People all over the DOC talk a lot about ADA dietary guidelines. So I got a copy of the basics – and it’s not what I thought it was. Seems to me they are very flexible. But I don’t know about the American Dietitians’ Association, which is also called ADA, but sometimes ADtA. I’d really be interested in other people’s input on this, especially Laura and Franzi!
F. Medical nutrition therapy
General recommendations
Individuals who have prediabetes or diabetes should receive individualized medical nutrition therapy (MNT) as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. (A)
Because MNT can result in cost-savings and improved outcomes (B), MNT should be adequately covered by insurance and other payors. (E)
Recommendations for management of diabetes
Macronutrients in diabetes management
*The best mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic goals and individual preferences of the person with diabetes. (E)
*Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control. (A)
For individuals with diabetes, the use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone. (B)
Saturated fat intake should be <7% of total calories. (A)
Reducing intake of trans fat lowers LDL cholesterol and increases HDL cholesterol (A), therefore intake of trans fat should be minimized. (E)
Well, as you might suspect, I have opinions, but I will hold them for now. I will give you one more critical reference. The American Dietetic Association (ADtA) now has assumed the role of establishing public nutrition guidelines and has recently repeated the assessment
(1) “The Evidence for Medical Nutrition Therapy for Type 1 and Type 2 Diabetes in Adults” by Marion J Franz, MS, RD; Margaret A Powers, PhD, RD; Carolyn Leontos, MS, RD; Lea Ann Holzmeister, RD; Karmeen Kulkarni, MS, RD; Arlene Monk, RD; Naomi Wedel, MS, RD; and Erica Gradwell, MS, RD. It appears in the Journal of the American Dietetic Association, Volume 110 Issue 12 (December 2010)
The ADtA is usually pretty cagey about providing “access” to their evidence library, I was quoted $400. But they have posted the paper above.
Thanks for the reference! I only read the carbohydrate section, and there are no studies quoted which are really low-carb – although they do call them moderate-carb. But they were clear that they don’t approve of low-carb because you would be missing important nutrients and fiber, which means that they don’t understand that low-carb includes vegetables which also have phytonutrients and fiber!
And I WOULD like to hear your opinions – it’s the reason I posted this thread!
I asked my diabetes consultant (in England) what her views were on Bernstein and whether I should consider following a scaled-down version i.e. limiting carbs to a lesser extent than he advocates in his book. She didn’t know who he was at first and then when I started to explain she compared him to atkins and looking horrified, said that 60% CHO was the recommended amount and that I wouldn’t be able to function long term without them. Hmmm.
I’ve also noticed an approach from some dieticians and CDE’s that seems, imho to be a reaction against earlier stricter guidelines that make many diabetics react negatively, such as “no sugar”. Guided, I believe, by the belief that most diabetics are “non-compliant” (god I hate that phrase!) many professionals seem to have adopted a stance of “whatever works for you”, nothing is forbidden. This would seem, at first glance, to be a positive thing, in keeping with the YMMV stance most of us on this board take, recognizing that all diabetics (even within each type) are different and the best practice is to find what works for us by testing, testing, testing and by integrating our diets with our lifestyles. But I think it is one thing to talk about people already active in the DOC who are very self-directed and proactive in managing their diabetes, and the newly diagnosed or those whose sole influence is their “team”. I think some of those people need more guidance and at the very least exposure to the different models of eating and the pros and cons of each, and suggestions to “eat to their meter”. I have spoken to way too many diabetics who were given next to no information and in the case of type 2’s or prediabetics told to test once or twice a day and sent on their way. My own case is a good example. When I was newly diagnosed (misdiagnosed as type 2) I was asked how I ate and I responded that I “ate very healthy”. This was my belief based on the fact that I ate no sugar at all, was a vegetarian and didn’t eat fast foods. But if the dietician had probed one inch deep (or knew anything about vegetarian diets) she would have found I ate way too many carbs. I was told to test my fasting and after breakfast. Carbs were never discussed. With the usual ADA recommendation of an A1C of 7.0 and numbers “under 180” there wasn’t much motivation to do better. Everything I’ve since learned about carbs and my own response to them was on here or by trial and error. I think my experience was typical. I think this “laissez faire” attitude is as useless and probably as injurious as the “you must eat this and may not eat that”, I also think that, catering to “what people are willing to eat” it is an insult to humans ability to change based on relevant information.
The optimal macronutrient distribution of weight loss diets has not been established. Although low-fat diets have traditionally been promoted for weight loss, two randomized controlled trials found that subjects on low-carbohydrate diets lost more weight at 6 months than subjects on low-fat diets (19,20). Another study of overweight women randomized to one of four diets showed significantly more weight loss at 12 months with the Atkins low-carbohydrate diet than with higher-carbohydrate diets (20a). However, at 1 year, the difference in weight loss between the low-carbohydrate and low-fat diets was not significant and weight loss was modest with both diets. Changes in serum triglyceride and HDL cholesterol were more favorable with the low-carbohydrate diets. In one study, those subjects with type 2 diabetes demonstrated a greater decrease in A1C with a low-carbohydrate diet than with a low-fat diet (20). A recent meta-analysis showed that at 6 months, low-carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cholesterol was significantly higher on the low-carbohydrate diets (21). Further research is needed to determine the long-term efficacy and safety of low-carbohydrate diets (13). The recommended dietary allowance (RDA) for digestible carbohydrate is 130 g/day and is based on providing adequate glucose as the required fuel for the central nervous system without reliance on glucose production from ingested protein or fat (22). Although brain fuel needs can be met on lower-carbohydrate diets, long-term metabolic effects of very-low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability (22).
