New Review of Macronutrients for Diabetic Nutrition
For years, the legacy of the ADA (American Diabetes Association) and the ADtA (American Dietetic Association) (now staking the claim to the name Academy of Nutrition and Dietiecs (AND)) dietary recommendations have held up, arguing that diabetics should follow a high carb, low fat diet. The flag for this fight was handed off from the ADA to AND, but the individuals involved pretty much remained the same (a group of old guard non scientists with representation from industry).
The latest incarnate of their recommendations can be read in the JADA article "The Evidence for MNT for Type 1 and Type 2 Diabetes in Adults". I read through it and found it terribly flawed, just like its predecessor. And we continue to get flawed dietary advice based on this work. This is the core substantiation that is used to educate us on appropriate nutrition for managing our diabetes.
But the cracks may be widening. The latest salvo appears in the Diabetes Care issue with the article "Macronutrients, Food Groups, and Eating Patterns in the Management of Diabetes, A systematic review of the literature, 2010" Key findings on carbohydrates seem in total opposition to the AND assessment above.
Low Carb Findings (Up to 30% of calories from carbs)
In studies reducing total carbohydrate intake, markers of glycemic control and insulin sensitivity improved, but studies were small, of short duration, and in some cases were not randomized or had high dropout rates. Serum lipoproteins typically improved with reduction of total carbohydrate intake but, with the exception of HDL cholesterol, were not statistically greater than with the comparison diet. The contribution of weight loss to the results was not clear in some of these studies.
Moderate (40-65% of calories/carbs) to High (> 65%) Carb Findings
RCTs presenting information on moderate- and high-carbohydrate diets are diverse in terms of fat and protein content as well as length of study. Only two RCTs found significant differences in A1C between groups, with one study finding significantly lower A1C with the higher-carbohydrate diet only in a subgroup analysis, and the other study finding significantly lower A1C with the lower-carbohydrate diet. In terms of CVD risk factors, LDL cholesterol improved more with a high-carbohydrate diet in one study, whereas two studies found TGs improved more with a lower-carbohydrate diet.
Based on this assessment, it seems like a no brainer. The results suggest clear improvements in blood sugar control and no identified lipid problems with low carb diets. But no research seems to support the effectiveness of high carb diets. It doesn't really help your blood sugar control and it doesn't help your lipids either. The key argument has always been that low carb diets are a CVD risk because of adverse affects on lipids. Even if you believe the lipid hypothesis, this suggestst that low carb diets are heart healthy.
What do you all think of this? Is it progress? Will Hope Warshaw read it and understand it? Will it help lead to more progressive diet assessments and recommendations?
In either case, for those of you who have to deal with nutritionists and dieticians, print this journal article out. If you get harrassment from your medical team about following a low carb diet, you can pull this study out and show them that you are following a diet with some compelling evidence behind it.
Tags: ADA, Carbohydrates, Controversy, Diet, Evidence, Nutrition
Replies to This Discussion
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Permalink Reply by FHS on -
IIRC, that's a bump in daily carb total for you bsc. If so, is that because you started insulin?
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Permalink Reply by Brian (bsc) on
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Well, I've been very strict at times. I found that keeping to 50-100 g/day was good as 30 g/day. Everyone has their individual tolerance for carbs. This was even before insulin, but since insulin I've been able to significantly reduce after meal excursions.
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Permalink Reply by still_young_at_heart on -
Interesting but the low carb cut-off is rather different than the definition of low carb around here. A 2400 calorie per day diet which is what keeps my weight at around 150lbs. allows for 720 calories from carbohydrates per day. That comes to 180 grams which is probably twice what most of us consider low carb.
Maurie
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Permalink Reply by Brian (bsc) on
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I think you are right on target with this observation. The ADtA assessment defines low carb as anything below 45% of calories from carbs, a level that I hardly consider low carb. As you note, on a 2400 calorie diet, that is 270 g of carb/day, that is really, really not low carb. It is not surprising that it is difficult to see any benefit.
Frankly, I can't really imagine eating 270 g of carbs per day and keeping the krispy kreme donut bits out of my hair.
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Permalink Reply by garidan on -
First, I really DON'T LIKE they mix studies about type 1 on insulin and type 2 on different terapies: what's the meaning then to say 2 are better low carbs and one high carbs ? Were the low carbs studies about type 2, and the high about well controlled type 1 ?
