end of the low-carbohydrate spectrum (<50g of carbohydrate per day), improved glycaemic control and vascular function may be experienced via a lower HbA1c, time-in-range, and reduced insulin dosing.32 A recent case study examined the cardiovascular physiology of an individual with type 1 diabetes who has followed a ketogenic diet for 10 years.33 This individual achieved an HbA1c of 5.5% and 90% time-in-range (3.89–9.99 mmol/L) with low insulin requirements. Compared to normal findings in type 1 diabetes, health markers were favourable and included a decreased heart rate and reduced arterial stiffness, increased heart rate variability and improved endothelial function, and no sign of left ventricular diastolic dysfunction. The overall findings in this case study reflect a reduced risk of CVD relative to normal findings in individuals with type 1 diabetes.33 In a follow-on report,34 the long-term efficacy and safety of the ketogenic diet were examined. In addition to excellent glycaemic control and a 43% reduction in insulin requirements, no adverse effects were recorded on thyroid metrics, renal function, or bone mineral density. The overall lipid profile did not appear to increase the risk of CVD.33,34 While this is a single case report, the findings are encouraging and invite further study.

While VLC diets show significant promise for T1DM management, there are also benefits observed from reducing carbohydrate intake from traditional high-carbohydrate diets. A randomised, crossover trial conducted by Sterner Isaksson et al. (2023) compared interventions with 30% of energy from carbohydrate (moderate carbohydrate) versus 50% of energy from carbohydrate (traditional diet) followed by individuals with T1DM with baseline haemoglobin A1C levels of ≥ 7.5% (≥ 58 mmol/mol).29 The study revealed that reducing carbohydrate intake led to significantly lower mean glucose levels (a mean difference of -0.6 mmol/L). Additionally, participants experienced more time in range and tighter range (though the majority did not reach the target of 70% time in range), less time with high and very high glucose levels, and increased treatment satisfaction. This highlights the potential of even modest reductions in dietary carbohydrate, suggesting a step in the right direction for improving glycaemic control and diabetes outcomes, even though studies indicate that VLC and low-carbohydrate eating patterns yield better results.

Potential for reduced frequency of and time spent in hypoglycaemia

Given the significant concern surrounding hypoglycaemia in individuals with T1DM and their healthcare providers, TCR presents a potential approach for reducing the risk of hypoglycaemia. While hypoglycaemia is mainly a result of excessive or poorly-timed administration of exogenous insulin, the choice of food can influence the amount of insulin needed for a meal. Opting for an eating pattern that requires less insulin coverage may lower the risk of hypoglycaemic episodes, though further studies are required to systematically demonstrate this.

While a recent clinical trial by Turton et al. (2023) found no significant difference in the frequency of hypoglycaemic episodes between TCR and a diet consisting of over 150g of carbohydrates daily, various clinical case studies and trials, including those conducted by Nielsen (2005, 2012), Schmidt (2019), Ranjan (2017), and Mahmood (2023), have reported substantial improvements in the rate of hypoglycaemia or a reduction in the duration spent in hypoglycaemia.35,36,37,38,39,40 A clinical report by Nielsen (2005) revealed that individuals adhering to TCR experienced a reduction in the mean rate of symptomatic hypoglycaemia by 94% after three months and 82% at twelve months from baseline.36 Additional studies examining TCR’s impact on hypoglycaemia are warranted.

Evidence does not suggest increased risk of diabetic ketoacidosis

The current evidence does not suggest an increased risk of diabetic ketoacidosis (DKA) in individuals with T1DM who adhere to a TCR eating pattern. With sufficient insulin and effective blood glucose management, individuals with T1DM can safely follow TCR. Findings from research trials and clinical case studies have suggested no incidence of or elevated risk of DKA compared with prevailing rates.29,31,35,38,39,41 However, it’s important to note that all individuals with T1DM, regardless of dietary patterns, are susceptible to DKA and more systematic studies are needed. All individuals with T1DM should have a sick day management plan in place for times when they may be more vulnerable to DKA.

Efficacy of TCR nutrition interventions across co-morbidities related to T1DM

Patients with T1DM often experience comorbidities such as obesity,42 metabolic syndrome,43 hypertension, and insulin resistance.2 The prevalence of obesity among people with T1DM, historically typically lean, has reached epidemic levels, contributing to the emerging phenomenon of ‘double diabetes’,44,45,46 which occurs when an individual with T1DM develops insulin resistance characteristics of metabolic syndrome and type 2 diabetes.47

This sub-type of diabetes, where insulin resistance has occurred, is more at risk of micro- and macrovascular disease.1,2 Studies reflect a higher incidence of complications in this sub-group, irrespective of glycaemic control, indicating that poor glycaemic control is not the sole driver of complications in type 1 diabetes. Insulin requirement or insulin resistance is an important and independent risk factor even in well controlled type 1 diabetes.2 Restoring or maintaining insulin sensitivity could be a significant step towards improving outcomes in type 1 diabetes, particularly given some inconsistencies in outcomes relating to glycaemic control alone.48 Reduced insulin dosing is a feature of therapeutic carbohydrate reduction in the management of type 1 diabetes and therefore represents a strategy that may mitigate the development of double diabetes.32,34

Patients with T1DM experience comorbid major depression and depressive symptoms at a rate of 11% and 31%, respectively.49 Psychological issues and, separately, diminished quality of life have both been linked with suboptimal glycaemic control and diabetes complications. In light of these comorbidities and early evidence,5 TCR should be more widely studied.

