ADA 2009 Recommendations Reaffirm Acceptance of Low Carb Diet

Low Carb Food Pyramid, from <a href=></a>

Dec 29, 2008

Every year the American Diabetes Associations revises and updates its Clinical Practice Recommendations, a publication upon which many doctors and medical caregivers depend as a primary source of diabetes treatment information.

The current edition reaffirms the ADA's landmark decision in 2008 to accept low carbohydrate diets as one method people with diabetes can use to lose weight in the short term (up to one year).

Previously, the ADA, as well as many other public health organizations, had recommended low fat diets that precluded any more than very light consumption of red meat, eggs, dairy products, and other high protein, high fat foods. Because diabetes increases the risk of cardiovascular disease, the concern was that a high fat intake could lead to arterial plaque and other vascular obstructions.

However, subsequent research has shown that a high carbohydrate intake-even if the carbs rate well on the glycemic scale-may be at fault for excess weight in certain people with diabetes. Excess weight can lead to heart problems and envelope vital organs in fat.

The ADA remains cautious, however, recommending that people with diabetes who go on low carb diets monitor their lipid profiles and renal function and, if they have nephropathy, watch their protein intake. 

Other Updates

The updated recommendations include discussions of treatment approaches, glycemic control, testing and prevention, and addressing complications.

Regarding treatments for type 1 and type 2, the guidelines emphasize general approaches rather than specific drug regimens. For type 1s, the recommendation is for multiple daily injections using both basal and prandial insulins, with anticipated carb intake and post-meal activity in mind. The ADA also advises type 1s to consider using insulin analogs if they have problems with hypoglycemia.

For type 2s, the recommended treatment includes metformin, diet, exercise, and the use of other drugs when needed to keep BG levels as close to normal as possible. While the ADA recommends that doctors consider prescribing insulin soon after diagnosis for patients who experience severe weight loss or hyperglycemia, the guidelines no longer endorse a certain progression of drugs. How a patient moves from metformin to a sulfonylurea or combination product and then on to Januvia, Byetta, or insulin is left up to the medical practitioner.

The ADA's recommendations on glycemic control are unchanged from early 2008. The goal is an A1c of 7% for most patients and an A1c of 6% for patients who are not prone to hypoglycemia. In cases where patients have severe hypoglycemia or have had diabetes for a long time but have suffered few complications, A1c's can go higher.

(The association has taken a wait-and-see stance with its decision to stick with the 2008 glycemic control recommendations. When the acclaimed ACCORD study of strict glycemic control among 10,000 patients was abruptly stopped earlier this year in the wake of an unexpected increase in heart attack deaths among tightly controlled type 2s, the ADA decided not to revise its recommended A1c levels downward. Interestingly, a parallel European study tracking strict glycemic control among a similarly sized population of type 2s showed no increase in mortality from cardiovascular events.)

Regarding prediabetic conditions, the recommendations come down explicitly in favor of testing-and even medicating-individuals who run an apparent risk of developing type 2. Risks include being overweight, suffering from hypertension, being physically inactive, and having a family history of the disease. The ADA also advises everyone 45 years and older to be tested for impaired glucose tolerance and impaired fasting glucose, indicators of vulnerability to the onset of type 2.

Preventive measures include weight loss and increased physical activity. The recommendations call for people under 60 who are obese or at high risk to begin taking metformin, both for its efficacy as a glucose inhibitor and its low cost.

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Categories: A1c Test, Diabetes, Diabetes, Diets, Food, Insulin, Losing weight, Low Blood Sugar, Low Carb, Professional Issues, Research, Type 1 Issues, Type 2 Issues

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Posted by Steve Parker, M.D. on 29 December 2008

My understanding is that the ADA's OK of low-carb weight-loss diets applies to people with type 2 diabetes, not type 1. Sorry if this sounds like nit-picking, but I didn't want type 1s to get the wrong idea.

