Standards of Medical Care in Diabetes 2019–Summary

The New ADA Standards of Medical Care

The American Diabetes Association (ADA) released its 2019 Standards of Medical Care in Diabetes (both type 2 and type 1) in advance of the official January, 2019 publish date. It is open access to all.  I decided to summarize one particular part that seems to have “hit the road” by various other blogs, some twisting it out of context completely. As a member of the ADA, in this blog I feel obligated to summarize the essence of the new guide so that there is no confusion about what it does or doesn’t recommend. I also provide my thoughts at the end.

The ADA Standards of Medical care has 16 chapters, of which, in terms of the treatment of diabetes (both T2 and T1), Chapter 5. Lifestyle Management is most important, so I will focus most of this summary on that chapter with few exceptions. The following is a long section of quotes from the document, in which I emphasized some sentences by bold to call special attention. 

…Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals. Consider personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) as well as metabolic goals when working with individuals to determine the best eating pattern for them…

…In addition, research indicates that low carbohydrate eating plans may result in improved glycemia and have the potential to reduce antihyperglycemic medications for individuals with type 2 diabetes…

There is inadequate research in type 1 diabetes to support one eating plan over another at this time

…A simple and effective approach to glycemia and weight management emphasizing portion control…

it provides a visual guide showing how to control calories (by featuring a smaller plate) and carbohydrates (by limiting them to what fits in one-quarter of the plate) and puts an emphasis on low-carbohydrate (or nonstarchy) vegetables

Weight loss can be attained with lifestyle programs that achieve a 500–750 kcal/day energy deficit or provide…

From Table 5.1–Medical nutrition therapy recommendations

Carbohydrates

5.12 Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high in fiber, including vegetables, fruits, legumes, whole grains, as well as dairy products.

5.15 People with diabetes and those at risk are advised to avoid sugar-sweetened beverages (including fruit juices) in order to control glycemia and weight and reduce their risk for cardiovascular disease and fatty liver and should minimize the consumption of foods with added sugar that have the capacity to displace healthier, more nutrient-dense food choices

Dietary fat

5.17 Data on the ideal total dietary fat content for people with diabetes are inconclusive, so an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated and polyunsaturated fats may be considered to improve glucose metabolism and lower cardiovascular disease risk…

5.18 Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA), is recommended to prevent or treat cardiovascular disease; however, evidence does not support a beneficial role for the routine use of n-3 dietary supplements.

End Table 1

Carbohydrates

monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose control…

For people with type 2 diabetes or prediabetes, low-carbohydrate eating plans show potential to improve glycemia and lipid outcomes for up to 1 year. Part of the challenge in interpreting low-carbohydrate research has been due to the wide range of definitions for a low-carbohydrate eating plan

… both children and adults with diabetes are encouraged to minimize intake of refined carbohydrates and added sugars and instead focus on carbohydrates from vegetables, legumes, fruits, dairy (milk and yogurt), and whole grains. The consumption of sugar-sweetened beverages (including fruit juices) and processed “low-fat” or “nonfat” food products with high amounts of refined grains and added sugars is strongly discouraged

Protein

Some research has found successful management of type 2 diabetes with meal plans including slightly higher levels of protein (20–30%), which may contribute to increased satiety

Fats

The ideal amount of dietary fat for individuals with diabetes is controversial… Randomized controlled trials also do not support recommending n-3 supplements for primary or secondary prevention of CVD

Micronutrients and Supplements

Metformin is associated with vitamin B12 deficiency with a recent report from the Diabetes Prevention Program Outcomes Study (DPPOS) suggesting that periodic testing of vitamin B12 levels should be considered in patients taking metformin, particularly in those with anemia or peripheral neuropathy

Nonnutritive Sweeteners

some research suggests an association with weight gain

Physical Activity and Glycemic Control

Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes. If not contraindicated, patients with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise (exercise with free weights or weight machines), with each session consisting of at least one set (group of consecutive repetitive exercise motions) of five or more different resistance exercises involving the large muscle groups

…For type 1 diabetes, although exercise in general is associated with improvement in disease status, care needs to be taken in titrating exercise with respect to glycemic management. Each individual with type 1 diabetes has a variable glycemic response to exercise

My Thoughts

In reading the entire book, one cannot help but be mused by the ice-age thoughts that still drive diabetes care. It is striking how the understanding of the progression of T2D is till not understood by the experts at the ADA. For example, the standard diagnostic tools for T2D includes a questionnaire that is to be used by doctors to evaluate if their patients have the likelihood for having T2D. In order to come to the conclusion that a doctor should continue with testing, one must score 5 or higher on this questionnaire:

T2D potential assessment chart

T2D potential assessment chart

 

Note how the columns on the right assume that one is overweight before T2D presents itself. This is physiologically impossible and the ADA should know better.

