Every few years, the American Diabetes Association publishes "Nutritional Therapy Recommendations for the Management of Adults with Diabetes". In October 2013, the most recent version was published online ahead of print in the journal Diabetes Care.
Summary: At the end of the statement is the following paragraph: "There is no standard meal plan or eating pattern that works universally for all people with diabetes. In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals, personal and cultural preferences, health literacy and numeracy, access to healthful choices, and readiness, willingness, and ability to change. Nutrition interventions should emphasize a variety of minimally processed nutrient-dense foods in appropriate portion sizes and part of a healthful eating pattern and provide the individual with diabetes practical tools for day-to-day food plan and behavior change that can be maintained over the long term."
Translation: There is no one set of dietary recommendations that is going to be best for everyone with diabetes - and by extrapolation, we can probably add people on the "diabetes spectrum" that do not (yet) have diabetes. The document hit this point again and again: under the topics "Protein", "Carbohydrate", "Fat", "Weight Loss" and more. There is truly no one amount of any particular type of food that is best for everyone. The important thing is to guide people to find out what works best for them in achieving the best possible blood glucose, blood pressure, and other goals. Then support them in following that eating pattern. Period. This, of course, is what low-carb authors and researchers have been saying for years. (More specifically, most of them say a version of, "Find the amount of carbohydrates and proteins that are best for you. Fill in the rest with fats.")
Here's what the guidelines say about some specific issues which I think will be of interest to my readers.
Blood Glucose Control"Metabolic control can be considered the cornerstone of diabetes management." In other words, top priority is given to good blood glucose control, because this is what prevents all the horrible complications of diabetes. This includes the increased risk for heart disease and stroke that comes along with diabetes, as well as the well-known complications of poor kidney function, compromised eyesight (and possibly blindness), neuropathy (nerve pain), damage to the circulation (possibly leading to amputation) and general disability.
Carbohydrate Consumption, Including Sugar"Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains a key strategy in achieving glycemic control." In other words, the important thing is to figure out how much carbohydrate works for you, and then make sure you are eating that amount. Also, make sure your carbohydrate comes from nutritious sources -- "vegetables, fruits, whole grains, legumes, and dairy products". More specifically, avoid refined carbohydrates and added sugar, especially sugar-sweetened beverages.
Weight LossAgain and again "modest weight loss" is mentioned as the goal, for two reasons: 1) Research has shown that large weight losses are difficult to maintain and 2) most of the benefit of weight loss is achieved by losing 5-10% of body weight, so that is what is recommended. The guidelines also emphasize the importance of preventing weight gain, as people with diabetes have a strong tendency to gain weight over time.
Low-Carbohydrate DietsFor the first time, the guidelines devote a fair amount of space to describing the research on reduced-carbohydrate diets. They include positive effects from carbohydrate restriction, and also some of the problems with the research (which are well-known) such as 1) vastly varying definitions of "low-carbohydrate" make comparing these studies difficult, and 2) separating the effects of diet from the effects of weight loss is an issue not completely resolved (this is not just a problem with low-carb diet research, but diet research on diabetics in general).
A Few Other RecommendationsKeep saturated fat low. Moderate alcohol consumption for people who drink is OK (one drink per day for women, two for men), but watch it if you are taking diabetes medications, as blood sugar can drop low a few hours later. Half of your grains should be whole grains. Eat fatty fish instead of taking fish oil. Get vitamins from food instead of pills. Salt recommendations same as for non-diabetics.
Changes from Previous Guidelines
In looking at previous versions of the Nutritional Recommendations for Adults with Diabetes guidelines (2008, 2004, 2002), there have been quite a few changes, particularly when comparing the 2002 guidelines with the present ones. Of particular interest:
1) Low-carb diets are definitely now considered to be a viable option deserving consideration. No longer is there even a mention of a minimum requirement of carbohydrate. When they say "the diet should be individualized to the person", they definitely are meaning "including people who respond well to low-carb diets". Although they have been slowly evolving into this stance (and indeed have said as much in recent years), I think this is the clearest the official recommendations have been about it.
