The SBU (Swedish Council on Health Technology Assessment) is charged by the Swedish government with assessing health care treatments. Their recent acceptance of low-carbohydrate diets as best for weight loss is one of the signs of big changes in nutrition policy. I am happy to reveal the next bombshell, this time from the American Diabetes Association (ADA) which will finally recognize the importance of reducing carbohydrate as the primary therapy in type 2 diabetes and as an adjunct in type 1. Long holding to a very reactionary policy — while there were many disclaimers, the ADA has previously held 45 – 60 % carbohydrate as some kind of standard — the agency has been making slow progress. A member of the writing committee who wishes to remain anonymous has given me a copy of the 2014 nutritional guidelines due to be released next year, an excerpt from which, I reproduce below.
Nutrition Therapy Recommendations for the Management of Adults With Diabetes
This position statement on nutrition therapy for individuals living with diabetes replaces previous position statements, the last of which was published in 2013  and incorporated into the Standards of Medical Care of 2014 . In particular, evidence suggests that the starting point for therapy for type 2 diabetes and adjunct treatment of type 1, should be some form of very low-carbohydrate diet. The amount of carbohydrates is the most important factor influencing glycemic response after eating and should be considered when developing the eating plan. Carbohydrate intake has a direct effect on postprandial glucose levels in people with diabetes and is the primary macronutrient of concern in glycemic management. While it is still recognized that there is not an ideal percentage of calories from carbohydrate for all people with diabetes, carbohydrate intake should be as low as possible for most people.
There are several good references for implementation [3, 4] although the degree of reduction of dietary carbohydrate should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. Collaborative goals should be developed with the individual with diabetes. For good health, any carbohydrate intake should come from vegetables, fruits, legumes, and dairy products rather than intake from other carbohydrate sources, especially those that contain high starch and sugar. In recognizing the importance of removing carbohydrates, the current guidelines deviate from, and consider inappropriate, previous recommendations from 2008  that “sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose lowering medications.” While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, it is now recommended that consumption should be minimized to avoid displacing nutrient-dense food choices.
Recommendations for low-carbohydrate diets.
The new recommendations emphasizing low-carbohydrate diets follow from the observations noted previously  that improvements in serum lipid/lipoprotein measures including improved triglycerides, VLDL triglyceride, and VLDL cholesterol, total cholesterol, and HDL cholesterol levels are now recognized as a reliable feature of lower-carbohydrate diet compared with higher carbohydrate intake levels. Through the collaborative development of individualized nutrition interventions and ongoing support of behavior changes, patients should understand the rationale of carbohydrate restriction and be made aware of its potential value.
Most important for clinicians is understanding results of two independent comparative studies from the laboratories of David Jenkins  and of Eric Westman  shown in Figure 1.
The role of body mass in diabetes.
More than three out of every four adults with diabetes are at least overweight, and nearly half of individuals with diabetes are obese. Because of the relationship between body weight (i.e., adiposity) and insulin resistance, weight loss has long been a recommended strategy for overweight or obese adults with diabetes. Two important experimental results bear on the new recommendations. First, in numerous trials, low-carbohydrate diets of one type or another out-perform other diets to which they are compared. No diet is better than carbohydrate restriction for weight loss. However, it has been shown that the features of both type 1 and type 2 diabetes are improved by low-carbohydrate diets even in the absence of weight loss.
Previous recommendations on nutritional therapy have failed to take account important work of Nuttall and Gannon who have clearly shown that the symptoms of type 2 diabetes can be improved without the requirement for weight loss [8-10]. Even under weight-maintenance conditions, dietary carbohydrate restriction dramatically improves glycemic control as well as HbA1c and lipid markers. This fact is important given the resistance that many individuals show to weight loss. A series of papers from Nuttal and Gannon [8-10] measured many hormones and parameters in response to various carbohydrate-reduced diets. Although the percentage of carbohydrate differed in many of these studies, the most effective level of carbohydrate in improving the markers was the lowest level of carbohydrate used. Results from one study from Nuttall and Gannon’s lab  are shown in Figure 2. A low-carbohydrate (20% energy) diet was instituted for five weeks under conditions where weight was maintained. It is clear from the figure 24-hr integrated and postprandial glucose as well as hemoglobin A1c was improved after the five-week diet period (●) compared to performance before (▲). These results contrast with outcomes from low-fat and calorie-restricted diets, which generally require weight loss for diabetes symptoms to improve. While the results have recently been extended to longer periods , it is important to recognize that nothing in the results contradicts the idea that benefit will continue to accrue as long as the diet is adhered to.
Figure 2. Comparison of blood glucose, endogenous insulin and glycosylated hemoglobin in sixmales with mild untreated type 2 diabetes fed a low-carbohydrate/ high-protein diet (non-ketogenic;20% carbohydrate, 30% protein). Results are shown before (▲) and after (●) the five-week regimen.
