Re: ADA Dietary Advice Explored [Long]

Hi Alan,

Thanks for pointing us towards that paper.

Here are a couple of things you did not quote from the same section of
it:

"Recommendations

* People with diabetes should receive individualized MNT [medical
nutritional therapy] as needed to achieve treatment goals, preferably
provided by a registered dietitian familiar with the components of
diabetes MNT.
* Both the amount (grams) of carbohydrate as well as the type of
carbohydrate in a food influence blood glucose level. Monitoring total
grams of carbohydrate, whether by use of exchanges or carbohydrate
counting, remains a key strategy in achieving glycemic control.
* The use of the glycemic index/glycemic load may provide an
additional benefit over that observed when total carbohydrate is
considered alone."

"MNT involves a nutrition assessment to evaluate the patient's food
intake, metabolic status, lifestyle, readiness to make changes, goal
setting, dietary instruction, and evaluation. To facilitate adherence,
the plan should be individualized and take into account individual
cultural, lifestyle, and financial considerations. Monitoring of
glucose and A1C, lipids, blood pressure, and renal status is essential
to evaluate nutrition-related outcomes. If goals are not met , changes
must be made in the overall diabetes care and management plan."

"Regulation of blood glucose to achieve near-normal levels is a primary
goal in the management of diabetes, and thus, dietary techniques that
limit hyperglycemia following a meal are important in limiting the
complications of diabetes. Both the amount (grams) and type of
carbohydrate in a food influence blood glucose level. The total amount
of carbohydrate consumed is a strong predictor of glycemic response,
and thus, monitoring total grams of carbohydrate, whether by use of
exchanges or carbohydrate counting, remains a key strategy in achieving
glycemic control."

And, directly relevant to the question raised in this discussion:

"For those individuals seeking guidance regarding macronutrient
distribution, the DRIs [dietary reference Intake] may be helpful The
DRI report recommends that to meet the body's daily nutritional needs
while minimizing risk for chronic diseases, adults (in general, not
specifically those with diabetes) should consume 45-65% of total
energy from carbohydrate, 20-35% from fat, and 10-35% from protein
(41). Although numerous studies have attempted to identify the optimal
combination of macronutrients for those with diabetes, it is unlikely
that any one such combination of macronutrients exists. The best mix of
carbohydrate, protein, and fat appears to vary depending on individual
circumstances."

If 45-65% of clalories from carbohydrates is the right proportion for
the non-diabetic population, and "monitoring total grams of
carbohydrate, whether by use of exchanges or carbohydrate counting,
remains a key strategy in achieving glycemic control" it is fairly easy
to see how the dieticians who look at this paper might recommend, as my
CDE did 3 years ago, that I consume about 30-33% of my calories from
carbohydrates. She did not put in those terms, but recommended 45
grams of carbs at 3 meals plus 1-2 snacks with 15 grams of carbs in a
total 2000 calorie diet, which works out to those percentages. The
technique of testing after meals to determine how particular foods
affect blood glucose. was stressed for fine tuning whatever
recommendations you were working on. All of which worked very well for
me-I only had to slightly modify the numbers she gave me--mostly for
breakfast. As I posted earlier on this or another thread, this was in
a Diabetes Education Program which the ADA certifies meets standards of
excellence and which it refers people in my area to fromtheir web site.

Just today, a poster on the ADA board who had recently taken classes.
referred to the ADA diet, and explained that by that she meant 30 grams
per meal, with 2 15 gram snacks per day. Even though the ADA does not
say it has a "diet plan" people are coming away for many of the classes
they have approved with the right ideas. I think it is fair to judge
them as much by their current practice as by their theory. It could
well be that the educators are ahead of the website makeover, which is
ahead/behind the theoretical underpinnings and position papers.

Morris

Alan S wrote:
On 4 Apr 2006 13:03:40 -0700, "morris"
<morrisolder@xxxxxxxxxxx> wrote:

"For
a healthy meal plan that is based on your individual needs, you should
work with a registered dietitian (RD) with expertise in diabetes
management,"

Hi All

Thanks Morris, and Jim.a

We hear that repeatedly. In effect, it allows the ADA to
appear to be saying "we are only suggesting - go see the
experts".

So, that begs the question - what is the training on
diabetes care that the registered dieticians receive, and
who or what sets the guidelines for that training?

To save those who don't want to read it all, regardless of
what contradictory advice is on the various web-site pages,
guidelines published in 2006 by the ADA for dieticians are:

Fat: 25-35%, including <7% saturated and 0% trans-fat.
Protein: ~10%
Carbohydrates: 55-65%, not less than 130gm daily.

