Everyone has been very excited over the last few days over the changes in the American Diabetes Association nutrition guidelines that are more supportive of low carb and keto for type 2 diabetes, (and what this could mean for diabetes in Dubai). Vanessa Emslie takes a deeper dive into the report, what it is, what it isn’t and what we might expect looking forward.
28-Apr 2019, by Vanessa Emslie
Recently, nutrition sites have been awash with the new release from the American Diabetes Association (ADA) titled, Nutrition Therapy for Adults with Diabetes or Pre-diabetes: A Consensus Report, as at 18th April 2019 in USA. The hope has even been that perhaps this may have some impact on diabetes Dubai too in time. I would like to speculate whether the appointment last year of the new CEO of ADA, Ms Tracey D. Brown who is a type 2 Diabetes sufferer, has had some influence in the current changes that have been laid down in this report.
With many things in life, breaking from the status quo and leaving behind ingrained beliefs often starts with small steps. I truly believe that this is the start of significant change that may span the next 10-20 years as research catches up to support current Keto and Low Carb for diabetes.
A brief review of the report picking out some key points (though not exhaustively) follows. But even though this is as a scientific reference article, it is not a complicated read and I would encourage you to attempt a read of the report itself if this is of interest to you.
THE KEY IMPROVEMENTS
Carbohydrates were previously pegged at 200g/day minimum and then dropped to a minimum of 130 g/day. The first key win here is the removal of the recommendation that carbohydrates as a macronutrient has a known, optimal level for consumption. Though the reliance on carbs is mediated somewhat with the following statement, it also raises an ongoing debate and reference to formation of glucose (through gluconeogenesis). This debate abounds in Keto forums (with reference to diabetes in Dubai), that glucose can be obtained through fat and protein substrates. It is worth noting that this is the only time the mention of Ketosis appears in the report.
“The amount of carbohydrate intake for optimal health in humans is unknown. Although the recommended dietary allowance for carbohydrate for adults without diabetes (19 years and older) is 130 g/day and is determined in part by the brain’s requirement for glucose, this energy requirement can be fulfilled by the body’s metabolic processes, which include glycogenolysis, gluconeogenesis (via metabolism of the glycerol component of fat or gluconeogenic amino acids in protein), and/or ketogenesis in the setting of very low dietary carbohydrate intake (49).”
Coinciding with this, and probably a supporting reason the carbohydrate limitation has been removed, GI and GL (glycemic index and load respectively) were given the inconclusive rating regarding their ability to help manage Diabetes.
The report also washes away the premise that there is an ideal ratio split of calories between Carbs, Proteins and Fats and that the macro recommendations should be determined individually. Increasing dietary fat in place of carbs gets a big approval to improving glycemia, HDL and triglyceride markers, and the quality of fats consumed is also highlighted as important in this aspect.
For the management of pre-diabetes, the top dietary recommendations are the Mediterranean and DASH intervention. The recommendation as to which dietary modality is better for management of type 2 Diabetes, is reported as unclear due to lack of compelling evidence, and simply summarised as 3 key points common to most of the diets evaluated: eat more non-starchy vegetables, reduce sugars and refined grains and choose whole foods over highly processed.
Weight Management for both pre-diabetes and Type 2 Diabetes management is positively correlated with improved metabolic markers, with the supporting evidence being lifestyle interventions referenced, but again, no clear direction on dietary selection.
Another key strategic lifestyle tool, Intermittent Fasting, is included in the review without consideration to change in macro ratios/diet as stand alone intervention. The report supports the research references for improved B- pancreatic cell activity (where insulin is made), insulin sensitivity, blood pressure, oxidative stress and appetite suppression. IF is certainly here to stay and with good reason!
LOOKING TO THE FUTURE
The report is absolutely a step in the right direction and in future work by the ADA, it would be hopeful to see them re-consider their definitions of low carb for diabetes to be closer to those used in general public domain.
They referenced “Low Carbohydrate” and “Very Low Carbohydrate” where the carb % was limited to <45% and <26% respectively of macros, which is challenging to correlate to the current Low Carb movement, where traditionally, Low Carb for diabetes will range between approximately 10-20% (50-100g/CHO per day) and Keto for diabetes is 5% or around 15-25g CHO per day depending on personal objectives and activity levels.
Ketosis is mentioned once, which begs the question, do they consider this as a therapeutic intervention or is this option something that will only come into consideration once un-refuted scientific evidence from the likes of research entities such as The Noakes Foundation, Professor Schofield, KetoNutrition (Dr D’Agostino) to mention a few of the leading researchers in this field.
Would the recommedations be different if a stricter definition of Low Carb for diabetes was implemented? What would the inclusion of Keto research included in this report mean, as only 1 keto for diabetes study was included by using the supporting research titles as a quick filter. I would foresee that the recommendations could have been vastly different.
The premise of calorie counting hasn’t be mentioned, but the recommendation of including at least 150min of physical activity per week for weight loss implies the “calories in – calories out” philosophy still holds some value with the American Diabetes Association. It’s useful to note that many keto interventions see radical improvements in weight and muscle tone with little or no reference to calorie counting. Many overweight people initially have an inherent aversion to physical activity due to excess weight, and Keto and Low Carb provide a good solution to this until they are more comfortable being placed in physical activity regimes, either independently in or in a group.
The word “individual” or permutations thereof with regards to nutrition is mentioned 19 times which is a significant amount in this sort of report, which is aimed around the dietary options as opposed to how to implement a successful intervention for Diabetes. And whilst this is something I personally believe in wholeheartedly, that biochemical, genetic and environmental individuality of a person is key to the success of an intervention, the challenge is that the synergy between the Academy of Nutrition and Dietetics, who is the registrar of Registered Dieticians in the USA, is clearly anything but synergistic.
Whilst individualisation is supported, the only actionable point given to a pre-diabetic or Diabetic sufferer is to engage the service of a Medical Nutritional Therapy plan devised by a Registered Dietician. As we know, most dieticians are not supportive of Very Low Carb for diabetes (never mind Keto for diabetes) and a huge review of the current mindset of this profession is needed to bring the successful implementation of the ADA’s recommendations and learning from this Report into reality.
IS TYPE 2 DIABETES BEING CHALLENGED FROM THE TOP?
It is worthwhile noting that in June 2018, the ADA welcomed Ms Brown as their CEO. As an active diabetic community leader, having suffered with both gestational and type 2 Diabetes for over 14 years, in her welcoming statement, she states,
“In my personal life, I strive to to be a living example of how to manage and thrive with this disease.”Ms Tracey D Brown CEO, American Diabetes Association
In recent months since her appointment, she has been very active in the public arena and been seen engaging with Low Carb and Keto solutions to type 2 Diabetes, as she aims to understand everything she can in relation to the condition.
Below, is her Facebook post of 12th February 2019 where she posts her meeting with Dr Bernstein.
Dr Berstein is a prominent type 1 sufferer who manages his condition effectively with a Low Carb approach, and author of a variety of books on the topic. Dr Ali Al Lawati, who heads up the Lifestyle Clinic in Oman, (will also be helping with impacting Diabetes in Dubai) and is an ingfit advisory board member, trained in the US under Dr Berstein for some time.
When she hashtags herself as #Type2CEO and her twitter handle is @type2ceo, we can only be hopeful that positive change is well on its way, and this way of thinking will continue to grow and expand under her influence in the ADA.
Written for ingfit by Vanessa Emslie of WELLBYNESS. Registered Nutritionist (UK) and Functional Medicine Health Coach (IFM Member)
image credits: American Diabetes Association