On Monday, December 17, 2018, the American Diabetes Association released its new 2019 Standards of Medical Care in Diabetes including its Lifestyle Management Standards of Care which includes use of a low carbohydrate diet saying it may result in lower blood sugar levels and also has the potential to lower the use of blood sugar lowering medications[1] in those with Type 2 Diabetes. In support, they cite the one-year study data by Virta Health[2], as well as two other studies [3,4].
“…research indicates that low carbohydrate eating plans may result in improved glycemia and have the potential to reduce antihyperglycemic medications for individuals with type 2 diabetes…”
The new 2019 Standards of Care reflect the American Diabetes Association’s change in approach which began in 2018 to revise the guide throughout the year as new scientific evidence warrants it, rather than to wait annually to update guidelines. Towards that end, in November 2018, the American Diabetes Association launched a joint partnership with the American Heart Association to raise awareness about the increased risk of cardiovascular disease for those diagnosed with Type 2 Diabetes and in October, the American Diabetes Association in conjunction with the European Association for the Study of Diabetes (EASD) released a joint Position Statement which approved use of a low carbohydrate diet as Medical Nutrition Therapy (MNT) for adults with Type 2 Diabetes (you can read more about that here).
The American Diabetes Association’s newly released 2019 Lifestyle Management Standards of Medical Care in Diabetes builds on this joint consensus paper released with the EASD by including use of a low carbohydrate diet in the section on Nutrition Therapy where it emphasizes a patient-centered, individualized approach based on people’s current eating patterns, personal preferences and metabolic goals;
“Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals. Consider personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) as well as metabolic goals when working
with individuals to determine the best eating pattern for them.”
The ADA deemphasizes a focus on specific nutrients; whether fat or carbohydrate and stresses that a variety of eating patterns are acceptable.
“Emphasis should be on healthful eating patterns containing nutrient-dense foods, with less focus on specific nutrients. A variety of eating patterns are acceptable for the management of diabetes”.
The Lifestyle Management Standards of Care underscores the importance of having a Registered Dietitian involved in the process of assessing a person’s overall nutritional status, as well designing an individualized Meal Plan for them that is tailored to their health, cooking skills, financial resources, food preferences and health goals and that is coordinated with the person’s physician who is responsible for prescribing and adjusting their medications.
“…a referral to an RD or registered dietitian nutritionist (RDN)
is essential to assess the overall nutrition status of, and to work collaboratively with, the patient to create a personalized meal plan that considers the individual’s health status, skills, resources, food preferences, and health goals to coordinate
and align with the overall treatment plan including physical activity and medication.”
They outline a few eating patterns that are examples of healthful eating
patterns that have shown positive results in research, including the Mediterranean diet, the DASH diet, plant-based diets and add that
“low-carbohydrate eating plans may result in improved glycemia (blood sugar) and have the potential to reduce anti-hyperglycemic medications (medications to lower blood sugar) for individuals with type 2 diabetes.”
The documents emphasizes again that individualized meal planning should focus on personal preferences, needs, and goals rather than focusing on any specific macronutrient distribution.
Without citing any references, the Standards of Care state that there are challenges with the ability of people to continue to follow a low carbohydrate diet long term and as a result that it’s important to reassess people who adopt this approach.
“As 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.”
It’s unfortunate that the ADA did not have access to the very recently released two-year data from Virta Health’s study which showed a 74% retention rate in the low carb intervention.
The ADA takes the position that a low carbohydrate meal plan is not recommended for women who are pregnant or breastfeeding, people who have- or are at risk for eating disorders, or have kidney disease and that caution should be taken with those taking SGLT2 inhibitor medication* for management of Type 2 Diabetes, as there is the potential risk of a condition known as diabetic ketoacidosis (DKA).
*This article outlines the risk of SGLT2 inhibitors, as well as other medications used to treat high blood pressure and some mental health disorders that need supervision when following a low-carbohydrate diet.
Low Carbohydrate Diets for Weight Loss
The ADA’s new 2019 Lifestyle Management Standards of Care also includes use of a low carbohydrate diet in the Weight Management section of the document, which underscores the benefit in blood sugar control, blood pressure and cholesterol (lipids) of weight loss of at least 5% body weight in overweight and obese individuals and that weight loss goals of 15% body weight may be appropriate to maximize benefit.
In this section dealing with Medical Nutrition Therapy (MNT), the role of a Registered Dietitian (RD) / Registered Dietitian Nutritionist (RDN) is emphasized;
“MNT guidance from an RD/RDN with expertise in diabetes and weight management, throughout the course of a structured weight loss plan, is strongly recommended.”
The ADA’s Lifestyle Management Standards of Care indicates that studies have demonstrated that a variety of eating plans with different macronutrient composition can be used safely and effectively for 1-2 years to achieve weight loss in people with Diabetes, including the use of a low-carbohydrate diet and that no single approach has been proven to be best;
“Studies have demonstrated that a variety of eating plans, varying in macronutrient composition, can be used effectively and safely in the short term (1—2 years) to achieve weight loss in people with diabetes. This includes structured low-calorie meal plans that include meal replacements and the Mediterranean eating pattern, as well as low-carbohydrate meal plans. However, no single approach has been proven to be consistently superior.”
It is concluded that more study is needed to know which of these dietary patterns is best when used long-term and which is best accepted by patients over a long period of time.
