Wednesday, October 30, 2013

The Nutrition Debate #156: The New ADA Nutrition Guidelines: Some Misgivings


My last column, “Cowabunga, the ADA makes the turn,” is my overview of the groundbreaking move by the ADA to a patient-oriented approach to healthy eating for type 2 diabetics. Their new Position Paper, “Nutrition Therapy Recommendations for the Management of Adults with Diabetes” is a truly refreshing breath of fresh air; it is completely devoid of evidence of “industry support,” which plagues virtually every other dietary prescription coming out of government, public health/medical organizations (e.g., AHA or AMA) or public interest groups.

This new Position Paper is in strong contrast with the “Dietary Guidelines for Americans, 2010,” which has hardly varied from its inception in 1980. The 1980 cover states in boldface: EAT LESS FAT, SATURATED FAT, AND CHOLESTEROL. Its predecessor document, the 1977 “Dietary Goals for the United States,” was prepared, not by scientists, but by the staff of the Senate Select Committee headed by Senator George McGovern (Dem., S. Dakota) and aimed to promote the corn and soy bean-based Agribusiness industry. If you want to get your hackles up, read the “Illustrated History of Heart Disease 1825-2015,” a diet-heart “timeline” prepared by Diet Heart Publishing.

The new ADA Nutrition Guidelines are 22 pages long, including 14 pages of text and tables and almost 250 references. While I obviously am very pleased that the American Diabetes Association (ADA) has turned the corner on “nutritional therapy,” I would still pick a quarrel here and there. Their glycemic, blood pressure and lipid goals, for example, are unambitious in the extreme: They adhere to the “general recommended goals of the ADA for these markers.” Okay, they didn’t want to pick a quarrel there, obviously, plus they allow that “they may need to be adjusted for the individual…” based on various factors, from which I inferred (gasp!) less stringent goals as “can be found in the ADA Standards of Medical Care in Diabetes.”

 
And while this document was written by, for and from the perspective of the Medical Nutrition Therapist (MNT), it acknowledges that “a large percentage of people with diabetes do not receive any structured diabetes education and/or nutrition therapy” and that “in addition to MNT provided by an RD,
diabetes self-management education and support are critical elements of care for all people with diabetes and are necessary to improve outcomes in a disease that is largely self-managed.” This point is very important in two respects: Too few type 2 diabetics take responsibility for self-education or self-care (readers of this blog excepted, of course). Most type 2 diabetics just let their doctor (who is generally clueless in nutrition) take care of their diabetes; he takes their blood, writes a script, tells them to lose weight, and it’s “next patient”                   

The second reason is that most RDs and CDEs haven’t got the word yet; they still espouse the one-size-fits-all dietary advice in the Dietary Guidelines for Americans prescribed for the whole population, diabetics included – restricted-calorie, low-fat, and thus high-carb – which is very bad for the general population (raising their risk for CVD and diabetes) but disastrous advice for type 2 diabetics. So, hopefully, these new recommendations will have some impact on them, i.e., on the clinical practice of nutrition therapy. I can hope so, anyway. You could help (they’re “busy”) by printing this column – better yet, print the entire 22 page ADA document – and take it with you to your next appointment with your MD, RD or CDE. It’s “continuing education.”

Achieving and maintaining body weight goals and delaying or preventing complications of diabetes are other stated goals, and they say that “due to the progressive nature of type 2 diabetes, nutrition and physical activity interventions alone (i.e. without pharmacotherapy) are generally not adequately effective in maintaining persistent glycemic control over time for many individuals.” Now some of us (and I include myself among “us”), find that nutritional therapy alone, totally without physical therapy or pharmacotherapy, is sufficient in and of itself to keep type 2 diabetes in total remission! Progressive disease, harrumph!  I say this as a T2 of 26 years.

Anyway, achieving and maintaining body weight goals and delaying or preventing complications of diabetes are very important goals and highly desirous. The report states further, “More than three out of every four adults with diabetes are at least overweight, and nearly half of individuals with diabetes are obese.” And, “Among the studies reviewed, the most consistently reported significant changes of reducing excess body weight on cardio vascular risk factors were an increase in HDL cholesterol, a decrease in triglycerides, and a decrease in blood pressure.” See #67, #68 and #70, here, here, and here for my take on these topics.

“Weight loss appears to be most beneficial for individuals with diabetes early in the disease process.” (But your knees can benefit at any time.) If you are a newly diagnosed type 2, this might be helpful, and the ADA Position Paper wisely ducks the surgery issue. “Bariatric surgery is recognized as an option for individuals with diabetes who meet the criteria for surgery and is not covered in this review. For recommendations on bariatric surgery, see the ADA Standards of Medical Care,” they say. I say, read The Nutrition Debate #145, “Gastric Bypass vs. Medical Therapy for Metabolic Syndrome,” carefully before you contemplate bariatric surgery.
The ADA Position Paper does address the macronutrients individually, as well as various micronutrients, vitamins and minerals. It also expresses a “bias” (with reasons) for the Mediterranean Diet. I will delve into this and other aspects of this important new blueprint into the frontier of “nutrition therapy” in upcoming columns. Stay tuned. It should be interesting.

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