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

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