The American Diabetes Association (ADA) has just released its new Standards of Medical Care in Diabetes (2020)  which begins the section on Medical Nutrition Therapy by referring to the ADA’s April 2019 Consensus Report which emphasized that there is no “one-size-fits-all” eating pattern for the prevention or management of diabetes (more in this article).
In the section on Medical Nutrition Therapy (MNT), the new Standards of Medical Care 2020 underscores that for many people with diabetes, the most challenging part about treatment is determining what to eat — and for this reason the ADA emphasizes that meal planning needs to be individualized.
The ADA also states that all people diagnosed with diabetes should be referred to an a Registered Dietitian (RD/RDN) who is “knowledgeable and skilled in providing diabetes-specific MNT at diagnosis and as needed throughout the life span” and that research indicates that edical Nutrition
Therapy delivered by an RD/RDN is associated with decrease in HbA1C of between 0.3 and 2.0% for people with type 2 diabetes .
In the section on Eating Patterns, Macronutrient Distribution and Meal Planning, the new Standards of Medical Care in Diabetes re-iterated what the Consensus Report stated, 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 individualized assessment of current eating patterns, preferences, and metabolic goals.”
As well, the new Standards of Medical Care re-iterates that a low carbohydrate eating pattern is an example of one that is both healthful and helpful in controlling blood glucose;
“The Mediterranean-style ([4-5], low-carbohydrate* [6-8] and vegetarian or plant-based [9-10] eating patterns are all examples of healthful eating patterns that have shown positive results in research, but individualized meal planning should focus on personal preferences, needs, and goals. “
*In the Consensus Report referred to in this section, a low carbohydrate eating pattern was defined as 26-45% of total calories from carbohydrate and a very low carbohydrate eating pattern (ketogenic) was defined as 20-50 g of non-fiber carbohydrate per day.
The new Standards of Medical Care encourages healthcare practitioners to not only consider a person’s metabolic goals, but also their personal preferences, including tradition, culture, religion, health beliefs, goals, and economic situation in helping them choose a suitable eating patterns.
It encourages each member of the healthcare team;
“to be knowledgeable about nutrition therapy principles for people with all types of diabetes and be supportive of their implementation.”
Given that a low carbohydrate diet is one of the eating patterns that the ADA considers both healthful and helpful in the management of diabetes, healthcare professionals ought to be prepared to be supportive of a person seeking to implement this approach.
The Standards of Medical Care states that until there is stronger evidence surrounding comparative benefits of different eating patterns in specific individuals, “healthcare providers should focus on the key factors that are common among the patterns:
1) emphasize non-starchy vegetables
2) minimize added sugars and refined grains
3) choose whole foods over highly processed foods to the extent possible”.
Similar to what was stated in the Consensus Report, the Standards of Medical Care reiterates that “research studies on some low-carbohydrate eating plans generally indicate challenges with long-term sustainability, it is important to reassess and individualize meal plan guidance regularly for those interested in this approach”. Given the wide range of “low carbohydrate” diets people may be following, it makes good sense to ensure a person is following one that is evidence-based and appropriate for them.
The Standards of Medical Care restates that at this time a low carbohydrate eating pattern is not recommended for women who are pregnant or lactating, people with or at risk for disordered eating, or people who have renal disease, and should be used with caution in patients taking sodium–glucose cotransporter 2 inhibitors due to the potential risk of ketoacidosis [11-12]. (Note: This caution regarding those taking certain medication is covered in this previous article).
The section of the Standards of Medical Care in Diabetes on Carbohydrates re-emphasizes the benefits to blood sugar (glycemic) control of a low carbohydrate eating patterns that was previously outlined in the Consensus Report, namely;
“For people with type 2 diabetes or prediabetes, low-carbohydrate eating plans show potential to improve glycemia and lipid outcomes for up to 1 year [6, 8, 13, 14-17]
The new Standards re-iterates that “part of the challenge in interpreting low-carbohydrate research has been due to the wide range of definitions for a low-carbohydrate eating plan [8, 18]”.
There is nothing really “new” in the section on Medical Nutrition Therapy in the new Standards of Medical Care as it pertains to the safety and efficacy of low carbohydrate eating patterns, or in their ability to help improve blood sugar control. This, in and by itself is very encouraging because it means that the ADA has considers a well-designed low carbohydrate diet to be both healthful and helpful in the management of diabetes for the second year in a row.
When will Diabetes Canada complete their review of the current literature, including that cited by the ADA in the Consensus Report and their new Standards of Medical Care in Diabetes 2020 and update their position on the use of low carbohydrate diets in those with diabetes in Canada?
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- American Diabetes Association, Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2020
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