“more data are needed to identify and validate those meal plans that are optimal with respect to long-term outcomes as well as patient acceptability.”
In the section dealing specifically with Carbohydrates, it is indicated that for people with Type 2 Diabetes or prediabetes that low-carbohydrate eating plans show the potential to improve blood sugar control and cholesterol outcomes for up to one year, and that part of the problem in interpreting low-carbohydrate research has been due to the wide range of definitions of what “low-carbohydrate” is (i.e. <130 g of carbohydrate, <50 g carbohydrate).
Point of Interest: No where in the Lifestyle Management Standards of Medical Care in Diabetes does the American Diabetes Association define what they mean by “low carbohydrate diet”. The fact that they cite the one-year study data from Virta Health[2] (see above) as evidence for safety and efficacy in lowering blood sugar and Diabetes medication usage when that study clearly employs a ketogenic approach is most interesting.
” 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. Part of the challenge in interpreting low-carbohydrate research has been due to the wide range of definitions for a low-carbohydrate eating plan.”
The Standards of care stated that because most people with Diabetes say they eat between 44—46% of calories as carbohydrate, and that changing people’s usual macronutrient intake usually results in them going back to how they ate before, that they recommend designing meal plans based on the person’s normal macronutrient distribution, because it is most likely to result in long-term maintenance.
“Most individuals with diabetes report a moderate intake of carbohydrate (44—46% of total calories). Efforts to modify habitual eating patterns are often unsuccessful in the long term; people generally go back to their usual macronutrient distribution. Thus, the recommended approach is to individualize meal plans to meet caloric goals with a macronutrient distribution that is more consistent with the individual’s usual intake to increase the likelihood for long-term maintenance.”
NOTE: Most people are likely to indicate they eat within the recommended range of carbohydrate intake (45-65% of calories as carbohydrate) because that is how they were counselled when they were diagnosed with Type 2 Diabetes, but stating that they should continue to eat that way because they are most likely to be compliant makes no sense. If a person realizes they are not able to meet optimal blood sugar levels eating that level of carbohydrate intake and are interested and motivated to lower it, then as healthcare professionals, we need to be equipped to support that in an evidenced-based manner.
In this section on Carbohydrates, it was emphasized that;
“…both children and adults with Diabetes are encouraged to minimize intake of refined carbohydrates and added sugars…”
and
“The consumption of sugar-sweetened beverages (including fruit juices) and processed ”low-fat” or ”nonfat” food products with high amounts of refined grains and added sugars is strongly discouraged.”
Protein
With respect to protein intake, it was emphasized that;
(1) there isn’t any evidence to suggest that adjusting protein intake from 1—1.5 g/kg body weight/day (15—20% total calories) will improve health.
(2) research is inconclusive regarding the ideal amount of dietary protein to optimize either blood sugar control or cardiovascular disease (CVD).
(3) “some research has found successful management of type 2 diabetes with meal plans including slightly higher levels of protein (20—30%), which may contribute to increased satiety.”
Caution for those with diabetic kidney disease (i.e. urine albumin and/or reduced glomerular filtration rate) advise that dietary protein should be maintained at the recommended daily allowance of 0.8 g/kg body weight/day.
Fats
The Standards of Care acknowledged that the ideal amount of dietary fat for individuals with diabetes is controversial and underscored that the National Academy of Medicine has defined an acceptable macronutrient distribution for total fat for all adults to be 20—35% of total calorie intake. They stated that the type of fats consumed are more important than the total amount of fat when looking at metabolic goals and cardiovascular (CVD) risk and recommended that the percentage of total calories from saturated fats be limited. It was recommended that people with Diabetes follow the same guidelines as the general population when it comes to intakes of saturated fat, dietary cholesterol and trans fat and they recommended a focus on eating polyunsaturated and monounsaturated fats for improved glycemic (blood sugar) control and blood lipids (cholesterol) and that there does not seem to be a CVD benefit of supplementing with omega-3 polyunsaturated fatty acids.
Other Points of Interest
It is interesting that the Lifestyle Management Standards of Care indicated that the literature concerning Glycemic Index (GI) and Glycemic Load (GL) in individuals with Diabetes often yields conflicting results and that “studies longer than 12 weeks report no significant influence of glycemic index or glycemic load independent of weight loss on A1C”.
Conclusion
The American Diabetes Associations 2019 Lifestyle Management Standards of Medical Care in Diabetes emphasis on a patient-centered, individualized approach is under-girded by an acknowledgment that based on the current evidence, a low-carbohydrate diet is both safe and effective used as Medical Nutrition Therapy for up to two years in adults in order to lower blood sugar, reduce Diabetes medication usage and support weight loss.
I’m a Registered Dietitian that has years of experience working with non-insulin dependent individuals with Type 2 Diabetes. I can assess your overall nutritional status, review your personal and family medical background and lifestyle habits and create a individualized Meal Plan just for you that considers your health status, cooking skills, food preferences, resources as well as your health and weight goals. I even offer a single package (the Complete Assessment Package) that will do just that.
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References
- American Diabetes Association, Lifestyle Management Standards of Medical Care in Diabetes – 2019. Available at: http://care.diabetesjournals.org/content/42/Supplement_1. Accessed: Dec. 17, 2018.
- Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583—612
- Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes 2017;7:304
- Sainsbury E, Kizirian NV, Partridge SR, Gill T, Colagiuri S, Gibson AA. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract 2018;139:239—252