February 2014 Issue
Evaluating the New ADA Guidelines — There’s No One-Size-Fits-All Diet Plan
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
Vol. 16 No. 2 P. 10
The new position statement released last fall by the American Diabetes Association (ADA) updated nutrition recommendations that will change the way dietitians counsel clients and patients with diabetes.
The overarching message of the new guidelines is that there’s no single eating pattern that’s best for everyone with diabetes; the key to achieving optimal health and nutrition is individualization. Variations of the word “individualized” are mentioned more than 20 times in the statement compared with just four times in the 2008 position statement, driving home the point that RDs should develop meal plans based solely on each patient’s needs.
This article will discuss the highlights of the new ADA position statement, “Nutrition Therapy Recommendations for the Management of Adults With Diabetes”; how it differs from the previous position statement published in 2008; and how the updated individualized recommendations may impact the way dietitians counsel clients and patients moving forward.
The revised position statement attests to the fact that, as research evolves, nutrition advice changes. For the latest update, and the first one made by the ADA regarding these guidelines, the association conducted a systematic review of all available diabetes nutrition research using a strict grading system.
“I think it’s very important for dietitians to understand that for an ADA systematic review, studies must meet stringent criteria to be included as evidence for a position statement,” says Patti Urbanski, MEd, RD, LD, CDE, a diabetes and nutrition consultant and member of the ADA’s Nutrition Recommendations Writing Group Committee. “Studies must be randomized controlled trials, prospective observational, cross-sectional observational, or case-control studies, with at least 10 subjects in each study group. [And they must be] at least six months in length and have a retention rate of over 80%.”
One Size Does Not Fit All
Based on the review of the scientific evidence, the ADA confirmed, and therefore restated several times in its position statement, that there’s not a one-size-fits-all eating pattern for individuals with diabetes. Instead, it calls for all adults diagnosed with diabetes to eat a variety of minimally processed, nutrient-dense foods in appropriate portion sizes as part of an eating plan that takes into account individual preferences, cultures, religious beliefs, traditions, and metabolic goals.
However, the concept of individualization isn’t completely foreign to the ADA. A previous literature review the organization conducted in 2001, which was published in the February 2002 issue of Diabetes Care, supported the idea that there isn’t one ideal macronutrient distribution for all people with diabetes.
But while the ADA has just confirmed that individualized nutrition therapy is best for diabetes patients, some dietitians already had considered it standard practice. “This has been a basic component of good counseling skills,” says Marie Fasano Ruggles, RD, CN, CDE, diabetes education program manager at Mercy Medical Center in Rockville Centre, New York.
Ruggles shows patients with diabetes how to continue eating traditional foods by tweaking the ingredients and rethinking the ingredient proportions and methods of preparation. “People love when you show respect for their cultural heritage by working out ways for them to keep favorite dishes in the plan,” she says.
High or Low Carb?
The new guidelines note that there’s no conclusive evidence regarding an ideal amount of carbohydrate intake for people with diabetes. “We still have a lot to learn about carbohydrates and how different carbohydrates may affect blood glucose levels and glycemic control,” Urbanski says, adding that “many of the studies about carbohydrate are small, have low retention rates, and/or were of short duration.”
The 2008 guidelines recommended a minimum carbohydrate intake of 130 g/day, which was based on providing enough glucose to fuel the central nervous system without relying on glucose production from ingested protein or fat. The new guidelines don’t have this recommendation.
“The recommendation of a minimum of 130 g of carbohydrate per day originally came from the 2006 Institute of Medicine [IOM] recommendation, which doesn’t have anything to do with blood glucose control and should be thought of as more of a guideline than a precise minimum amount. Therefore, the ADA committee felt that the recommendation [of 130 g carbohydrate per day] was no longer appropriate to include in the nutrition position statement,” Urbanski says.
The new recommendations place emphasis on where the carbohydrates come from and suggest that whatever carbohydrates are eaten should come from vegetables, whole grains, fruits, legumes, and dairy products over other sources that contain added fats, sugar, or sodium.
Some disagree with this recommendation, though. “I don’t think dairy or whole grains are essential components of the diet,” says Kathie Madonna Swift, MS, RDN, LDN, owner of SwiftNutrition and coauthor of The Inside Tract: Your Good Gut Guide to Great Digestive Health. “In my practice, I’ve found that some people with diabetes may fare much better without these foods since they may be triggering their immune system and fueling inflammation.”
In addition, fiber recommendations no longer hold as much weight, in part because existing research showing improved glycemic control with fiber is unrealistic and requires fiber intakes of more than 50 g/day. The new recommendations state that people with diabetes should consume at least the amount of fiber and whole grains recommended for the general public.
Swift believes people with diabetes can get plenty of fiber from vegetables, fruits, legumes, nuts, and seeds. “Whole grains aren’t necessary,” she says. “Dietitians [also] should be aware of the connection between gluten, celiac disease, and type 1 diabetes, and nonceliac gluten sensitivity should be explored as a component of nutrition therapy.”
The recommendations regarding the substitution of sucrose for starch remains essentially the same. The writers did emphasize that consumption should be minimized to avoid displacing nutrient-dense food choices.
Sugar-sweetened beverages weren’t mentioned in the 2008 position statement. However, the revised guidelines state that people with diabetes should limit or avoid the intake of sugar-sweetened beverages from any caloric sweetener, including high-fructose corn syrup and sucrose. Swift would prefer the use of stronger language: “I prefer consumption of any processed food with sucrose be avoided and definitely avoid all sugar-sweetened beverages.”