Yes, the ADA and the ADtA do not approve of low-carbohydrate diets – at least currently (I have hopes for the future!) I have talked to many of my colleagues about the possibility of promoting low-carb diets, and they are all against it because it’s seen as being too restricted and nutritionally unsound. When I told a few of my coworkers that I am eating 100-120 grams of carbs per day in an attempt to reduce postprandial spikes, they thought that sounded extreme.
I must say that I love being a dietitian. I work primarily with patients with diabetes, but I also counsel those with cancer, ALS, Crohn’s disease, and many other health conditions. I truly believe I have the best job in the world! Having said that, I will continue to eat moderately low carb, do more thorough research about the effects of low carb and paleo diets, and try to promote more open-mindedness within my profession…
I think they don’t approve of a low-carb diet because they don’t understand that it doesn’t mean subsisting on nothing but meat, eggs and cheese, but rather including lots of low-carb but nutritious vegetables. Although I have to admit that that’s my sticking point, because I really don’t like most vegetables. My own personal goal is 60g of carbs a day, because I’m eating Greek yogurt in order to keep my intestines healthy (and it’s working like a charm!), and trying to manage one or two servings of vegetables a day. Other people, who are not picky eaters like me, could surely do more than that. As long as I stick near that 60g goal, my BGs are really good, and I have lost 28 lb. and gotten the best lipid numbers I have ever had, but I do feast occasionally, too – it means using more insulin, and sometimes miscalculating and getting high BGs, but I’m human! Perfection ain’t the name of the game!
I believe that between 2006 and 2008, the ADA “farmed it out” to the ADtA. I beleive the last “gasp” under the ADA was the ADA position statement “Nutrition Recommendations and Interventions for Diabetes,” written in 2007 and published in 2008. All the core people who did the ADA stuff, like Marion Franz just moved over to the ADtA under the cover of a “professional society” and continued the same old stuff.
In support of this thread, I’d also like to provide another key reference, this is the Dietary Reference Intakes from the Institute of Medicine, a part of the National Academy of Sciences. In case you didn’t get it, this is a report from scientists, not farmers, not corporate interests and not politicians You can read this on-line and of particular interest is the carb section. Let me quote from the report:
"The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate amounts of protein and fat are consumed. "
In the section, “Clinical Effects of Inadequate Intake”, the report goes on to basically argue that humans basically can get along with no carbs quite well.
I did not mean to imply that I accepted all the report synthesis, conclusions and recommendations, far from it. But much of the cited references and basic discussion is sound. The AMDR is one of those made up things, here is what they say:
The AMDR for fat and carbohydrate is estimated to be 20 to 35 and 45 to 65 percent of energy for adults, respectively. These AMDRs are estimated based on evidence indicating a risk for coronary heart disease (CHD) at low intakes of fat and high intakes of carbohydrate and on evidence for increased risk for obesity and its complications (including CHD) at high intakes of fat.
A careful reading of the section on fats and on saturated fats, section 6 finds that the science does not well support reduced fat diets and further there is an admission that high carb diets increases triglycerides and lowers HDL. So unfortunately, the discussion of the science does not support the recommendations of an AMDR. When you look closely, the AMDR in fact comes from the survey’s of food intake. There is “no” science suggesting that those ranges are appropriate. In fact, most of the surveys suggest that the population was following on average a lower carb diet than the 45-65% range suggested. The AMDR was in fact set to try to shift the population to eat more carbs and less fat, but it was not based on any science.
Although one might ague over the optimum diet for a healthy person, I am heartened by the fact that they find no negatives concerning a low carb diet. In the same paragraph bsc quoted above they state “There was no apparent effect on health or longevity.” in reference to traditional peoples on a low carb diet.
This just reinforces my belief that low carb is the best option for me and many other diabetics. I have noted the effect on my blood sugars of consuming the recommended 40 to 60g per meal and I know for sure that’s not a healthy level for me. Would I be eating this way if not for D, probably not, but you have to play the cards you’re dealt.
Some of the criticism of low carb diets are the claims that you “need” carbs for energy. That is pretty much refuted in the discussion. Another criticism is that the brain requires glucose, which is also discussed. The glucose needs of the brain are suggested to be higher than more recent research suggests, but the discussion actually says that all those brain needs can be met through gluconeogenesis. So the report doesn’t back up any claims that low carb diets will harm you ijn those ways.
In the end, what it all comes down to is the dietary fat argument.
You completely left out the discussion of LDL cholesterol and coronary heart disease. The discussion states quite emphatically on page 422:
"There is a positive linear trend between total saturated fatty acid intake and total and low density lipoprotein (LDL) cholesterol concentration and increased risk of coronary heart disease (CHD). A UL is not set for saturated fatty acids because any incremental increase in saturated fatty acid intake increases CHD risk."
It contains a similar statement about trans-fats: “As with saturated fatty acids, there is a positive linear trend between trans fatty acid intake and LDL cholesterol concentration, and therefore increased risk of CHD. A UL is not set for trans fatty acids because any incremental increase in trans fatty acid intake increases CHD risk.”
So to the extent that a low-carb diet replaces carbs with saturated fats (or worse trans-fats), this paper argues it is not healthy.
To answer your earlier question, then, yes I can see science behind the AMDR.
But a lot of people that have gone low carb have seen improvements in their cholesterol numbers (me included). It is my understanding that statements like you quoted don’t have any science behind them – they are merely statements of what people “think” is the case but there is no research proving it.
