In December 2008, the American Diabetes Association (ADA) issued its Clinical Practice Recommendations which included the option for Diabetics to follow low-carbohydrate diets as a weight-loss option. While this is obviously not ‘news’, it is important to note that the Canadian Diabetes Association – now called Diabetes Canada, does not as yet make the same recommendation.
Why is that?
Is there something inherently different about Diabetics in Canada than Diabetics in the United States?
For the last 9 years the American Diabetes Association has given people the option of following what they call a “moderate” carbohydrate diet by (a) omitting some of the carb-containing foods on their standard meal plan or (b) substituting them for much lower carb alternatives. They also (c) provide Americans with the option of following a low carb diet for weight loss.
Let’s take a look at the American dietary recommendations compared with the Canadian ones.
Dietary Recommendations of the American Diabetes Association
On their web page, the American Diabetes Association states that their standard Meal Plans that are “moderate” in carbohydrates provide ~45% of calories from carbs, but they add;
Your healthcare provider may ask you to limit carbohydrate more than our meal plan suggests. This means you should cut back on the carbohydrate foods that you eat throughout the day. To keep your calorie intake about the same, substitute sources of lean protein or healthy fats for those higher carbohydrate foods.
Then they give some examples of how people can lower carbohydrate intake by making some adjustments to the posted meal plan, such as;
- omitting the slice of whole wheat toast at breakfast
- replacing the whole wheat wrap for a lettuce wrap at lunch
- skipping the serving of brown rice at dinner and adding another non-starchy vegetable instead.
For the last 9 years (2008), Diabetics in the US have also been given the option by the American Diabetes Association to follow a low carb diet in order to lose weight. The 2008 Summary of Revisions for the Clinical Practice Recommendations was changed to include the following;
The “Medical Nutrition Therapy” section has been revised; updates to this section include the following revised recommendations for weight loss:
For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short-term (up to 1 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.
What the last sentence means is that doctors should monitor the cholesterol and triglyceride levels of their patients on low-carb diets and adjust the dosage of the medication prescribed to control blood sugar levels.
As has been the experience of physicians that prescribe a low carb high fat diet to their patients, as blood sugar levels drop – they need to reduce their patient’s medications dosages and in time, these medications are often discontinued entirely.
What are the dietary recommendations given to Diabetics in Canada?
Dietary Recommendations of Diabetes Canada
Diabetes Canada basic meal planning information advises people to;
“Choose starchy foods such as whole grain breads and cereals, rice, noodles, or potatoes at every meal. Starchy foods are broken down into glucose, which your body needs for energy.”
The sample meal plan for small appetites on the Diabetes Canada website recommends that people consume 193 g of carbohydrates per day which is approximately 13 servings* of carb-containing food per day (* based on the Diabetic exchanges, where 1 serving is 15 g of carbohydrate).
The Diabetic Sample Meal Plan for larger appetites is the same as above, but also includes an afternoon snack with a medium apple or small banana (+ 25 g carbohydrates), plus a medium pear at supper (+29 g carbohydrates) and another glass of milk with the above evening snack (+12 g carbohydrates), amounting to 259 g of carbohydrates per day, which is almost 17 servings* of carb containing foods.
Diabetics in Canada are advised to eat 45 – 60 g of carbs at each of 3 meals, plus 15 – 30 grams of carbs at each of 1-2 snacks.
This is a lot of carbohydrate for someone whose body isn’t handling carbohydrates well.
The Diabetes Canada webpage, under Healthy Living Resources, there is a section titled Diet and Nutrition. Under this are the organizations recommendations concerning Carbohydrates. They encourage carbohydrate counting which “focuses on foods that contain carbohydrate as these raise your blood glucose (sugar) the most.”
They encourage Canadian Diabetics to “follow these steps to count carbohydrates and help manage your blood glucose levels”.
What are those steps?
- Step 1: Make healthy food choices
- Step 2: Focus on carbohydrate
- Step 3: Set carbohydrate goals
- Step 4: Determine carbohydrate content
- Step 5: Monitor effect on blood glucose level
Diabetes Canada recommends that Diabetics eat ~ 1/2 of their calories as carbohydrate while at the same time advising people that “foods that contain carbohydrate … raise your blood glucose (sugar) the most”.
