The most recent Standards of Medical Care published by the American Diabetes Association (ADA), as well as spokespeople I have talked to, say that the diet of those with diabetes and prediabetes should be customized to the individual, and if a healthy low-carb diet helps patients to control blood glucose, it is within the parameters of what they advise (more about the specifics). They emphasize that there is no ADA diet, and that the amount of carbohydrate, fat, and protein in the diet should be adjusted to meet treatment goals, as well as the patient's lifestyle (what they are willing and able to do). For weight loss, a low-carb diet is one of the suggested options.
Problem: A lot of people don't seem to know about the acceptability of low-carb diets vis a vis diabetes management. This applies to diabetics (and others on the diabetes spectrum, such as those with prediabetes), but also health care professionals including diabetes educators, and diet researchers, who often use the "Standard ADA Diet" as a control group. It turns out that this is a source of frustration for people at the ADA. I was able to speak with Stephanie Dunbar, the Registered Dietician who is the Director of Nutrition and Medical Affairs for the American Diabetes Association, and Dr. Elizabeth Mayer-Davis, who is a professor of nutrition at the University of North Carolina at Chapel Hill and is on the Board of Directors of the American Diabetes Association. We discussed these issues and others related to low-carb diets and diabetes.
How did the myth of the ADA diet get started? Dunbar says that it's really unknown, but it has been persistent. She says that for almost 30 years, there has been an emphasis on customizing the diet of diabetics for each individual.
Why isn't a low-carb approach suggested as the default diet to begin with? Dunbar says that for most people, the carbohydrate amount they suggest starting with (45-60 grams of total (not net) carbohydrate per meal) is a large reduction in carbohydrate for most people. "You can't underestimate the amount of carbohydrate people are already eating", she said, adding that the goal is to help people make gradual, sequential changes that they can stick to. (I think that there is merit in this approach for some people, but there are advantages to the opposite approach as well.)
The importance of a healthy diet - Dunbar pointed out that no matter how much carbohydrate is in the diet, the focus should be on being sure the diet is healthy. Healthy fats such as those in olive oil, avocado, nuts, etc, should be emphasized (avoiding saturated fats), eating a lot of different non-starchy vegetables, and getting enough fiber are some of the key points. More On the ADA Web Site
Both women pointed out that there is research showing that some people respond well to a low-fat approach to blood glucose control, although I noted that the subjects in most of those studies were losing weight, and weight loss is a small period of time in a person's life. Mayer-Davis agreed, and responded that "there's a lot we don't know about individual variability in response to diet" and the possible affects that diet may have on risk factors for different people. There are many different genes that can contribute to a risk for diabetes, and they may interact with diet in different ways. Thus the emphasis on supporting individuals in customizing their diets.
Dunbar considers the lack of diabetes educators, and diabetes education in general, to be a big problem. There are over 26 million people living with diabetes in the U.S., and only 17,000 diabetes educators. She feels that diabetics are often not able to get the guidance they need to effectively cope with this challenging condition. She says that some diabetes educators and health care providers are not always aware changing standards, or have developed biases regarding the best approach. She also notes that credentialing for diabetes educators is not connected with the ADA. This is done through the National Certification Board of Diabetes Educators.
I agree that people often feel they are on their own. I hear from people who come to this Web site for help and often hear stories from patients whose health care professionals and diabetes educators do not support them or give them guidance for following a low-carb approach to weight loss or blood glucose control. I find this to be quite sad, when I know a healthy low-carb approach has been incredibly helpful to so many.
The Bottom Line: Everyone agrees that as long as the diet has the proper nutrients in it, the amount of carbohydrate can be customized to the individual. One of the great tools diabetics have is that their blood glucose meters can help them with this.
American Diabetes Association. Standards of Medical Care in Diabetes-2012. Diabetes Care. January 2012 vol. 35 no. Supplement 1 S11-S63.
Dunbar, Stephanie. Personal Communication. 2012
Mayer-Davis, Elizabeth. Personal Communication. 2012.