Weight gain is only possible with higher than normal insulin levels–note that those with little or no insulin, such as T1D, the body is unable to build up fat storage. Insulin is an anabolic hormone whose job is to store energy and it can only do so in the form of fat. This automatically implies that one must have insulin resistance (an early stage of T2D) in order to gain weight. So T2D starts when one is still thin! In fact, the world has many large populations of thin people with T2D, such as in Japan, India, China, and elsewhere in the world. These should be a puzzle to the ADA and doctors who follow the ADA guidelines–but they just get ignored. Weight in and of itself is also quite unreliable. A very healthy body builder or weight lifter may have a larger weight than the same size and gender individual who sits in front of the TV all day and is obese. There is some culture attached to weight as well. Asians tend to be very light in weight and Africans much heavier, but the propensity to end up with T2D is currently greater in Asia than in Africa.

Note also how age is a very big factor in the risk of diabetes according to the ADA and if you are <40 years old, they consider your risk to be zero. Yet the very same institution published an article in 2004, discussing diabetes in the young and called it an evolving epidemic. There is a major conflict there.

I was very happy to see one particular research cited in this guide: Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583–612. My joy comes from the fact that this is one of the first clinical trials that show that T2D is reversible using the ketogenic (very low carbohydrate and high fat) diet. While the Standards of care didn’t mention the ketogenic diet all, it finally did mention the low carbohydrate diets with the caveat that it is not well defined what “low carbs” actually means–and I agree with that statement.

I was also very happy to see the incorporation of dairy for T2D reduction–something that the USDA “my plate” barely recommends. I was disappointed to see the hesitation over fats. Fat is the only macronutrient that doesn’t spike glucose or insulin, so it would be quite logical to recommend the consumption of something that is carbohydrate free and is highly nutritive. The hesitancy goes back to the time when Ancel Keys misunderstood his own research (this is putting it nicely) and convinced the world that saturated fat is unhealthy. This has been proven to be incorrect by many studies, all of which were ignored in this guide.

And finally, I was particularly disturbed by the ADA recommending “portion” size reduction by serving food on a smaller plate. This tells me that, on the one had, they still believe that all calories are equal–meaning it doesn’t matter if my plate contains a salad with salmon or its equal in sugar, as long as the plate is small. The most problematic is that portion-size reduction implies a mental trickery. This still holds the afflicted guilty: the person is overweight because of lack of emotional controls. Thus, being obese, is a mental disease. This nonsense has caused several generations of people with eating disorders. I think it is time to stop this line of thought and accept that what we eat matters more than how much and how big a plate it is placed on. Healthy wholesome foods are filling and sating whereas carbs promote hunger. Mind what you place on your plate instead of the size of your plate!

In conclusion: this is a great first baby step by the ADA. Let’s hope that next year, the 2020 Standard will incorporate more aggressive diabetes care that truly can reverse T2D.

Comments are welcome, as always, and are moderated for appropriateness

Angela

About Angela A Stanton, Ph.D.

Angela A Stanton, PhD, is a Neuroeconomist focusing on chronic pain--migraine in particular--physiology, electrolyte homeostasis, nutrition, and genetics. She lives in Southern California. Her current research is focused on migraine cause, prevention, and treatment without the use of medicine. As a forever migraineur from childhood, her discovery was helped by experimenting on herself. She found the cause of migraine to be at the ionic level, associated with disruption of the electrolyte homeostasis, resulting from genetic variations of all voltage dependent channels, gates, and pumps (chanelopathy) that modulate electrolyte mineral density and voltage in the brain. In addition, insulin and glucose transporters, and several other variants, such as MTHFR variants of B vitamin methylation process and many others are different in the case of a migraineur from the general population. Migraineurs are glucose sensitive (carbohydrate intolerant) and should avoid eating carbs as much as possible. She is working on her hypothesis that migraine is a metabolic disease. As a result of the success of the first edition of her book and her helping over 5000 migraineurs successfully prevent their migraines world wide, all ages and both genders, and all types of migraines, she published the 2nd (extended) edition of her migraine book "Fighting The Migraine Epidemic: Complete Guide: How To Treat & Prevent Migraines Without Medications". The 2nd edition is the “holy grail” of migraine cause, development, and prevention, incorporating all there is to know. It includes a long section for medical and research professionals. The book is full of academic citations (over 800) to authenticate the statements she makes to make it easy to follow up by those interested and to spark further research interest. It is a "Complete Guide", published on September 29, 2017. Dr. Stanton received her BSc at UCLA in Mathematics, MBA at UCR, MS in Management Science and Engineering at Stanford University, PhD in Economics with dissertation in neuroscience (culminating in Neuroeconomics) at Claremont Graduate University, fMRI certification at Harvard University Medical School at the Martinos Center for Neuroimaging for experimenting with neurotransmitters on human volunteers, certification in LCHF/ketogenic diet from NN (Nutrition Network), certification in physiology (UPEN via Coursea), Nutrition (Harvard Shool of Public Health) and functional medicine studies. Dr. Stanton is an avid sports fan, currently power weight lifting and kickboxing. For relaxation (yeah.. about a half minute each day), she paints and photographs and loves to spend time with her family of husband of 45 years, 2 sons and their wives, and 2 granddaughters. Follow her on Twitter at: @MigraineBook, LinkedIn at https://www.linkedin.com/in/angelaastantonphd/ and facebook at https://www.facebook.com/DrAngelaAStanton/
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6 Responses to Standards of Medical Care in Diabetes 2019–Summary

