The Wandering RD

I was at a diabetes conference last week and it was eye-opening, but maybe not in the way you are thinking. (Get ready to wander with me…) As a certified diabetes educator (CDE), I am all too familiar, as maybe you are too, with type 2 diabetes and its disease process, progression, and complications. And while I did learn several new and fascinating treatment options from the conference, the most important thing I took away is much more of a practical revelation.

These well-respected medical professionals were presenting valuable information on how to manage the “train wreck” that is full-blown diabetes, but we are still largely ignoring (thanks mostly to a lack of insurance coverage) the prevention of diabetes in the whopping 86 million Americans who have prediabetes.(1)  What struck me is that while I have not been working with patients as a CDE for more than 10 years, there have been many advances in medication and technology, but not much has changed in our efforts to prevent people from getting this terrible obesity-related disease.

There are 29 million people who already have diabetes, 8 million of whom are undiagnosed. (1) What if we could also help them reduce the number of medications they are taking (and paying for), prevent complications, and improve their quality of life? It’s not just prevention, but better management we could help people attain with practical lifestyle interventions–involving easy, real food, of course.

In general, would you agree that it’s easier to prevent problems than to deal with them after the fact? It’s better to have money in the bank before you shop. It’s better to have insurance before you need it. It’s better to have a will or trust before you die. Well, I strongly believe it’s better to delay or prevent diabetes than to treat it.

Research shows lifestyle interventions, which often result in weight loss, are able to drastically slow the progression of diabetes and prevent it in many people. In the landmark study, Diabetes Prevention Program, the lifestyle therapy resulted in a 58% lower incidence of diabetes than the control. (2) Other studies have shown similarly beneficial results from lifestyle interventions. (3) I feel excited to be in a profession in which I can help people prevent diabetes. But I’m frustrated because I have encountered health professionals (not necessarily at the conference!) who seem either unaware, complacent, disillusioned–or even self-righteous at times–when dealing with people already in the throes of diabetes. Then there are food bloggers (not necessarily RDs) in the Internet realm who may seem extremist, fanatical and maybe even on the fringes of nutrition. And there seems to be no platform in between to reach the 86 million Americans with prediabetes…or the two-thirds of Americans who are overweight or obese and may develop diabetes if they haven’t already.(4)

Further, it has never been more obvious to me that there is stark division between this RD’s idea of optimal nutrition and what most Americans are eating. But of course most RDs have to negotiate and compromise and teach whatever the patient is willing to learn. I get that there are stages of change and we need to be sensitive to a patient’s needs, but couldn’t we do better? We can and need to do better. I can say this because the number of people with diabetes is expected to double by 2050 (5) and this epidemic isn’t going to stop with advances in medications and technology alone. Indeed, they are vital for the management of diabetes, but they are like Band-aids on the symptoms (and metabolic dysfunctions) of diabetes, not solutions to the underlying problem.

I believe RDs could be a much bigger part of the solution to the problem of diabetes (and obesity). What if we were relentless in expressing our empathy and passion for helping our patients understand they have more control over their health than they may feel they do? What if the foods they are eating and their hormones are making it harder to stick with healthy changes? What if we gave them support to change how they are eating and stick with it along the way?  I believe that we all have the power to change our health habits and want to help people understand that. But I believe most health professionals working in health care institutions are limited by guidelines (and insurance policies) that are not serving their patients well.

For example, at the conference the RD presented how the 2015 Dietary Guidelines for Americans (6) recommends a limit of 10% calories from added sugar (50 grams for a 2000 calorie diet, or about 13 teaspoons of sugar), and how the new Nutrition Facts label (7) will include added sugars. This is factual information the RD was probably asked to cover. But here are my concerns: all carbohydrates affect your blood sugar, natural or added. So, 1) that is too much added sugar and it’s taking the place of more nutritious sources of carbohydrate from real foods, and 2) having added sugar on the label is not at all helpful to someone with diabetes. It’s the total carbohydrate that matters when controlling their blood sugar or dosing insulin.

