Posted on by Joy Kiddie, MSc, RD

New ADA Standards of Medical Care Includes Low Carbohydrate Diet

The American Diabetes Association (ADA) has just released its new Standards of Medical Care in Diabetes (2020) [1] which once again includes a low carbohydrate diet.  The section on Medical Nutrition Therapy begins by referring to the ADA’s April 2019 Consensus Report[2] 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”[1] and that research indicates that Medical 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 [3].

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
and
3) choose whole foods over highly processed foods to the extent possible”[2].

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).

Carbohydrates

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]”.

Final Thoughts…

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?

More Info

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To your good health!

Joy

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References

  1. American Diabetes Association, Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2020
    American, Diabetes Care Jan 2020, 43 (Supplement 1) S48-S65; DOI: 10.2337/dc20-S005
  2. Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care 2019;42:731—754
  3. Franz MJ, MacLeod J, Evert A, et al. Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet 2017;117:1659—167
  4. Esposito K, Maiorino MI, Ciotola M, et al. Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: a randomized trial. Ann Intern Med 2009;151:306—314
  5. Boucher JL. Mediterranean eating pattern. Diabetes Spectr 2017;30:72—76
  6. 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
  7. van Zuuren EJ, Fedorowicz Z, Kuijpers T, Pijl H. Effects of low-carbohydrate- compared with low-fat-diet interventions on metabolic control in people with type 2 diabetes: a systematic review including GRADE assessments. Am J Clin Nutr 2018;108:300—331
  8. Snorgaard O, Poulsen GM, Andersen HK, Astrup A. Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes. BMJ Open Diabetes Res Care 2017;5:e000354
  9. Rinaldi S, Campbell EE, Fournier J, O’Connor C, Madill J. A comprehensive review of the literature supporting recommendations from the Canadian Diabetes Association for the use of a plant-based diet for management of
  10. Pawlak R. Vegetarian diets in the prevention and management of diabetes and its complications. Diabetes Spectr 2017;30:82—88
  11. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. Accessed 1 November 2019. Available from http://www.fda.gov/Drugs/DrugSafety/ucm475463.htm
  12. Blau JE, Tella SH, Taylor SI, Rother KI. Ketoacidosis associated with SGLT2 inhibitor treatment: analysis of FAERS data. Diabetes Metab Res Rev 2017;33:e2924
  13. 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
  14. 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
  15. van Wyk HJ, Davis RE, Davies JS. A critical review of low-carbohydrate diets in people with type 2 diabetes. Diabet Med 2016;33:148—157
  16. Meng Y, Bai H, Wang S, Li Z, Wang Q, Chen L. Efficacy of low carbohydrate diet for type 2 diabetes mellitus management: a systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2017;131:124—131
  17. Tay J, Luscombe-Marsh ND, Thompson CH, et al. Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial. Am J Clin Nutr 2015;102:780—790
  18. Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database Syst Rev 2009;1:CD006296