Wednesday, January 09, 2008

ADA Says Low-Carb Okay for Weight Loss, So What?

An article published today in Diabetes Health, ADA Now Supports Low-Carb Diets, reminded me that I have not yet posted my thoughts on the updated guidelines for Medical Nutrition Therapy (MNT) recently issued by the American Diabetes Association (ADA). This will probably be longer than usual, so bear with me!

On December 28, 2007, the ADA issued a press release to highlight the publication of and changes within their clinical practice recommendations, better known as the Standards of Care in Diabetes.

Each year the guidelines are updated and this year was no exception - as noted in the press release, "Until now, the ADA did not recommend low carbohydrate diets because of lack of sufficient scientific evidence supporting their safety and effectiveness. The 2008 Recommendations include a statement recognizing the increasing evidence that weight-loss plans that restrict carbohydrate or fat calorie intake are equally effective for reducing weight in the short term (up to one year). The "Standards of Medical Care in Diabetes--2008" document reviews the growing evidence for the effectiveness of either approach to weight loss. In addition, there is now evidence that the most important determinant of weight loss is not the composition of the diet, but whether the person can stick with it, and that some individuals are more likely to adhere to a low carbohydrate diet while others may find a low fat calorie-restricted diet easier to follow."

There are two main issues I'll look at in the above statement today:

1. that low-carbohydrate diets are as effective as low-fat calorie restricted diets for weight loss for up to one-year

2. that composition of diet is less important than whether a person can stick with the dietary approach for weight loss.

In order to fully understand exactly what the ADA is saying with regard to the first issue, we need to return to the August 2006 issue of Diabetes Care, where an updated consensus statement was published, Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement from the American Diabetes Association [ADA] and the European Association for the Study of Diabetes [EASD]

As I noted in my review of that consensus statement "Rather than question the dietary recommendations, or explore emerging data supportive of dietary interventions that are different from the recommendations, the statement instead concludes that "the limited long-term success of lifestyle programs to maintain glycemic goals in patients with type 2 diabetes suggests that a large majority of patients will require the addition of medications over the course of their diabetes."

The final sentence in the section discussing medications, which followed the section on lifestyle intervention, sets the stage for what is to come, "addition of medications is the rule, not the exception, if treatment goals are to be met over time."

In August 2006 the ADA, along with the EASD, threw up their hands and decided that dietary and lifestyle intervention was futile, therefore the only logical place to go was intensive pharmaceutical intervention at diagnosis.

The authors wrote, in the paper's conclusion, "We now understand that much of the morbidity associated with long-term complications can be substantially reduced with interventions that achieve glucose levels close to the nondiabetic range. Although new classes of medications, and numerous combinations, have been demonstrated to lower glycemia, current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes."

On this the ADA remains steadfast - pharmacological intervention is the first step with lifestyle intervention upon diagnosis. The freely available full-text of the Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy clearly continues with the August 2006 consensus that lifestyle intervention for those diagnosed with diabetes will not work, therefore medication must be initiated upon diagnosis.

Yet we find the ADA falling all over itself to tout its position change for weight loss - that now a low-carbohydrate diet is considered as effective as a low-fat calorie restricted diet for weight loss? And somehow we're supposed to be jumping for joy that they made this change?

If we take the entire package of documents published in the Diabetes Care Supplement, we cannot reach any conclusion other than the ADA has made up its mind and is not going to review the evidence. They may concede that a low-carbohydrate diet can help with some loss of weight, but nothing else - and even that carries the caveat that one must be intensely monitored if they do decide to follow a low-carb diet.

But, going back to the first point - the concession that low-carbohydrate diets and low-fat calorie restricted diets are both effective for weight loss over the short-term.

Quite frankly this statement by the ADA is meaningless when we consider the full context of their position because they hold that "current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes."

While many lauding the change as a step in the right direction for the ADA, I'm not impressed, nor convinced - if anything, the ADA only confirmed what they've already said previously.

