Retrospective #155: Cowabunga, the ADA makes the turn

In 2013, for the first time in 5 years, the American Diabetes Association (ADA) issued new nutritional guidelines for adults with Type 2 diabetes. They were revolutionary, and I was ecstatic. The implications of this shift were great.

The changes were summed up by Miriam Tucker in a Medscape Alert. Her lede was, “New nutritional guidelines …focus on overall eating patterns and patient preference, rather than any particular dietary prescription.” “The authors intentionally avoided using the word diet,” lead author Alison Evert told Medscape Medical News.

“Throughout the document, we refer to 'eating plans' or 'eating patterns' rather than 'diet,'” Evert, MS, RD, CDE, told Medscape. “We want to work with patients and help them achieve individual health goals. A variety of eating patterns can help, and people are more likely to follow an eating plan that speaks to them," she said. Boy is that true! “Doctors and dietitians have long recognized that ‘diets’ work best if you, the patient, like them.” To which I add, “And you are more likely to stick to it if you can lose weight and feel great without hunger and cravings!”

“Indeed, the new evidence-based position statement…reviews the evidence for several popular eating plans, including Mediterranean style, vegetarian, low fat, low carbohydrate, and Dietary Approaches to Stop Hypertension (DASH), but does not recommend any specific one.” "Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals [my emphasis] should be considered when recommending one eating pattern over another," they said. To me this means that for Type 2s, Low Carb is best.

Remember, it was only a few decades ago that Robert Atkins, MD, was scoffed at and ridiculed. And it’s been only 17 years since Gary Taubes’s seminal piece in The New York Times, “What If It’s All Been a Big Fat Lie?” Then, after years of ‘anecdotal reports’ of the success of Low Carb eating on both weight loss and “metabolic goals,” in 2010 the ADA allowed that low carb dieting could be tried for a year, but the long-term safety of low carb eating was unknown. And then last year the ADA allowed Low Carb, maybe for two years… Well, they’ve decided now, folks: Low Carb is safe! YOU can now pick the eating plan that works best for you, and the ADA says, “…we want to work with patients and help them achieve (their) individual health goals” because “nutrition therapy is a core tenet of diabetes management.” Note: Nutrition is “core” and you can now choose the eating plan that works best for you.

Of course, to get to this point the ADA had to construct a giant ‘workaround.’ Here’s how they did it. Starting with their 2008 guidelines, and in recognition of the growing controversy around macronutrient proportions (e.g., low-fat, high-carb vs. low-carb, high-fat), they ducked. It was a beautiful finesse. With respect to the guidelines for each macronutrient – dietary fat, protein and carbohydrate – they said “the evidence is inconclusive…therefore, goals should be individualized.” That’s very convenient and a brilliant way to transition to the 2013 ADA guidelines.

They now say, “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.” The only caveat is your eating pattern should consist of “nutrient dense foods in appropriate portion sizes to improve overall health.” Otherwise, choose your eating plan “based on personal preferences and metabolic goals. So, if you’re a “woke” Type 2, your eating pattern should be Low Carb!

It further urges “that each person with diabetes be actively engaged in self-management, education and treatment planning with his or her health care provider” since “for many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat.” They got that right! And then this: “Carbohydrate intake has a direct effect on postprandial glucose levels in people with diabetes and is the primary macronutrient of concern in glycemic management.” And this: “Monitoring carbohydrate amounts is a useful strategy for improving postprandial glucose control. Evidence exists that both the quantity and type of carbohydrates in a food influence blood glucose level, and total amount of carbohydrate eaten is the primary predictor of glycemic response.” Type 2s knows this, but I didn’t expect to hear it from the ADA. “Congratulations, ADA!” This is a patient-centered manifesto!