  1. chris c says:

    Well that’ll never get on Wikipedia!

    Diabetics on the ADA Forum have routinely improved their A1c by 5 – 8% and I have seen up to 13% – yes from 18% to under 6% – plus improved their weight, symptoms and all other health markers going back nearly two decades now, thanks to my old mate Alan, Jenny and Jennifer who first wrote this

    http://loraldiabetes.blogspot.com/2009/04/test-test-test.html

    Just think, if they had chosen to study these people (including some Type 1s who have a better A1c than many “nondiabetics”) they would by now have two decades of evidence. But they didn’t.

    Same with Diabetes Uk and most other national organisations, the patients were way ahead of The Authorities.

    I suspect what they are now trying to do is to back down so slowly that no-one will notice and hit them with a lawsuit. Currently we have dieticians in the UK claiming that they never trashed low carb diets, but the effect is rather runied by their colleagues who still trash low carb diets. The opinion seems to be that if you can’t make a “healthy” low carb, Mediterranean or vegan diet work, then perhaps you can try low carb, but not too low or for too long.

    Back when John Buse was in charge, they did list low carb briefly purely for weight reduction, not BG control, but some of their sponsors pulled out and Buse went away. Then there was this

    https://www.carbwarscookbooks.com/so-close/

    Liked by 1 person

    • There are some huge flaws, I agree. The A1c is completely useless–they even note its useless in some health conditions, such as anemia, etc. The best way to fool the A1c is to donate blood the day before the the A1c test and regardless how diabetic one is, the A1c will be perfect. It will also be perfect is someone has huge swings of high and low blood glucose since the average of high and low is normal. However came up with measuring hemoglobin A1c as a tool for glycation and thereby diabetes status was an idiot.

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      • chris c says:

        Yes that’s why my diabetes (or prediabetes or not-diabetes depending on how you look at it) was missed for fifty years despite the obvious symptoms. My fasting glucose is almost always normal and my A1c is normal because the postprandial spikes are followed by post-postprandial lows. Look at around 1 hour postprandial and whoosh!

        Yes I’ve met not a few diabetics who are high or low glycators for whom the A1c is useless. Some of them managed to get fructosamine tested, which was much better aligned to their spot meter readings. In the UK I think only vets use this.

        Agree with Roald about fat, doctors are trained to believe that diabetes is caused by being fat and being fat is caused by eating fat. However about 20% of diabetics are normal weight and about 80% of obese people are nondiabetic. This would have amused Count Pareto. Then of course their belief is reinforced when they only test fat people for diabetes and miss all us skinny ones.

        Now it is being claimed that diabetes is caused by meat. Well that’s a non-starter to anyone with a working brain, diabetes has increased massively while meat consumption has fallen, especially red meat. Then there are all the diabetic vegetarians in India.

        It’s what a friend called “ficts” – things you want to believe because they sound as if they must be true, but actually they aren’t.

        Liked by 1 person

        • well, that diabetes isn’t caused by meat is pretty simple to see: carnivores in nature are not diabetic. So then people will say “chimps in nature are not diabetic” and that is true… they are diabetic in our zoos where they get the same fruits we are fed… yep.. must be the meat the chimps are not getting! 🙂

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  2. Roald Michel says:

    Ro, the therapist of the Other People, says: Hmmm, maybe the concealed reason why ADA, and the rest of their vassal mishpokhe, keep(s) scapegoating fat because “fat” is considered repugnant and sounds so ugly in a society where skeleton bodies are celebrated and worshiped? 😈

    A former tenant of mine was as skinny as one can get, and yet, she was as diabetic as one can get as well. And she’s not alone in my neighborhood.

    Liked by 1 person

    • I totally agree Roald. The problem is the NIH that is not funding the research into low carbs high fat. I actually think the ADA did pretty darn good considering the limitations of very few clinical trials that are acceptable for an adjusted mindset–particularly when the NIH is not funding them. The lead research they referred to (Sarah Hallberg et al.,) was privately funded. This is the problem.

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