Friday, August 2, 2019

Retrospective #167: Don Quixote on “Making the Turn”

In Retrospective #155, “Cowabunga, the ADA makes the turn,” I lauded the ADA on their new (2013) Position Paper, “Nutrition Therapy Recommendations for the Management of Adults with Diabetes.” I pointed out that it was written by and primarily for RDs and CDEs and could be 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.”
From my POV that meant that low-carb eating was now “healthful,” period. No caveats, as the ADA had before.
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 generally unqualified to practice in this area. Some clinical practices employ and others refer patients to RDs and CDEs. The RDs and CDEs could lead the way.
I also noted in #155 that I had some misgivings about the new nutrition guidelines, especially with respect to the ADA’s problematic position on dietary fats. It was beyond the purview of the ADA’s RD and CDE committee, they said; It would have been “tilting at windmills” for them to take it on. They would “duck.” But did they? You decide.
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.” So, this is still what the ADA advocates.
While the MUFA (monounsaturated fat) recommendation has universal endorsement, 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 is on the way. The battle is about to begin. On one side we have the RDs and CDEs who have their domain: nutrition therapy. On the other, the physicians whose bailiwick is medical, guided by the “ADA Standards of Medical Care in Diabetes.” It is all-governing for them.
And on the sidelines, The Lancet, one of the world’s leading medical journals. A few weeks after the ADA produced the new guidelines, The Lancet issued this: “Diabetes -- a call for research papers.” What’s so unusual about that?
In the first paragraph, the “call” notes that oral hypoglycemic agents, and later Metformin specifically, became “mainstays of treatment for Type 2 diabetes.” 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 Type 2 diabetes. Doctors prescribe “diet and exercise” -- the wrong diet, and exercise for weight loss, both of which are fruitless, and then they add pharmacotherapy, to “delay or prevent” the complications of diabetes.
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.” “Priority will be given to studies that have the potential to change clinical practice.” Do you see this the way I do? Do you see the potential for a conjunction of nutrition therapy with clinical practice? Is this a call for research to show that the right diet, a low-carb diet, can be effective in treating Type 2 diabetes?
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. At least now it will not be because they were told that low-carb eating is unhealthy.” But, if the ADA’s RDs and CDEs can “make the turn,” why cannot los medicos make the turn as well? 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 to be in earnest. Good on them, I say.

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