2) Low-fat diets are no longer as spoken of as positively as they once were. In fact, there are hints that a diet of less than 20% fat may be a bad idea for diabetics. This is pretty much a total flip from ten years ago.
3) This is the first time in this century, that the ADA has strongly advised against eating foods with added sugars, particularly sugar-sweetened beverages. (Longer ago they did advise against sugar, but that's a separate story.)
4) The importance of focus on preventing weight gain is emphasized more than previously. In fact it is called "equally important" as weight loss. I think this is an important advance.
Commentary about the 2013 ADA Nutritional Recommendations
I'm quite happy with this new set of guidelines. In some ways, they seem to have rediscovered some of the principles of diabetes treatment of the last century that had fallen out of favor for awhile (e.g. avoiding sugar and being clearer about embracing low-carb diets as an option).
Also, most organizations giving dietary recommendations have tended to fall back on what they consider to be the simplest and clearest messages, rather than addressing individual differences. I really acknowledge the ADA for consistently fighting this trend in a way that seems to be going in the "more complex" direction rather than the "oversimplify" direction. I think this is a very important message and the sooner the general public begins to understand it, the better.
The ADA also seems to be acknowledging the complexity of nutrition management in perhaps a stronger way than previously. The recommendations say, "For many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat", and they emphasize the importance of nutritional guidance and ongoing support for every diabetic.
Additionally, there is acknowledgment that not only is there a lot of variation in the ideal diet for each person, but there is variation in the ability and motivation to stay with the "ideal" diet. Some people are willing to do whatever it takes, but for others it seems to be beyond them for a variety of reasons. It's important to be practical when counseling people about this.
I like the emphasis on "modest weight loss" (this isn't new, but I think they are pushing it more) and avoiding weight gain. There seems to be a tactic acceptance of the fact that people can maintain a "negative energy balance" for awhile, but not indefinitely. This is an important understanding, because many of the dietary recommendations for diabetes have been based on people who are in a negative energy balance - indeed, most the nutritional studies have been done on people in this phase. But this is a relatively short phase in the course of a person's life. Most obese people will not reach a "normal" BMI, and need to be counseled that most of the benefits of weight loss can be achieved with a modest weight loss. Anecdotally, even people who don't lose as much weight as they would like on a reduced-carbohydrate diet often halt the progression of weight gain, which is usually overlooked as an important goal.
Although there is a lot of language about individualizing nutritional approaches, there isn't a lot of explanation on how they think this should be done. In the past, I have talked to an ADA staff member about this and was told that they advocate a gradual reduction of carbohydrate to see how the individual responds, and then further reduction if necessary. The idea is that people adapt better to less drastic changes. This makes sense, but there are also advantages to the opposite approach, which many low-carb diet advocates such as Atkins, describe, where people start at a low level of carbohydrate and then gradually adding until there are problems such as weight gain or carb cravings. I discuss the pros and cons of the different approaches here.
There are also areas where they fall back on the recommendations from other organizations aimed at the general public (salt, saturated fat, whole grains). Over time, these will hopefully also individualized.
Their advice on whole grains is a little confusing. In the summary, they say that "People with diabetes should consume at least the amount of fiber and whole grains recommended for the general public." This makes it sound as though there is a minimum daily grain requirement. On the other hand in the body of the document they say that this means "half of the grains eaten should be whole grains", which to me means "if you are going to eat grains, make them whole grains", but doesn't make a statement about whether grains are important at all. Since I think it's clear that many people do better without grains, and that grains have a lot of glucose (starch) which is too much for some people, I think this is an important distinction.
All in all, I think these guidelines are moving in a very encouraging direction, and I hope other organizations (e.g. The American Heart Association and the committee that draws up the Dietary Guidelines for Americans) take note!