American Diabetes Association Embraces Low-Carbohydrate Diets.

The Swedish Health Ministry’s acceptance of low-carbohydrate diets as best for weight loss is one of the signs of big changes in nutrition policy.  I am happy to reveal the next bombshell, this time from the American Diabetes Association (ADA) which will finally recognize the importance of reducing carbohydrate as the primary therapy in type 2 diabetes and as an adjunct in type 1.  Long holding to a very reactionary policy — while there were many disclaimers, the ADA has previously held 45 – 60 % carbohydrate as some kind of standard — the agency has been making slow progress. A member of the writing committee who wishes to remain anonymous has given me a copy of the 2014 nutritional guidelines due to be released next year, an excerpt from which, I reproduce below.

Nutrition Therapy Recommendations for the Management of Adults With Diabetes 

This position statement on nutrition therapy for individuals living with diabetes replaces previous position statements, the last of which was published in 2013 [1] and incorporated into the Standards of Medical Care of 2014 [2]. In particular, evidence suggests that the starting point for therapy for type 2 diabetes and adjunct treatment of type 1, should be some form of very low-carbohydrate diet. The amount of carbohydrates is the most important factor influencing glycemic response after eating and should be considered when developing the eating plan. Carbohydrate intake has a direct effect on postprandial glucose levels in people with diabetes and is the primary macronutrient of concern in glycemic management. While it is still recognized that there is not an ideal percentage of calories from carbohydrate for all people with diabetes, carbohydrate intake should be as low as possible for most people. 

There are several good references for implementation [3, 4] although the degree of reduction of dietary carbohydrate should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. Collaborative goals should be developed with the individual with diabetes. For good health, any carbohydrate intake should come from vegetables, fruits, legumes, and dairy products rather than intake from other carbohydrate sources, especially those that contain high starch and sugar.  In recognizing the importance of removing carbohydrates, the current guidelines deviate from, and consider inappropriate, previous recommendations from 2008 [5] that “sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose lowering medications.” While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, it is now recommended that consumption should be minimized to avoid displacing nutrient-dense food choices.

Recommendations for low-carbohydrate diets.

The new recommendations emphasizing low-carbohydrate diets follow from the observations noted previously [5] that improvements in serum lipid/lipoprotein measures including improved triglycerides, VLDL triglyceride, and VLDL cholesterol, total cholesterol, and HDL cholesterol levels are now recognized as a reliable feature of lower-carbohydrate diet compared with higher carbohydrate intake levels. Through the collaborative development of individualized nutrition interventions and ongoing support of behavior changes, patients should understand the rationale of carbohydrate restriction and be made aware of its potential value.

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