Details here:


Posted by seashore on 29 December 2008

Diabetes is a disease of excessive blood sugar, and blood sugar comes primarily from carbs. Hence, the obvious means of combating diabetes is a low-carb diet.

Yet the ADA continually insists that a low-fat, high-carb diet is the best way to oppose diabetes. Do they have evidence that their dietary approach is as effective in treating diabetes as a low-carb diet?

Posted by Jerry1423 on 29 December 2008

I am a type 1 diabetic, for 33 years.
One problem with this article is that it did not mention how high "high" is when referring to high carb diets.
In my opinion people who will restrict too many carbs from their diets may have more problems ... Can a low carb diets affect brain function? I really don't know (I am not a doctor) but I assume that it can.
It is much easier for me to deal with carbs than it is proteins because those seem to take a couple hours before they show up in my blood sugar reading - at that time I may need to take a couple more units of insulin.

Posted by Green Lantern on 29 December 2008

It'd be nice if they defined "low" carb, too...

Posted by Anonymous on 30 December 2008

Re: seashore's comment that ADA recommends a low-fat diet. I do not see that in their recommendations. I see recommended limits only on saturated fat and trans fats.

Posted by DM Preg on 31 December 2008

Regarding prediabetic conditions,the highest risk factor was not mentioned and that is a history of gestational diabetes (GDM). More than 135,000 women per year in the US have GDM.Up to 1/3 have prediabetes when screened after delivery. More than 50% will have overt type 2 diabetes within 5 years. It is important to raise awareness of this risk factor as the potential for prevention is great- especially if dietary changes such as reducing carb intake can be made.

Posted by Anonymous on 14 January 2009

Three steps forward, two steps back. Despite the experience of most of the posters on their forums I assume they cannot endorse a low carb diet in case there is a class action lawsuit when it is discovered how much better the results are than their previous recommendations.

I DO agree with their plea to have lipids monitored on a low carb diet, how else could you discover the massive improvements in trigs and HDL seen by most low carbers?

Over the years they have slipped their recommended carb consumption down from 250 - 300g to 135g, still twice what I can effectively handle.

Posted by Anonymous on 19 January 2009

Well, nobody has mentioned the importance of the source of the carbohydrates. Any carbs that are processed (all vitamins, minerals, antioxidants and fibre stripped away) will bring the immune system down and pave the way for all sorts af ailments, such as type II diabetes, cancer etc. The ONLY good source of carbs is fresh fruit and veg and whole meal products. ANY processed food, including all softdrinks will only worsen any medical condition. Arthur De Vany knows probably more about the subject than 99% of doctors poisoning people with these artificial chemicals.

Posted by chanson on 2 February 2009

This is interesting, but I was looking for more detail in the article. Is it possible to link to the ADA recommendations or quote the language?

My feeling is that the issue of carbohydrate in the ADA recommendations has always been kind of indirect. When I was diagnosed years ago, I was told about the evil of too much fat and protien - leaving carbohydrate as the safe altrnative. I was also told that sugar was bad (simple cabohydrate) but potatoes (complex carbohydrate) were okay. I don't tink the ADA came out and recommended a "high carbohydrate" diet.

Since then, there has been movement in the ADA recommendations, but it is not obvious unless you analyse the recommendations over time (like 30 years). Could be an interesting article.

Posted by mgordon on 23 March 2009

I believe depending or activity, weight, and gender a dietician will decide which low carb diet is good for you. In addition the diet will require a decrease in meds. At least that's what happen with me, and I'm not over weight. It's jus a healthy way of eating and I'm not starving

Posted by Anonymous on 30 August 2009

interesting but I really want to see their approval from ADA website. I could find only low-fat options and its food pyramid from their homepage.

Posted by phishery on 14 October 2009

For anyone looking for additional information on the treatment of both Type I and Type II diabetes using a low carb diet I have put together the following site:

On the site I have a free PDF with 300 recipes that I have used to help manage my own diabetes in addition to a centralization of research on the subject.

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