So, when Diabetics eat the large percentage of their diet as carbs and their blood sugar is raised, what should they do?
Well, the Diabetes Canada webpage goes onto explain under Step 5 that they should “monitor the effect (of carbohydrates) on blood glucose level and
Work with your healthcare team to correct blood glucose levels that are too high or too low.
I had to read this several times to make sure I wasn’t misreading it.
Diabetics in Canada are being told;
- carbs raise their blood sugar the most
- that they are to take in ~1/2 of their calories as carbs
- when their blood sugars get too high, they need to have their medication adjusted to handle the load.
Could this be why Diabetes is said to be “a chronic, progressive disease”?
Change in the American Diabetes Association Postion
In 2007, a year before the revised recommendations came out approving either a low-carb diet or a low calorie restricted diet, the American Diabetes Association recommendations stated that ‘low carb diets were not recommended for the treatment of overweight or obesity—even in the short term, because their long-term effects were unknown and they did not seem to provide better maintenance of weight loss than low-fat diets over the long term’.
However, in a press release with the release of the 2008 recommendations the American Diabetes Association reversed its position saying;
“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.”
Furthermore, in the same press release, the American Diabetes Association President of Health Care & Education at the time, Registered Dietitian Ann Albright, PhD, RD, said;
“We’re not endorsing either of these weight-loss plans over any other method of losing weight.”
Albright added that it was ‘more important that people with Diabetes choose a weight-loss plan that works for them and that their healthcare team supports their efforts and monitors their health accordingly‘.
The Canadian Clinical Practice Guidelines recommends that people with Diabetes receive nutrition counselling from a Registered Dietitian. They recommend that those who are overweight or obese reduce caloric intake to achieve and maintain a healthier body weight and state that it is consistency in carbohydrate intake and in spacing and eating regular meals that may help control blood glucose levels and weight.
From the 2017 Guidelines:
People with diabetes should receive nutrition counselling by a registered dietitian.
Reduced caloric intake to achieve and maintain a healthier body weight should be a treatment goal for people with diabetes who are overweight or obese.
The macronutrient distribution is flexible within recommended ranges and will depend on individual treatment goals and preferences.
Replacing high glycemic index carbohydrates with low glycemic index carbohydrates in mixed meals has a clinically significant benefit for glycemic control in people with type 1 and type 2 diabetes.
Intensive lifestyle interventions in people with type 2 diabetes can produce improvements in weight management, fitness, glycemic control and cardiovascular risk factors.
A variety of dietary patterns and specific foods have been shown to be of benefit in people with type 2 diabetes.
Consistency in carbohydrate intake and in spacing and regularity in meal consumption may help control blood glucose and weight.
Why are Diabetics in the US recommended to lose weight by following either a low-carb diet or a low calorie restricted diet, yet Diabetics in Canada are recommended to eat 13-17 servings of carb-containing foods per day, with 45 – 60 g of carbs at each of 3 meals, plus 15 – 30 grams of carbs at each of 1-2 snacks? That’s a good question.
Many physicians report that Diabetics following LCHF diets have their medications reduced and in many cases discontinued entirely. As a Dietitian this seems preferable as a first approach, than recommending that Diabetics eat half of their calories as carbs, which would necessitate having their medication adjusted upwards when their blood sugars get too high, and having people’s Diabetes continue to worsen in time.
Why should Canadians with Diabetes not be provided with choice?
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American Diabetes Association, Adjusting the Meal Plan, http://www.diabetes.org/mfa-recipes/2017-07-adjusting-the-meal-plan.html
Dairman T., Diabetes Self-Management, ADA’s New Guidelines OK Low-Carb Diets for Weight Loss, 2008 Jan 7, www.diabetesselfmanagement.com/blog/adas-new-guidelines-ok-low-carb-diets-for-weight-loss/
Dworatzek PD, Arcudi K, Gougeon R, Husein N, Sievenpiper JL, Williams SL. Nutrition Therapy, Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, http://guidelines.diabetes.ca/browse/chapter11