The ADA (American Diabetes Association) released an updated guideline on facilitating behavior change to improve health outcomes for people with diabetes. While they support low-carb, they do so in a cautious manner.
First, they emphasize avoiding judgmental words that can cause feeling of shame or guilt, and instead focus on using positive, strength-based language. Sounds pretty basic and common sense, but I wonder how many clinicians think about that?
It may make a difference. When they discuss nutritional therapy, they emphasize supporting patients in a nonjudgmental manner. The central message is one of acceptance and individualization which they sum up by saying:
"Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for people with diabetes. Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals."
While there is definite truth that people have different preferences and metabolic goals, the ADA could risk oversimplification if they stopped there. Fortunately, they get more specific, mentioning the benefits of low-carb:
"For individuals with type 2 diabetes not meeting glycemic targets or for whom reducing glucose-lowering drugs is a priority, reducing overall carbohydrate intake with a low- or very-low-carbohydrate eating pattern is a viable option"
My first question is, who wouldn't prioritize reducing medications? That should be a given for everyone. Unfortunately, in our pharmaceutically driven medical society, that's not always the case. But I give kudos to the ADA for mentioning it. I only hope that it will become the new standard, so that next time the ADA can say, "Since reducing or eliminating diabetes medications is a universal goal, we recommend low-cab diets."
My second question is, what are the glycemic targets? Is it the standard HgbA1c of 7? Or is it time to recognize we can do much better with lifestyle, as opposed to drugs, and set the goal as less than 5.7 for everyone?
After an initial backing of low-carb diets, the guideline then takes a questionable turn.
"As research studies on some low-carbohydrate eating plans generally indicate challenges with long-term sustainability, it is important to reassess and individualize meal plan guidance regularly for those interested in this approach."
With Virta Health reporting 83% compliance at 1 year and 74% at 2 years, I would take issue with a blanket statement that compliance is challenging. In fact, any behavioral change has long-term sustainability issues, and carbohydrate restriction may be no different, but it does not deserve to be singled out as particularly difficult. Certainly, if we discuss it with a patient saying "this is difficult to maintain long term," that has less chance of success than if we say, "All behavior change is difficult, but given the potential health benefits, this is worth committing to for the long-term." As they say in the beginning of the guide, the words we use matter and we should focus on positive and inspiring messages.
Then, they summarize the benefits of low-carb eating.
Reducing overall carbohydrate intake for individuals with diabetes has demonstrated evidence for improvement of glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences (41). For people with type 2 diabetes or prediabetes, low-carbohydrate eating plans show potential to improve glycemia and lipid outcomes for up to one year.
In all, we should be encouraged that the ADA continues to recognize low-carb nutrition as an effective strategy for treating type 2 diabetes. Large influential organizations tend to change slowly, if ever. Just read the AHA's recent scientific update on dietary cholesterol as a prime example. The ADA has taken important steps to recognize that low-carb nutrition has an important role in diabetes management.
As more clinicians become familiar with this approach, we hope the questions of compliance and sustainability slowly disappear as low-carb becomes mainstream for glycemic control.
Are you a clinician wanting to know more about low-carb nutrition? Or maybe you want to help your doctor learn more? You can start by reading and sharing our low-carb for clinicians guide, which links to multiple other helpful resources. Please let us know how else we can help you, your clinician and the ADA spread the benefits of low-carb nutrition.
Thanks for reading,
Bret Scher, MD FACC