It is now recognized that the amount of dietary saturated fat and cholesterol recommended for people with diabetes is the same as that recommended for the general population. Recent studies have confirmed that there is no relation between dietary saturated fat and cholesterol and cardiovascular disease [11-13]. Previous statements that “patients on low-carbohydrate diets, monitor lipid profiles” is no longer considered appropriate although all patients with diabetes should monitor their lipids.
Is this real? Can you believe it?
Is this real? No. It’s not real. It could be real if the American Diabetes Association adopts it. You believed that it was real because it is reasonable and it follows from both common sense and scientific principles. You believed it because it provided you with the data rather than giving you the opinion of a committee that chose whatever studies it wanted to, and took the conclusions at face value. Most of all, you believed it because we all want to believe it. Previous guidelines from the ADA have been incomprehensible and ultimately embarrassing. Since the principles of low-carbohydrate diets are so reasonable, bloggers and others have continually tried to find signs of their acceptance in each new position statement from the ADA, signs that could be described as “encouraging first steps.” Invariably, the ADA guidelines have been, instead, the camel-like creations of a committee characterized by stultifying clichés — one reason that you might have believed that the version above was real is that I included trivial phrases — the text that is in blue — from the 2013 guidelines. I wrote this because several bloggers tried to put a positive spin on the 2013 guidelines and I was going to comment on how little it would have taken for them to get it right. So I decided to write it for them.
Imperial Dishabilement. Critique of the 2013 Guidelines
Diabetes Care is the house organ of the ADA. The 2013 guidelines are subject only to internal review. No real peer review is possible and it shows. We are not supposed to be too critical, however. Standards of propriety are expected of the reader. We are supposed to refrain from blunt criticism of style and content, like Robert French’s critique of A companion to Woody Allen in the Times Literary Supplement (October 4, 2013):
“The book is 90% of obfuscation, 10% illumination. Statements of the obvious abound (‘Like many Christians, Jews, Muslims and others, Allen can practice a faith without always believing in it’).”
We are expected to ignore fatuous remarks stating that one of the goals of nutrition therapy is:
“To maintain the pleasure of eating by providing positive messages about food choices while limiting food choices only when indicated by scientific evidence.”
I admit that I had to ask an English professor for an explanation as to why this particular line is so annoying. “It implies that there is some agency out there who wants to deny you pleasure or unjustly limit your food choices.” But statements of the obvious do abound. Some examples:
“For overweight or obese adults with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss.” (twice)
“Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another.”
“A healthful eating pattern, regular physical activity, and often pharmacotherapy are key components of diabetes management.”
“Effective nutrition therapy interventions may be a component of a comprehensive group diabetes education program or an individualized session achieved.”
“Health professionals should collaborate with individuals with diabetes to integrate lifestyle strategies that prevent weight gain or promote modest, realistic weight loss.”
All such documents have a certain degree of boiler plate but here it is relentless and overpowering and it takes the place of the science. And it protests too much. “Individualized” appears 21 times in the guidelines. But it is disingenuous. Individualized is just what the previous guidelines were not and those recommendations are specifically not retracted. It is not sufficient to say that your paper “replaces previous position statements.” You have to explain what the previous ones were and why they are no longer applicable.
If therapy is individualized, what principles is individualization based on? “Individuals who have diabetes should receive individualized Medical Nutrition Therapy (MNT) as needed to achieve treatment goals, preferably provided by a registered dietitian (RD) familiar with the components of diabetes MNT.” In other words, you’re on your own, or worse, turn it over to the RD’s. Where do the RD’s get their understanding of diabetes MNT? Well, probably from the last implementation of the ADA guidelines which were unabashed in what they opposed:
“Low-carbohydrate diets might seem to be a logical approach to lowering postprandial glucose. However, foods that contain carbohydrate are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability”  and…
“For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to1 year).”
“For patients on low-carbohydrate diets, monitor lipid profiles, renal function,and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed.”
In other words, low-carb diets are okay if you don’t mind having a heart attack or kidney failure (oh, of course only if you have nephropathy; it’s not a failure to understand of English usage that puts the disclaimer in the wrong place in the sentence ) and the low-carb diet will lead to hypoglycemic episodes.
Most of all, you have to provide new guidance. But guidance is not available in the 2013 position statement. :
“The optimal macronutrient intake to support reduction in excess body weight has not been established.”
“Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.”
“The evidence suggests that several different macronutrient distributions/eating patterns may lead to improvements in glycemic and/or CVD risk factors (88). There is no “ideal” conclusive eating pattern that is expected to benefit all individuals with diabetes (88). ” (Reference 88 is to the same group’s review of low carbohydrate diets).
Evidence does not generally suggest what is not ideal. This is especially true if you don’t look at all the evidence and this is the ADA guideline’s greatest failing. The two figures above, by themselves, constitute a strong case for low carbohydrate diets. These papers are not cited by the 2013 guidelines although I have personally pointed them out to members of the committee. Non-scientists ask me: “Can you do that? Can you just leave out relevant papers?”
