Wednesday, November 20, 2013

The Nutrition Debate #162: The ADA’s Glycemic, Blood Pressure and Lipid Goals

I hope I have made it clear how absolutely thrilled I am by the ADA’s new Position Paper titled “Nutrition Therapy Recommendations for the Management of Adults with Diabetes.” It proclaims that “there is not a ‘one-size-fits-all’ eating pattern for individuals with diabetes.” Importantly, the ADA declares “it was written at the request of the ADA Executive Committee, which has approved the final document.” The committee was comprised almost entirely of MSs, MPHs and PhDs who are all also RDs and/or CDEs. Please take note of this important fact.

However, we do not live in a perfect world, and there is only so much one committee can do to turn the Titanic. This is an apt metaphor because we who have adopted a Western Diet are all in the same boat. We are going to die from one of the diseases of Western Civilization if we stay on our present course, i.e., if we continue to eat the Standard American Diet (SAD) that we have been told to eat ever since the diet/heart hypothesis was first promulgated in the 1950s.

Think back - Ancel Keys made the cover of Time magazine in January 1961 and joined the board of the American Heart Association. In 1977, George McGovern’s Senate Select Committee’s staff produced Dietary Goals of the United States. To say that both of these individuals were misguided would be an understatement of, well, Titanic proportions. They will be remembered as the principal enablers of the corrupt consortium of agribusiness, big pharma, and self-serving, so-called “scientists” in the professional organizations and government agencies who continue to perpetuate this mess today.

Today, the ADA committee’s changes represent just one voice in the ADA, on the nutrition therapy side. Their goal, it seems to me, was increased flexibility to help patients by “individualizing” the therapeutic approach. I think it was a brilliant and a practical ‘workaround’ for the proscription on low-carb diets in previous iterations: low-carb nutrition therapy was first deemed “safe” for one year in 2008 and then more recently, for two years. Now, the time limit has been eliminated. A low carb “eating pattern” is now perfectly okay to use indefinitely. It is now at full par with others. There are no limitations.

So, with that as preface, what outcomes can be expected? What goals do we set our sights on achieving? How aspirational can we afford to be without seeming to be unreasonable? Of course, I know what is possible, but my n = 1 experience is purely anecdotal. What I am more interested in seeing is what the ADA thinks may be possible. What goals do they set for glycemic control, and blood pressure and lipid improvement? The answer, sadly, is abysmal. But don’t blame this committee. That was, as it should be, beyond the scope and purview of their recommendations. Who then?

Answer: the ADA’s doctors. The goals the ADA hopes to achieve for the management of adults with diabetes are as follows:

1.       Attain individualized glycemic, blood pressure, and lipid goals. General recommended goals from the ADA for these markers are as follows*:

·         A1C < 7%

·         Blood pressure < 140/80mmHg

·         LDL cholesterol < 100 mg/dl

·         Triglycerides < 150 mg/dl

·         HDL > 40mg/dl for men; > 50mg/dl for women

2.       Achieve and maintain body weight goals

3.       Delay or prevent complications of diabetes

* A1C, blood pressure and cholesterol goals may need to be adjusted for the individual based on age, duration of diabetes, health history, and other present health conditions. Further recommendations for individualization of goals can be found in the ADA Standards of Medical Care in Diabetes (emphasis mine). This asterisk is by way of saying that doctors may find it necessary to set less ambitious goals (gasp!) than the already lax goals they have specified above. This is truly shocking.

So, in case you have not divined where I’m coming from, it is the ADA’s medical doctors who set these goal and who are not yet “up to speed.” Or, continuing the Titanic metaphor, as the mighty ship of state (our health) continues to sink, “the band [the medical doctors] plays on.” The  RDs and CDEs “rearrange the deck chairs” in issuing new nutrition therapy recommendations – but will this make a difference or will it just be a futile exercise as our health continues to sink? We’ll have to wait and see if the doctors at the ADA come around. Or, even if not, if more patients will do as David Letterman has done and aspire to higher goals to control their diabetes (and blood pressure and blood lipids),”through diet, mostly.”
If you do work to control your type 2 diabetes “through diet, mostly,” you can reasonably expect to “achieve and maintain body weight goals” and “delay or prevent complication of diabetes.” And you can achieve splendid lipids! As I am always crowing, I have now lost 140 pounds, my most recent blood pressure was 110/70 (with meds), and my A1c 5.7%. My latest Total Cholesterol was 217, LDL 122, HDL 85 and TRIG 49. In a separate test my LDL particles were Pattern A (large buoyant). I have achieved and maintain this with a Very Low Carb WOE: 75% fat, 20% protein and 5% carbohydrate. The triglycerides are particularly influenced by carb in the diet. This puts my Trig/HDL ratio at a stellar 0.57, indicating a very low risk of CVD. Does you doc do that ratio for you? If not, look at your own #’s and do the interpretation yourself!


  1. Very informative post. Nutrition and proper exercise plays an important role in everybody life. Thanks for sharing such an interesting and informative information.

  2. Thanks for exploring the blog, Sud...