American Diabetes Association Nutrition Recommendations: One Size Doesn’t Fit All (and Low Carb is One of the Sizes that Might Fit)!

The American Diabetes Association

American Diabetes Association Nutrition Recommendations: One Size Doesn’t Fit All

Dr. Sean Wheatley, PhD – Science and Research Lead/10 May 2019  

The American Diabetes Association (ADA) recently published a report providing an outline of their dietary guidance for people with prediabetes or diabetes. Although these guidelines are not the official recommendations for people here in the UK it is reassuring that much of the advice they provide is in line with that of our equivalent of the ADA, Diabetes UK (DUK). This week’s blog takes a brief look at some of the key recommendations for people with or at risk of Type 2 diabetes. The full report also includes Type 1 diabetes, but I won’t be focusing on that here.

What is this new report?

This new report, titled “Nutrition Therapy for Adults with Diabetes or Prediabetes: A Consensus Report”, is based on an agreement between a panel of experts. Using an earlier report (published in 2014) as a start they reviewed evidence published since then to see if they needed to make any changes. The ADA are an influential organisation. Not just in the US but also throughout much of the rest of the world. Their recommendations have the potential to have a big impact.

What are their recommendations?

Some of the key messages are:

Nutrition is therapy is a key component of diabetes care. It is important that all members of an individual’s health care team know and champion the benefits of nutrition therapy.

A “one-size-fits all” approach may be simple, but it is not supported by the available evidence. It is also unrealistic as individuals have different needs, cultural backgrounds, personal preferences, socio-economic situations, and possibly other health conditions too.

People with or at risk of diabetes should be referred to lifestyle programmes that include individualised goal-setting components.

There are a range of different dietary approaches that can be successful.

Which dietary approaches are recommended?

The overriding message in relation to nutrition therapy is that healthy eating patterns that can improve blood glucose control, blood pressure and blood fats/cholesterol. Also, helping an individual to achieve or maintain a healthy body weight should be promoted and supported.

They also emphasise that individual needs and preferences need to be taken into account. That helping an individual “to maintain the pleasure of eating while limiting food choices only when indicated by scientific evidence” is important. Considering the enjoyment of food is something that is often overlooked when guidelines are developed. But it is a key factor if there is any chance that an individual is going to stick to any dietary approach.

When it comes to specific diets, the ADA panel concluded that there is no evidence that there is an ideal percentage of calories people should consume from carbs, protein or fat. Dietary approaches included as possibly suitable options include low fat, Mediterranean style, vegetarian or vegan, and low (or even very low) carb. Each of these can have benefits. If it suits the individual and is planned appropriately any of these could be the right fit for someone. It is essential to consider however that the quality of the diet is important, whichever approach is taken. Foods that are high in sugar or refined grains should always be avoided. Foods that are not highly processed should be chosen where possible.

What do they say about low carb diets?

Despite growing evidence and support for the benefits and safety of low carb approaches there are still some lingering concerns and controversies. This report from the ADA arguably provides the strongest endorsement for carb restriction as an option from a major national organisation yet, stating:

“Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individuals needs and preferences”.

“For select adults with type 2 diabetes not meeting glycemic targets or where reducing anti-glycemic medications is a priority, reducing overall carbohydrate intake with low- or very low- carbohydrate eating plans is a viable approach”.

“Most of the trials using a carbohydrate-restricted eating pattern did not restrict saturated fat. From the current evidence, this eating pattern does not appear to increase overall cardiovascular risk, but long-term studies with clinical event outcomes are needed”.

Is this the same as what is recommended in the UK?

It depends whose guidance you follow! DUK guidelines are remarkably similar, concluding there isn’t enough evidence to promote any particular approach. They say that multiple diets can work, and that individualised advice and support is essential. Particularly as adherence to a diet long-term will be the best predictor of sustained success. DUK are perhaps less explicit in relation to the possible benefits of carb restriction. However it is still included as one of the options that might work for some people (and has been since 2011).

The National Institute of Health and Care Excellence (NICE) guidelines are not truly consistent with the ADA and DUK however. The majority of the dietary advice in the current version is actually from 2009 (though the year on the full document is 2015) and so could be considered to be dated. These guidelines recommend dietary advice to focus on “healthy balanced eating that is applicable to the general population”. Though do talk about individualised recommendations for carbs and meal patterns and encourage high-fibre, low glycaemic index carbs.

A consultation on an update to these guidelines is currently ongoing. X-PERT Health have provided a response to this, stating that we believe the guidance should be updated to be more specific about which different dietary approaches can be effective.

So what’s the bottom line?

The take home message really is that one size doesn’t fit all. And that a growing number of national and international guidelines are now strongly supporting and promoting that. Adopting and adapting a dietary approach based on high quality foods in a way that suits the individual’s needs and preferences is the best way to improve the management, or reduce the risk, of Type 2 diabetes.

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