And “ideal” may not be possible anywhere in medicine. What you want is best practice or, as we describe it, the “default diet,” what you try first, your best bet.
The bottom line is that the 2013 guidelines are weak on science and dreadful in style. The two are closely linked. Obfuscation rather than clarification. The emperor is naked. The document would never survive real peer review. In the end, we have to ask why this is tolerated. The answer is usually that the ADA is a private organization and they may do as they choose. Or are they? They are tax exempt and their officers and editors have federal grants. On publication, Diabetes Care is their journal and the editors can publish whatever they like. Or can they? Is any paper in such a publication to be believed if there is this level of bias among the editors? Are they accountable at all?
The writing committee.
There are no real credentials in science. We all accept that a major part of our understanding of the physical world comes from a clerk in a patent office. But that’s only true if the science is correct. So who did the ADA get to present their position? The list is below. You can Google them to see their qualifications. There are two PhD’s and, oddly, only one representative of the M in MNT (Medical Nutrition Therapy), Will Yancy, who, in fact, has provided strong evidence supporting low-carbohydrate diets. Yancy is a co-author on the un-cited study in Figure 1 (ref. 4). The first author of the 2013 Guidelines, Allison Evert has two publications: those Guidelines and the review paper on low-carbohydrate diets, a subject with which she appears to have no experience. Most of the other authors also appear to have no experience with research on the effects of macronutrients. Most have little research experience at all. As for Yancy, who has made a major contribution to dietary carbohydrate restriction, it is generally assumed that they threatened his life.
Allison B. Evert, MS, RD, CDE
Jackie L. Boucher, MS, RD, LD, CDE
Marjorie Cypress, PhD, C-ANP, CDE
Stephanie A. Dunbar, MPH, RD
Marion J. Franz, MS, RD, CDE
Elizabeth J. Mayer-Davis, PHD, RD
Joshua J. Neumiller, PharmD, CDE, CGP, FASCP
Robin Nwankwo, MPH, RD, CDE
Cassandra L Verdi, MPH, RD
Patti Urbanski, MED, RD, LD, CDE
William S. Yancy, Jr., MD, MHSC
1. American Diabetes Association: Nutrition Recommendations and Interventions for Diabetes–2013. Diabetes Care 2013, 36(Suppl 1):S12-S32.
2. Association AD: Standards of Medical Care in Diabetes — 2014. Diabetes Care 2014, 37, Supplement 1:S15-S80.
3. Bernstein RK: Dr. Bernstein’s diabetes solution : the complete guide to achieving normal blood sugars, 4th edn. New York: Little, Brown and Co.; 2011.
4. Vernon MC, Eberstein JA: Atkins Diabetes Revolution. The Groundbreaking Approach to Preventing and Controlling Type 2 Diabetes. New York: William Morrow; 2004.
5. American Diabetes Association: Nutrition Recommendations and Interventions for Diabetes–2008. Diabetes Care 2008, 31(Suppl 1):S61-S78.
6. Jenkins DJ, Kendall CW, McKeown-Eyssen G, Josse RG, Silverberg J, Booth GL, Vidgen E, Josse AR, Nguyen TH, Corrigan S et al: Effect of a low-glycemic index or a high-cereal fiber diet on type 2 diabetes: a randomized trial. JAMA 2008, 300(23):2742-2753.
7. Westman EC, Yancy WS, Mavropoulos JC, Marquart M, McDuffie JR: The Effect of a Low-Carbohydrate, Ketogenic Diet Versus a Low-Glycemic Index Diet on Glycemic Control in Type 2 Diabetes Mellitus. Nutr Metab (Lond) 2008, 5(36).
8. Gannon MC, Hoover H, Nuttall FQ: Further decrease in glycated hemoglobin following ingestion of a LoBAG30 diet for 10 weeks compared to 5 weeks in people with untreated type 2 diabetes. Nutr Metab (Lond) 2010, 7:64.
9. Gannon MC, Nuttall FQ: Control of blood glucose in type 2 diabetes without weight loss by modification of diet composition. Nutr Metab (Lond) 2006, 3:16.
10. Gannon MC, Nuttall FQ: Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes 2004, 53(9):2375-2382.
11. Forsythe CE, Phinney SD, Feinman RD, Volk BM, Freidenreich D, Quann E, Ballard K, Puglisi MJ, Maresh CM, Kraemer WJ et al: Limited effect of dietary saturated fat on plasma saturated fat in the context of a low carbohydrate diet. Lipids 2010, 45(10):947-962.
12. Jakobsen MU, Overvad K, Dyerberg J, Schroll M, Heitmann BL: Dietary fat and risk of coronary heart disease: possible effect modification by gender and age. Am J Epidemiol 2004, 160(2):141-149.
13. Siri-Tarino PW, Sun Q, Hu FB, Krauss RM: Saturated fat, carbohydrate, and cardiovascular disease. Am J Clin Nutr 2010, 91(3):502-509.