Monday, July 22, 2019

Retrospective #156: The New (2013) ADA Nutritional Guidelines: Some Misgivings

My last column, “Cowabunga, the ADA Makes the Turn,” was my overview of the ADA’s groundbreaking move in 2013 to a patient-oriented approach, allowing Low Carb as healthy eating for Type 2 diabetics. Their new Position Paper, “Nutrition Therapy Recommendations for the Management of Adults with Diabetes,” was truly refreshing; it was completely devoid of evidence of “industry support,” which plagues virtually every other dietary prescription coming out of government and public health/medical organizations (e.g., AHA or AMA) or “public interest” groups.
That Position Paper was 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 not prepared by scientists but by the staff of the Senate Select Committee headed by Senator George McGovern (from South Dakota) and aimed to promote the corn and soybean-based Agribusiness industry. If you want to get your hackles up, read the “Illustrated History of Heart Disease 1825-2015,” a diet-heart “timeline” by Diet Heart Publishing.
While I am obviously 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; the report was prepared by nutritionists, not MDs.
 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. 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 and tells them to lose weight.                  
The second reason is that most RDs and CDEs haven’t got a clue either; they still espouse the one-size-fits-all dietary advice in the Dietary Guidelines for Americans prescribed for the whole population, diabetics included – a restricted-calorie, low-fat, and thus high-carb diet – 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 RDs and CDEs, and thus on the clinical practice of nutrition therapy. I hope so, anyway.
Achieving and maintaining body weight goals and delaying or preventing complications of diabetes are other stated goals, and they say, “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.”  I have discovered, however, that nutritional therapy alone, without pharmacotherapy or physical activity, is sufficient IN AND OF ITSELF to put Type 2 diabetes in total remission!
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.” Bravo!
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 will be interesting.

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