Low-carbohydrate diets have been extensively studied for obesity and have consistently shown superior results for weight loss, even in systemic analysis.50 Calorie-controlled studies have also demonstrated that therapeutic carbohydrate reduction preferentially improves markers of metabolic syndrome.51 VLCD have been compared head-to-head with the DASH diet and the Mediterranean diet in clinical settings. Against the DASH diet, low-carbohydrate diets were found to be superior for reducing blood pressure, weight, and glycaemia.52 When directly compared to the Mediterranean diet, the ketogenic diet was found to decrease the need for diabetes medications in a sensitivity analysis, demonstrating improved glycaemia in patients with prediabetes and type 2 diabetes.53

Double diabetes has been used to refer to individuals with T1DM who are overweight, have a family history of type 2 diabetes and/or have clinical features of insulin resistance.54 It has been suggested that TCR may help protect individuals with T1DM from excessive weight gain, inflammation, and atherosclerosis and from developing metabolic syndrome, Alzheimer’s disease, and cancer by addressing insulin resistance.55

While further robust research, including comparative trials, on TCR for T1DM is warranted, the available evidence indicates TCR’s safety and potential efficacy as a dietary intervention. The SMHP encourages clinicians to acknowledge and offer support to individuals and families who choose TCR as part of their diabetes management, fostering an environment that embraces a variety of eating patterns for the management of diabetes and respects patient autonomy.

Call to action

MNT is quite confusing where most approaches still recommend starches, grains, legumes, and high-sugar fruit, which is antithetical to their recommendations to reduce overall carbohydrate and sugar intake. The current MNT promoted by professional diabetes associations is deemed inadequate by the SMHP, resulting in adverse outcomes. We must not settle for the status quo in T1DM management.

With emerging evidence demonstrating the efficacy of TCR nutritional therapy for people with T1DM, it is crucial to initiate systematic changes to incorporate TCR approaches. To address this, the SMHP recommends the following systematic changes:

  • Increase research efforts, including randomised controlled trials, to evaluate the efficacy of TCR nutrition interventions in patients diagnosed with T1DM.56
  • Facilitate immediate access to information regarding TCR as a viable option following a diagnosis of T1DM.
  • Guarantee equitable availability of clinical support for individuals opting for the TCR approach to managing T1DM.
  • Develop and disseminate educational materials tailored for implementing TCR effectively.
  • Issue clinical guidelines, nutrition resources, and specialised training opportunities for clinicians involved in the care of individuals with T1DM, emphasising the integration of TCR principles into clinical practice.

Conclusion

In conclusion, this consensus statement conducted by the SMHP advocates for open access and clinical support for TCR nutrition interventions for individuals with T1DM across all age groups. As a component of diabetes-focused MNT, TCR nutrition therapy exhibits promising results supported by emerging evidence. It is imperative that individuals diagnosed with T1DM, along with their families, receive comprehensive information, education, and support from their entire healthcare team regarding the option of TCR nutrition interventions. This proactive approach ensures that every patient can make well-informed decisions about the nutrition component of their treatment plan, with TCR being presented as a viable therapeutic option from the outset of diagnosis.

Acknowledgements

We acknowledge the amazing work of Dr. Adele Hite and Dr. Sarah Halberg; without their contributions to the field of nutrition and medicine, this work would not have been possible. We thank the Board of Directors and the leadership from the SMHP.

Competing interests

The author(s) declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.

Authors’ contributions

All authors, T.K., B.J.M., M.W.C., M.T.C., E.C.W., R.C., H.D., D.T.D., E.B.-R., S.M.R., I.L., L.A.B., D.B.R., and M.K. provided critical feedback and helped shape the research, analysis, and article. All authors have read and agreed to the published version of the article.

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings, and content.

Clinical consensus statements are crafted by selected experts in the field and serve as informational and educational resources. The goal of the development group is to distil information, including differing interpretations of the data, into clear and accurate answers to specific clinical questions. These statements may reflect uncertainties, knowledge gaps, and differing opinions. However, through a consensus-building process, many uncertainties are addressed, leading to a shared opinion and the formation of the final statement. It is important to note that clinical consensus statements are distinct from clinical practice guidelines and do not follow the same rigorous development procedures. These statements do not establish a legal standard of care. The treating physician must consider all aspects of the individual patient’s situation to determine the appropriate course of treatment, diagnosis, and management. Adhering to clinical consensus statements does not guarantee successful outcomes in every case. The SMHP emphasises that these statements are not exhaustive and do not encompass all possible diagnostic, management, or treatment decisions, nor do they exclude other reasonable approaches aimed at achieving similar results.

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