According to the new recommendations, the use of nonnutritive sweeteners could potentially reduce overall calorie and carbohydrate intake if substituted for caloric sweeteners without compensation by eating additional calories from food sources. While this may be true, Ruggles believes that nutrition professionals shouldn’t recommend nonnutritive sweeteners unless they’re from natural sources. “Nutritionists shouldn’t be recommending the consumption of artificial sweeteners that are factory-made chemicals and possibly neurotoxins,” she says. “Very acceptable natural zero-calorie sweeteners are available, such as products make with monk fruit extract and stevia. These also have no impact on the blood sugar level.”
Fat Quality Trumps Quantity
As with other macronutrients, evidence is inconclusive for an ideal amount of total fat intake for people with diabetes; goals should be individualized. Research suggests that fat quality appears to be far more important than quantity. “Dietary cholesterol and saturated fat aren’t the dietary villains we once thought,” Swift says. “A diet of diversity with high-quality sources of saturated fat, such as coconut, coconut oil, and grass-fed animal foods, are acceptable and amounts in the diet should be individualized.”
People with diabetes should follow the same guidelines for saturated fat, trans fat, and cholesterol as the general public. Saturated fat should be less than 10% of calories, cholesterol fewer than 300 mg/day, and trans fat limited as much as possible. Previous recommendations for fat limited saturated fat to 7% of calories and cholesterol to fewer than 200 mg/day, and stated that trans fat intake should be minimized.
The new recommendations suggest that people with type 2 diabetes may benefit from following a Mediterranean-style, monounsaturated fatty acid–rich eating pattern.
Vitamins and Herbs
The ADA’s position on vitamin supplementation remains essentially the same: There’s no clear evidence of benefit from vitamin or mineral supplementation in individuals without underlying deficiencies. However, since the previous position statement, there has been more conflicting research on the benefits of vitamin supplementation.
Swift believes dietitians should act earlier and not wait for underlying deficiencies to become evident. “We need to appreciate the spectrum that occurs with nutrient imbalances. We shouldn’t wait until these imbalances manifest in outright deficiency signs and symptoms,” she says. “The key here is [for clients to have an] evaluation by a skilled RDN in integrative and functional nutrition therapy. I’ve found in the 20-plus years of clinical practice that if you look for nutrient imbalances, you will find them.”
Ruggles agrees, stating that “professional-quality nutrient-herbal combinations can be very efficacious in supporting one’s overall plan. Many have seen this repeatedly in clinical practice.”
The ADA committee also believed there was insufficient evidence to support the routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes. Although in agreement with most of the position paper, Sheila Dean, DSc, RD, LD, CCN, CDE, an adjunct professor at the University of South Florida Health Morsani College of Medicine in Tampa, Florida, disagrees with the vitamin D recommendations: “There’s a plethora of very good evidence that supports the use of vitamin D in individuals with diabetes.”
The writers of the new guidelines also believed there was a lack of compelling evidence to support the use of cinnamon and other herbal products to improve glycemic control in people with diabetes. They stressed that herbal products aren’t standardized; they vary in the amount of active ingredients they contain and may have the potential to interact with other medications.
The Sodium Roller Coaster
In recent years, recommendations for specific dietary sodium targets have been the topic of much debate. The 2010 Dietary Guidelines recommend that people aged 14 to 50 limit their sodium intake to 2,300 mg/day. People aged 51 or older, blacks, and people with hypertension, diabetes, or chronic kidney disease—groups that together make up more than 50% of the US population—are advised to follow an even stricter limit of 1,500 mg/day.
In 2012, the World Health Organization recommended fewer than 2,000 mg of sodium daily for all adults; its previous recommendations were set at 2,000 mg. Then, in a May 2013 press release, the IOM stated that evidence doesn’t support a sodium intake recommendation of fewer than 2,300 mg.
Also parting ways with the 2010 Dietary Guidelines that recommend all people with diabetes reduce their sodium intake to 1,500 mg/day, the ADA’s new position statement recommends people with diabetes follow the same guidelines (fewer than 2,300 mg/day) as the general population.
For individuals with diabetes and hypertension, the guidelines suggest further reduction in sodium intake be individualized. The writers also suggest consideration be given to palatability, availability, and additional cost of specialty low-sodium products and the difficulty in achieving both low-sodium recommendations and a nutritionally adequate diet. “There’s some evidence that individuals may have difficulty meeting all other nutrient requirements when following a 1,500-mg sodium restriction,” Urbanski says.
There are many roads that lead to achieving a healthful diet, and no one meal plan or eating pattern works for all people with diabetes. To counsel clients effectively, nutrition professionals must remain open-minded, individualizing medical nutrition therapy based on their patients’ health goals, personal and cultural preferences, and health literacy and numeracy. In addition, patients must have access to healthful food choices and be ready, willing, and able to change.
“I think it’s challenging for dietitians when there’s not a single, clear-cut diet to recommend,” Urbanski says. “I think it’s also a challenge for us dietitians to avoid having some personal bias and to feel more comfortable with one particular diet approach or another. To best serve the patients we work with, we need to always remember what the evidence says and to keep in mind that every patient has personal tastes and preferences, which should be honored as much as possible.”
Nutrition intervention should emphasize healthful eating patterns and provide individuals with practical tools for following a day-to-day food plan and achieving behavior change that can be maintained over the long term.
— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is the national spokesperson for the Academy of Nutrition and Dietetics, specializing in African American nutrition, and author of the African American Guide to Living Well With Diabetes and Eating Soulfully and Healthfully With Diabetes.