New recommendations regarding diet represent a departure from the past.
The American Diabetes Association published its yearly update of its major position paper, "Standards of Medical Care in Diabetes." The paper contains all of the association's recommendations in a range of topics, including diagnosis and treatment of diabetes, diabetes care, and nutrition.
The biggest bit of news comes from the Medical Nutrition Therapy section. This year the ADA recommended either low-carbohydrate or low-fat calorie-restricted diets to achieve weight loss in diabetic patients. This is a stunning reversal from last year's standards that stated low-carbohydrate diets were not recommended because "the long-term effects of these diets are unknown."
"There is a lot of hype surrounding these recommendations since, until now, the ADA and other medical associations frowned upon low-carbohydrate diets due to the lack of long-term studies regarding their safety and efficacy," said Fraidy N. Maltz, B.S., Pharm.D., CDM, assistant professor of pharmacy practice, at Arnold & Marie Schwartz College of Pharmacy and Health Sciences. "The ADA is not promoting one diet over another, but they are the first highly regarded medical group to recognize the benefits of low-carbohydrate diets." Maltz remarked that she has seen in her own practice that patients following a low-carbohydrate diet were able to not only lose weight but also attain better glycemic control. "I was not surprised by the new ADA clinical practice recommendations that offer low-carbohydrate diets as an alternative to low-fat diets for short-term, sustained, moderate weight loss. I think that the ADA recognizes that many patients are not successful on low-fat diets and that low-carbohydrate diets should be a viable option for such patients. It has been known that overweight and obese patients with prediabetes or diabetes are at a much greater risk for developing complications."
There are a few other notable changes from the 2007 standards. For one thing, the ADA provided explicit testing recommendations for obese patients. Now any overweight or obese patients, defined as having a body mass index greater than 25 kg/m2, and who have one or more additional risk factors, should be screened for pre-diabetes.
The recommended A1C levels are unchanged for 2008; however, now an A1C of <7% has been clearly shown to reduce microvascular and neuropathic complications of diabetes and possibly macrovascular disease. For individual patients an A1C of as close to normal (<6%) as possible without hypoglycemia is recommended. Although an A1C of less than 6 is associated with lower risk of complications, it is not for everyone, due to the increased risk of hypoglycemia and the relatively small risk reduction.
The treatment options for hypertension and dyslipidemia have been simplified to place emphasis on a preferred regimen. Pharmacological therapies for patients with diabetes and hypertension are either angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs). The number of treatment recommendations for dyslipidemia has been reduced to emphasize use of statins for most patients.
"The Standards of Medical Care in Diabetes-2008" was published as a supplement to Diabetes Care [2008, 31; suppl 1] and is currently available at http://care.diabetesjournals.org/.
THE AUTHOR is a writer and a pharmacist in a family-owned pharmacy in Brooklyn, N.Y.