As hopeless as this may sound, we will never have completely conclusive research in nutrition. That’s the nature of the beast (nutrition science). You can’t always put people in randomized controlled trials to test what you want to test. And even when you can, you can’t expect the results to apply perfectly to everyday life. But to help people prevent diabetes (and obesity), we must do better than simply relying on guidelines (that of course are influenced by all sorts of bias) and not applying whatever new research we have as it becomes available. At the conference, for example, I was hoping to hear more about the newer, very relevant evidence supporting low-carb diets as not only a viable, safe option for someone with diabetes, but as an optimal treatment. (8,9) And I was hoping to hear less about dietary fat (and especially the very outdated concern about dietary cholesterol, which even the Dietary Guidelines downplays)(6), because the evidence is mounting that we need to be less concerned about fat and salt and much more concerned about sugar. (10-15)

In all honesty, I used to believe low-carb diets were potentially harmful and inadequate in nutrition, and that they were hard to stick with. But more and more research is showing low carb diets are not harmful, people can indeed function well on fewer than 130 grams of carbohydrate each day, and they can stick with this low-carb lifestyle and reap many benefits. So, who are we as health professionals to keep this evidence-based option from people if it may help them? Low carb diets may not help everyone, but in my opinion, they are worth a try with patients who are willing (and it’s worth trying to convince those who are not willing initially) because getting diabetes has the potential to be far more harmful than any effort to follow a relatively simple, low-cost, low-carb, real-food approach.

If you’re still with me…thank you!  Please share your comments or questions. Why are low carb diets so controversial? What’s your take or experience? And always feel free to share special requests for nutrition topics you’d like to explore!

References:

1. American Diabetes Association. Statistics About Diabetes. Overall Numbers, Diabetes and Prediabetes. Accessed 3/25/2017.
2. National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes Prevention Program. Accessed 3/25/2017.
3. Chen L. et al. Effect of lifestyle intervention in patients with type 2 diabetes: a meta-analysis. Metabolism. 2015; 64(2): 338-347. 
4. National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases. Overweight and Obesity Statistics. Accessed 3/25/2017. 
5. Matvienko OA. et al. A Lifestyle Intervention Study in Patients with Diabetes or Impaired Glucose Tolerance: Translation of a Research Intervention into Practice. J of Amer Board of Fam Med. 2009;22(5): 535-543.
6. US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for Americans 2015-2020. Eighth Edition. Accessed 3/25/2017.
7. US Food and Drug Administration. Changes to the Nutrition Facts Label. Accessed 3/25/2017.
8. Feinman RD et al. Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base. Nutrition 31 (2015)1-13.
9. Noakes TD, et al. Evidence that supports the prescription of low-carbohydrate high-fat diets: a narrative review. Br J Sports Med. 2017;51:133-139.
10. DiNicolantonio JJ, Lucan SC. The wrong white crystals: not salt but sugar as aetiological in hypertension and cardiometabolic disease. Open Heart 2014;1:e000167.
11. Johnson RJ, Segal MS, Sautin Y, Nakagawa T, Feig DI, Kang DH, Gersch MS, Benner S, Sánchez-Lozada LG. Potential role of sugar (fructose) in the epidemic of hypertension, obesity and the metabolic syndrome, diabetes, kidney disease, and cardiovascular disease. Am J Clin Nutr. 2007 Oct;86(4):899-906.
12. Te Morenga LA, Howatson AJ, Jones RM1, Mann J. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. Am J Clin Nutr. 2014 Jul;100(1):65-79.
13. Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS, Balise RR, Kraemer HC, King AC. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007 Mar 7;297(9):969-77.
14. Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, Golan R, Fraser D, Bolotin A, Vardi H, Tangi-Rozental O, Zuk-Ramot R, Sarusi B, Brickner D, Schwartz Z, Sheiner E, Marko R, Katorza E, Thiery J, Fiedler GM, Blüher M, Stumvoll M, Stampfer MJ; Dietary Intervention Randomized Controlled Trial (DIRECT) Group. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008 Jul 17;359(3):229-41.
15. Krauss RM, Blanche PJ, Rawlings RS, Fernstrom HS, Williams PT. Separate effects of reduced carbohydrate intake and weight loss on atherogenic dyslipidemia. Am J Clin Nutr. 2006;83:1025-1031.