Apple and oranges situation ....I think still_young_at_heart is right, he is pointing to this your cited article quote
Low Carb Findings (Up to 30% of calories from carbs)
And then they write:
Based on the studies in this systematic review, the following definitions are used:
very-low-carbohydrate diet: 21–70 g/day of carbohydrate
moderately low–carbohydrate diet: 30 to <40% of kcal as carbohydrate moderate-carbohydrate diet: 40–65% of kcal as carbohydrate high-carbohydrate diet: >65% of kcal as carbohydrate
These definitions are not all-inclusive (e.g., a 100-g/day carbohydrate diet may be <30% kcal), but they represent the typical definitions used by authors, and all published articles fit in one of these categories.
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Permalink Reply by Brian (bsc) on
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I also don't like the idea that there has been no studies of type 1. I suspect that result for certain subgroups may differ, not based on the type of therapy, but on things like insulin sensitivity. Gardners work at Stanford seemed to really highlight the differences between the groups. But our current T1 recommendations suggest that because we have not done the studies, T1s should eat what non-diabetics eat. Personally, when I look at America, I don't think that is workin too well.
And I agree with the problem of defining a low carb diet. The definition was whacked in the ADtA assesment and still weird in the cited review.
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Permalink Reply by acidrock23 on -
T1 are more fragile and need close supervision by their medical team, MD/CDE and dietitian, for any conversations about food...hee hee...
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Permalink Reply by Natalie ._c- on -
No, it's just AR who needs close supervision, because he does wacky things like running a lot, and then drinking his carbs. The dietitians definitely do NOT recommend this!!! :-P
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Permalink Reply by garidan on
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I'm reading and found this:
Lower (very low and moderately low) carbohydrate
Glycemic control.
Eleven clinical trials examined the effects of lowering total carbohydrate intake on glycemic control in individuals with diabetes. The carbohydrate content goal of the diet was very low in 7 studies (10–16) and moderately low in 4 studies (17–20).All studies included adults with type 2 diabetes
OK, so these arguments are not for type 1.
These findings are all for type 2, and they don't say if under insulin or other medications.
They say they got better A1c and so on .... I read no more, I find these meaningless.Why did you related this to ADA type 1 and 2 indications ?
The latest incarnate of their recommendations can be read in the JADA article "The Evidence for MNT for Type 1 and Type 2 Diabetes in Adults". I read through it and found it terribly flawed,
You have your opinions, but this article doesn't support them at all.
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Permalink Reply by Brian (bsc) on
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I think we have to understand that often these studies are hard pressed to get any result. They may well have broken out the patients by diabetes type or therapy, but once you start breaking the studies into little subgroups you start to lose the power of resolution. Only through including enough study members and observing enough of a significant difference can you conclude anything. For most of these studies, once you break it up into little groups it is no longer statistically significant.
You can make your own choices based on these studies and what you want to eat. But if you choose to eat low carb, I think this reviews supports the idea is a safe and effective option.
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Permalink Reply by BadMoonT2 on -
Agreed we can't seem to arrive at a definition around here but you could probably get agreement that 180 is not low carb
Here's the catagories they used for this study:
very-low-carbohydrate diet: 21–70 g/day of carbohydrate
moderately low–carbohydrate diet: 30 to <40% of kcal as carbohydrate
moderate-carbohydrate diet: 40–65% of kcal as carbohydrate
high-carbohydrate diet: >65% of kcal as carbohydrate
Sort of an interesting system in that one is in grams/day while the others are in % of total calories. I would agree < 70 is very-low carb, I think I'd loose the "very". A better name is ketogenic because in a way there is only one division, that between burning mostly fat or burning mostly carbs.
It's a lot to go through and I can't claim to have examined it in detail but the gist I get is that low carb is effective in treating T2 and its safe. As far as I can tell they didn't bring out their old canard about not knowing if low carb is safe because no long term studies of safety haven't been done.
None of this is really news. I've read enough studies to draw the same conclusion, but to see it in the ADA Journal is news.
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Permalink Reply by Anthony Holko on -
Well I will give the the results of a study of 1 yes one me. LC/HF vs HC/LF blood sugar well duh was just what all diabetics already know but the surprise was 30% better HDL and 25 % lower triglycerides with the same LDL with the low carb high saturated fat diet.
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