Saturday, December 7, 2013

The Nutrition Debate #167: An Editorial: “Making the Turn”

A short time ago I wrote a column, “Cowabunga, the ADA makes the turn,” lauding the ADA on their new Position Paper, “Nutrition Therapy Recommendations for the Management of Adults with Diabetes.” The paper was written by and primarily for RDs and CDEs. The groundbreaking aspect of the new guidelines is succinctly summed up thus: “It is the position of the American Diabetes Association (ADA) that there is not a ‘one-size-fits-all’ eating pattern for individuals with diabetes.” In other words, low-carb eating is “healthful,” period.

In the “Cowabunga…” column I noted that this position statement was requested and approved by the ADA Executive Committee, largely comprised of practicing physicians. Nutrition Therapy is pretty much the exclusive domain of RD and CDEs, since doctors are poorly trained and, frankly, generally unqualified to practice in this area. Some clinical practices employ, and others refer their patients to, RDs and CDEs. The RDs and CDEs are now leading the way.

I also noted in my next column that I had some misgivings about the new nutrition guidelines, especially with respect to the ADA’s problematic position on dietary fats. Their reasoning: this aspect of nutrition was beyond the current purview of the ADA’s committee; It would have been “tilting at windmills” for them to take it on. And, in fact, they “ducked.”

The ADA’s new position paper states, “Due to the lack of research [?!] in this area, people with diabetes should follow the guidelines for the general population” (“Dietary Guidelines for Americans, 2010,” 10% of calories from SFAs [saturated fats] to reduce CVD risk.” The paper continues, “Consumers can meet this guideline by replacing foods high in SFA (i.e., full-fat dairy products, butter, marbled meats and bacon, and tropical oils such as coconut and palm) with items that are rich in MUFA and PUFA (i.e., vegetable and nut oils, canola, corn, safflower, soy, and sunflower; vegetable oil spreads; whole nuts and nut butters, and avocado.” Ugh…

While the MUFA (monounsaturated fat) recommendation enjoys universal approbation, the PUFA (polyunsaturated) vegetable and seed oil recommendation is extremely troublesome and problematic. So, the next “windmill” is clearly on the horizon. Dulcinea, be patient. Don Quixote (and Rocinante) are on the way. Which brings me back to the dichotomous nature of the battle. On the one hand, we have the RDs and CDEs who have their domain: nutrition therapy. Then we have the physicians whose bailiwick is medical. Within the ADA, the “ancient wisdom” is the “ADA Standards of Medical Care in Diabetes.” It is all-governing for them.

But, do I see a crack in these standards? A few weeks after the ADA produced their new guidelines, The Lancet, one of the world’s leading medical journals, published weekly, issued this: “Diabetes -- a call for research papers.” What’s so unusual about that? Perhaps I am biased, - okay, I know I am - but I see an opening in the way this call was written. Bear with me for a minute.

In the first paragraph, the “call” notes that oral hypoglycemic agents, and later metformin specifically, became “mainstays of treatment for type 2 diabetes,” but their “precise mode of action…remains poorly defined and controversial,” and that the mode for metformin, “remains to be elucidated.” It then laments, “Although newer treatments with better defined modes of action have been developed, there is still no cure for this disease.” Okay, that’s the traditional thinking about disease in general and diabetes in particular: clinicians diagnose disease and then treat it. They prescribe “diet and exercise” -- the wrong diet, and exercise for weight loss, both of which are fruitless, and then pharmacotherapy, to “delay or prevent” the complications of diabetes, which they define as a progressive disease. So, inevitably, the disease progresses.

Now, The Lancet (el don) to the rescue: it “invites high-quality original research papers to be published to coincide with” the ADA’s Scientific Sessions in San Francisco in June 2014. The scope of research is wide open -- “any aspect of type 1 or type 2 diabetes,” and here’s the point which I see as “making the turn”: “Priority will be given to studies that have the potential to change clinical practice.” Do you see it the way I do? Do you see the potential for a nexus between nutrition therapy and the clinical practice of medicine? Is this a call for research papers that demonstrate that the right diet alone. i.e., low-carb (with perhaps a little help from metformin) can be effective in treating type 2 diabetes (and reduce the risk of overmedication in type 1s)?
Maybe, like the knight-errant, I live in a dream world on the plains of La Mancha. Maybe I should just accept that many people will fail on a low carb diet, but at least now it will not be because they were told that low-carb eating is “unhealthy.” If the ADA’s RDs and CDEs can “make the turn,” why cannot los medicos make it as well? All they need to do is look at the data and instead of saying “due to a lack of research,” accept that the proscription against saturated fat (SFAs) and dietary cholesterol was a humungous mistake. It’s time to get it right and by “publishing your best research…, advance knowledge and add to the clinical approaches needed to limit the global harm of diabetes.” The Lancet appears in earnest. Good on you, I say.

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