We only need to go back to the publication of a 22-month study, in which diabetic subjects were found to have significant health improvements following a low-carbohydrate diet, to read the ADA reaction in an article at WebMD - "While agreeing that carbohydrate restriction helps people with type 2 diabetes control their blood sugar, ADA spokesman Nathaniel G. Clark, MD, tells WebMD that the ADA does not recommend very low-carb diets because patients find them too restrictive. "We want to promote a diet that people can live with long-term," says Clark, who is vice president of clinical affairs and youth strategies for the ADA. "People who go on very low carbohydrate diets generally aren't able to stick with them for long periods of time."

Which brings us to issue two above - diet composition does not matter as much as a diet one can follow, a theme the ADA has been hot and heavy on for at least two years now.

Let's review the sentence in the ADA press release carefully, "In addition, there is now evidence that the most important determinant of weight loss is not the composition of the diet, but whether the person can stick with it, and that some individuals are more likely to adhere to a low carbohydrate diet while others may find a low fat calorie-restricted diet easier to follow."

Evidence? What evidence?

The Standards of Medical Care in Diabetes 2008 includes this sentence, "Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. For those individuals seeking guidance on macronutrient distribution in healthy adults, the Dietary Reference Intakes (DRIs) may be helpful;" referencing the IOM documents published back in 2002.

The Nutrition Recommendations and Interventions for Diabetes: A Position Statement of the American Diabetes Association 2008 includes "Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes. (E)"

Note with that the letter "E" assigned to it, classing it as "expert opinion" - so again, where is the evidence? Each study referenced dates between 1997 and 2004 - so what exactly is the new evidence alluded to in the updated documents?

Oh, that's right, there is NONE...this is simply an opinion and has already been stated numerous times before.

I've said it before, "evidence versus sophistry; with just enough opinion thrown in to ensure glycemic control remains elusive..."

The ADA refuses to acknowledge that diabetics deserve clear statements about how to achieve normal blood sugars, and instead continues headlong on this path that they somehow deserve to eat like anyone else in the population and can mediate the effects of carbohydrate-rich food with medications.


So yeah, the ADA now says one can try a low-carbohydrate diet for weight loss, for the short-term (up to 1 year) and that some will somehow manage to follow such a diet. But let's not forget, if you do decide to follow a low-carbohydrate diet, you're also going to be subjected to much more intense monitoring than your low-fat calorie restricted peer and you're left with no advice other than the same-old same-old once your year is up.

Then what?

The failed ADA diet?

Lifelong medication with continued stepped-up pharmaceutical requirements with each passing year until you're dependent upon insulin injections?

The ADA, even with this new position that a low-carbohydrate diet may be used for up to one year for weight loss, still continues to fail in their mission - to prevent and cure diabetes and to improve the lives of all people affected by diabetes - because they refuse to actually review the hard data available; and instead continue in this sophistry that dietary recommendations need to be based upon what one wants to eat rather than what one should eat based upon metabolic, hormonal and physiological facts.


  1. Organizations, just like organisms, adopt strategies to maximize their chance of survival. I believe this often occurs without much conscious thought - that's certainly the case for organisms, including plants, bacteria, etc. As such, any organization who's stated goal is to find a cure for a disease automatically faces a severe conflict of interest: achieving the goal as stated basically results in the death of the organization.

    If the ADA successfully pushed adoption of any strategy that actually resulted in lifelong glycemic control (basically curing Type II diabetes), their reason for existence would be severely curtailed. Funding would dwindle, many people would be out of a job, etc. Their recommendations scream "you need us forever!", and the latest round demonstrates the degree to which they'll twist existing evidence to ensure their continued survival. They can't ignore low carb, but they can try to make sure the recommended application ensures that the ADA continues to be relevant in the treatment of the disease.

    Like I said, I don't think this is conscious. I don't believe that the members of the ADA are actively conspiring to suppress science or twist the evidence to their own means. But they are definitely rationalizing a strategy which ensures their continued relevance. The same seems to apply to the AHA, the CDC, etc.

