The ADA Considers Alternative Diets
In April the American Diabetes Association (ADA) released a new Consensus Report on “Nutrition Therapy for Adults with Diabetes or Prediabetes.” While much of the report echoes old recommendations, of particular interest is the new attention paid to alternative diets. A press release proudly reported that the ADA panel was “authored by a group of experts who are extremely knowledgeable about numerous eating patterns.”
The ADA has asserted for 25 years now that there is no “one size fits all” diet for people with diabetes. But in practice, healthcare providers tend to direct patients towards the USDA’s boilerplate recommendations for healthy adults, which has had the effect of essentially endorsing a single diet, at least from the perspective of macronutrient mix. Previous editions of this report dealt with alternative diets only briefly, and usually dismissively.
The 2019 report, however, reviewed a record 8 alternative eating patterns: Mediterranean-style, vegetarian/vegan, low-fat, very low-fat, low-carb, very low-carb, DASH and paleo. The report looks favorably upon every one of these eating styles, particularly to the extent that they all share commonalities with current mainstream healthy eating advice: more non-starchy vegetables, fewer refined sugars and grains, fewer processed foods.
The specific discussion of low and very low-carb diets includes some pleasing material. Those diets are now listed with “potential benefits” that include lowered A1C, weight loss, lowered blood pressure and improved cholesterol numbers. The report also slays the pervasive myth that the brain requires 130g daily of carbohydrates, noting that “this energy requirement can be fulfilled by the body’s metabolic processes … and/or ketogenesis in the setting of very low dietary carbohydrate intake.”
While the paper falls well short of the full-throated endorsement of low-carb that many want to see, at the very least it provides some good ammunition for dieters that find themselves in conflict with an unsupportive medical team. The ADA imprimatur may help some convince their doctors that a low-carb diet is seen as increasingly viable by the medical establishment.
Inertia in Diabetes Care
These are positive steps, but they’re small ones, and realistically we can probably expect years to pass before the ADA meaningfully upgrades its endorsement. In her recent press conference, CEO Tracey D. Brown said that the organization examined itself and questioned whether over the past decades it had been too staid and slow-moving. While Ms. Brown has promised change on that front, it is disheartening to realize that this traditionally sluggish organization’s position papers may actually represent the tip of the spear in the effort to create meaningful change for mainstream diabetes care. Some excellent advice buried in the middle of a white paper may well take years or even decades to filter down to the world of doctors, endocrinologists, dieticians and diabetes educators.
Inertia can be a significant force in the diabetes community. In 1979, an ADA food and nutrition committee report set forth the following as its very first principle:
“The dietary recommendations for diabetic persons are, in most respects, the same as for nondiabetic persons…”
Although this principle was espoused many years before the modern era of diabetes management – most notably, a decade before the DCCT had conclusively shown the benefits of intensive glucose management – this core concept remains an essential element of the dietary advice that most people with diabetes encounter today.
Nearly 40 years after that report was published, I sat in a dietician’s office and was shown a copy of the USDA’s MyPlate image, today’s version of the food pyramid. The dietician proceeded to recommend the same exact diet that she would have recommended to any healthy adult. My doctor had already done the same. Why were they so reluctant to suggest that a life-altering disease might entail some special dietary requirements?
Meeting People “Where They Are”
The ADA and the medical community have always been loath to recommend significant dietary changes for people with diabetes. Doctors appear to have a fear that if they recommend unusual diets, patients that cannot fully “comply” will actually rebel and end up worse off than ever before. And so we are told, basically, to drink less soda and eat fewer sweets. This is fine advice, but it’s not truly tailored to the unique and comprehensive health challenges of diabetes.
It’s certainly worth remembering that a significant percentage of people with diabetes are currently incapable of pursuing alternative diets, for any number of reasons: cultural prohibition, lack of familial support, limited food access, poverty, stress, depression, lack of time, and complicating health issues, among others. But do these obstacles mean that we shouldn’t provide these same people with the tools and knowledge to achieve the best possible outcomes? When doctors decide for patients that they will be unable to adhere to a low-carb diet, they rob them of their potential to truly thrive with the condition.
There are undoubtedly millions of people with prediabetes and diabetes Types 1 and 2 that would be willing to make significant dietary changes but have not done so because they are simply unaware of the option. When my doctor and dietician recommended a mainstream “healthy” diet to me, it was after I had already pledged that I was motivated to make whatever changes were necessary. They hadn’t just omitted any mention of significant dietary change; they actually dissuaded me from pursuing dietary change.
When even those that are explicitly willing and able to embark on a new diet are pushed back towards the mainstream, the emphasis on meeting patients “where they are” has backfired.
No Small Task
Ms. Brown has pledged that the ADA will do more to publicize the benefits of alternative diets. That’s encouraging to hear, but the organization has an immense amount of work ahead if it’s serious about that effort. The entire landscape of mainstream diabetes care is still dominated by outdated thinking on nutrition, and reeducating the experts is no small task.
Meanwhile, the ADA’s own website, despite the appearance of a “lower carb” section, remains littered with recipes like cornflake-crusted chicken and an apple crisp that have no plausible relation to any reasonable form of diabetic nutrition therapy. And the official ADA cookbooks that mandate that grains be eaten at every meal are not going to just disappear.
Readers of this website know that many researchers have already concluded that carbohydrate restriction should be the first approach in diabetes management. As larger and more convincing studies follow on the heels of last year’s groundbreaking Pediatrics study, we can expect the case for low-carb dieting to only get stronger. The baby steps in the recent ADA consensus report are encouraging, but it would appear likely that organizational inertia and institutional deference to mainstream nutrition will continue to prevent the ADA from taking the leadership role that it ought to in advocating for carbohydrate restriction.