To see how I came to that, read on.

I did some googling on dietician's courses and syllabi.
There was limited detail on the web, but this is an example
of several:

http://www.worldwidelearn.com/continuing-education/dietitian-ceu.htm
In the "diabetes" section we find:
"Diabetes
* 2004 Update: American Diabetes Association Diabetes
Nutrition Recommendations
* Type 2 Diabetes in Youth: Rising to the Challenge
* Type 1 Diabetes and Exercise"

That, or an earlier version of it was common to most of the
sites I found.

So, to be fair, let's not go back to 2004. Let's look at the
latest version of "American Diabetes Association Diabetes
Nutrition Recommendations" which are used by those
registered dieticians. If you were a registered dietician,
living in a litigious society and wanting advice from a
revered authority that would stand up in court, would you
use any other source?

The name has changed slightly, but you'll find them at
http://care.diabetesjournals.org/cgi/content/full/29/suppl_1/s4

Diabetes Care 29:S4-S42, 2006
© 2006 by the American Diabetes Association, Inc.
POSITION STATEMENT
ORIGINAL ARTICLE
Standards of Medical Care in Diabetes-2006

Read them in detail. There are a few surprises. But there
are also a few unsurprising disappointments.

Specifically on carbs/fat/protein ratios, some snippets:

"Low-carbohydrate diets are not recommended in the
management of diabetes. Although dietary carbohydrate is the
major contributor to postprandial glucose concentration, it
is an important source of energy, water-soluble vitamins and
minerals, and fiber. Thus, in agreement with the National
Academy of Sciences-Food and Nutrition Board (41), a
recommended range of carbohydrate intake is 45-65% of total
calories. In addition, because the brain and central nervous
system have an absolute requirement for glucose as an energy
source, restricting total carbohydrate to <130 g/day is not
recommended."
<snip>
"Dietary intake of protein is similar to that of the general
public in individuals with diabetes and usually does not
exceed 20% of energy intake. Intake of protein in this range
may be a risk factor for the development of diabetic
nephropathy (42). Based on studies in patients with varying
stages of nephropathy (42-44), it seems prudent to limit
protein intake in those with diabetes to the RDA (0.8 g/kg),
which would be ~10% of total calories."
<snip>
"The most recent guidelines from the National Cholesterol
Education Program recommend that total fat be 25-35% of
total calories and saturated fat <7% (34). Guidelines from
the American Heart Association also recommend that saturated
fat be <7% in those with diabetes, given their increased
risk of CVD (45,46). Intake of trans fat should be
minimized."

Those are very specific.

Now, let's put those together.
Fat: 25-35%, including <7% saturated and 0% trans-fat.
Protein: ~10%
Carbohydrates: 45-65%, not less than 130gm daily.

But, if the maximum protein is 10%, and maximum fat is 35%,
then by subtraction, the minimum carbohydrate must be at
least 55%. One becomes a little concerned at the expertise
of the people who derived these numbers if something as
simple as that escaped them. That's elementary school "sums"
level.

So, the real guidelines published in 2006 by the ADA for
dieticians are:

Fat: 25-35%, including <7% saturated and 0% trans-fat.
Protein: ~10%
Carbohydrates: 55-65%, not less than 130gm daily.

PS.

Some of the syllabi were scary. For example, try the
required texts for Utah State University Dietetic Internship
http://ce.usu.edu/intern/files/uploads/clinicalnutrition/SyllabusClinical..pdf
Syllabus - Clinical Nutrition NFS 6250; NFS 6260

Required Texts:
Mahan L.K., Escott-Stump S.: Krause's Food, Nutrition and
Diet Therapy. 10th or 11th Ed. Philadelphia, PA:
WB Saunders; 2000
American Dietetic Association and American Diabetes
Association. Exchange Lists for Meal Planning.
Chicago, IL: American Dietetic Association and American
Diabetes Association; 1995. Purchase one copy in
English version and one Spanish version ($2.50 each at
www.eatright.org).
Charney P, Malone A: ADA Pocket Guide to Nutrition
Assessment, American Dietetic Association, 2004.
Food-Medication Interactions, 13th edition. PO Box 204,
Birchrunville, PA 19421-0204.
Holli B, Calabrese R: Communication and Education Skills for
Dietetics Professionals (4th Edition). Williams
& Wilkins.


Cheers, Alan, T2, Australia.
d&e, metformin 2x500mg
--
Everything in Moderation - Except Laughter.

.

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