    It seems our only recourse is to ignore the recommendations of such organizations, and attempt to assess the available evidence ourselves. That's why resources such as this blog are so valuable.

  2. Regina, I have to sort of agree and sort of disagree. Yes, absolutely, the ADA's "new" stance is, well, pathetic. But it's also ammunition for all the diabetics, like me, whose doctors have been hammering them about "why aren't you on a low fat diet like I said?" Now, at least, they can say "The ADA doesn't exclusively recommend a low fat diet any more. Keep up!"

    I say "they" because I'm instead working on getting another doctor. :P


  3. So, basically the ADA is a parasitic organism, feeding on the misfortunes of all us poor diabetics.

  4. I'm kind of curious as to why one would have reason to believe that people are going to be any more compliant with a low carb diet then any other?

  5. A low-carb diet doesn't require calorie restriction.

  6. Anonymous7:22 AM

    Some people will do better on a low-carb diet. Others won't. To be given that option as a medically supported choice will help because those people for whom it will work will not have to be swimming quite so hard upstream against an entrenched low-fat medical establishment.

  7. When I first heard the rumors of the ADA backing off on it's low carb stance, I thought I might have to change my moniker, renegadediabetic. Now I see that I can keep it. I'm still very much a renegade. :)

  8. First, I have to reply to Dave's comment. To suggest that nonprofit organizations subconsciously perpetuate the problems they're trying to solve is utterly absurd. Yes, even if you compare it to the basic function of all organisms. *eye roll*

    All markets fluctuate and change. Many markets fail. The nonprofit industry is no different, and most of its employees are staunchly dedicated to their work, and would happily close their doors, particularly if they have personal experience with their cause- burying a loved one due to a disease, lived on the streets, etc. Most make far less than their corporate counterparts. So, the logic of fearful clinging to jobs and subconscious promotion of societal ills is rather faulty.

    The author of JunkFood Science thinks she's right and has ample evidence to prove it. The author of this blog thinks she's right and has ample evidence to prove it. Every five minutes there's new evidence praising an approach accompanied by evidence demonizing said approach. The day when One Size Fits All medicine actually works is the day all hell freezes over.

    I'm sure the ADA is like every other organization trying to better folks' lives--continually re-evaluating information and providing what they deem to be the best solution possible based on the largest amount of evidence available. And whaddya know, not everyone agrees on what the best solution is.

    Criticism can be quite helpful. Assuming ultimate authority and righteousness rarely is. If this criticism is legitimate, what is being done to engage the ADA in this discussion?

  9. Demandra - I don't suppose you'd like to back up your "eye roll" with some evidence? Can you give me an example of a large organization (similar to the ADA), whose goal was to cure some disease, which actually cured said disease then closed up shop and sent everybody home?

    I absolutely agree that critical thinking and debate are vital to scientific progress. The problem that we face is an utter lack of critical thinking. The fact that apparently contradictory evidence exists requires evaluation of that evidence. One doesn't simply dismiss evidence becauase it doesn't agree with the currently accepted hypothesis - that is the antithesis of the scientific method. That evidence disagrees with a hypothesis does not weaken the the evidence; rather it is ALWAYS the belief in the hypothesis that is influenced by the evidence.

    So while the ADA may be "continually reevaluating evidence", I would suggest that most of the evidence they are evaluating is that which largely agrees with their current position. It's the only way to explain their behavior, unless they know something that the rest of us don't. The scientific evidence in favor of carbohydrate restriction for controlling Type II diabetes is significant. If the ADA's position were scientifically sound, then it would be easy for them to demonstrate why that position is supported by a greater weight of the evidence than the carbohydrate hypothesis. That they don't supply this evidence either means they don't have it, or for some strange reason are keeping it from the rest of us. And I've asked for it - twice.

    Maybe you'll have more luck getting than I did, because I would really like to see such evidence if it existed. You can only make good decisions if you have good information, so if the ADA has some important information on this point, they need to share it with the rest of us.

    I would be happy to engage in a debate with anyone from the ADA on this topic.