ADA Medical Nutrition Therapy by RDs

With eight of the eleven people being registered dietitians on the committee developing the ADA nutrition therapy recommendations for the management of adults with diabetes, is it any surprise that much of the information on page 4 conforms to the Academy of Nutrition and Dietetics (AND) policies. I feel that since the American Diabetes Association (ADA) was behind this and they were under the scrutiny of the ADA, we were spared much of the rhetoric of the AND.

Yet they did get in many policies and pronouncements of the AND. Take for example this statement, “Ideally, the individual with diabetes should be referred to a registered dietitian (RD) (or a similarly credentialed nutrition professional if outside of the U.S.) for nutrition therapy at or soon after diagnosis and for ongoing follow-up.” No, I don't like this statement as this is monopolistic in nature and I prefer someone that will work with us for the meal plan we are using and not some organization's meal plan. Nutritionists that will work with us and are not necessarily members of AND seem more interested in balanced nutrition than many RDs.

The above is from page 4 (PDF file) as is the following promoting RDs as being the only professionals that should be allowed to teach nutrition. The RDs also make a statement that should not set well with nutritionists in other countries when they state, “Health care professionals administering nutrition interventions in studies conducted outside the U.S. did not provide MNT as it is legally defined.” Legally defined here means only as defined by AND. Then they continue promoting RDs with this statement, “However, the unique academic preparation, training, skills, and expertise of the RD make him/her the preferred member of the health care team to provide diabetes MNT.” Bold is my emphasis.

Then at the top of the third column page 4, the RDs promote Table 2, Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines and list them. Remember that the national organization promotes Big Food and this determines what will be promoted. Even though many declared no conflict of interests, I feel that it should be pointed out that if the person is a RD and a member of AND, they automatically have a conflict of interest because of their ties to Big Food.

Once the authors moved past page four, the promotion of food plans did become possible and not the direct claims to how RDs should be the only ones teaching medical nutrition therapy (MNT).

For an article that is more balanced than mine, read this by Laura Dolson on about dot com. She likes this new version on medical nutrition therapy and can look past the points I find troublesome. After reading her summary of the ADA food guidelines, I need to revisit the PDF file.

ADA Ditches Diet, Now Has Food Plans

The American Diabetes Association (ADA) has done something right. They have dropped the word “diet” from their medical nutrition therapy prescription. Instead, they are focusing on overall eating patterns and patient preference. They are using “eating plans” or “eating patterns” in place of diet. This is according to Alison B. Evert, MS, RD, CDE, coordinator of diabetes education programs at the University of Washington Medical Center, Seattle.

Now it will be interesting to see if the American Association of Diabetes Educators (AADE) and the Academy of Nutrition and Dietetics (AND) follows. Because AND is supported heavily by Big Food, I sincerely doubt that there will be any change in their modus operandi.

I can understand why Ms. Evert would recommend a patient being referred to a registered dietitian (RD) as soon as possible following a diabetes diagnosis. This is the way they get people set up on a high carbohydrate/low fat (HCLF) diet when the new person with diabetes has not learned about other food plans. Once they learn about other food plans, they will be less likely to follow the mandates of the RD. At least she does recognize that the referral is often delayed.

From the number of registered dietitians and certified diabetes educators on the committee that wrote the 2013 Nutrition Therapy Recommendations (this is a PDF file), it is understandable why some policies are deemphasized and others are promoted. Several statements in the published recommendations are reflective of the monopolistic attitude of the AND and their attempt to become the only recognized source of nutrition information.

One idea not mentioned in any previous guidelines is a guide for coordinating food with different types of oral glucose-lowering agents and both fixed-dose and basal-bolus insulin regimens. These were included so that clinicians would have some talking points that are evidence based.

Because RDs and CDEs do not like low carbohydrate food plans it is not a surprise that this statement was included, "A lot of the studies on low-carb didn't meet our criteria for inclusion due to factors such as high dropout rates."

Then the following was stated, “As for other macronutrients, the document advises that foods containing unsaturated fats (liquid oils) be substituted for those higher in trans- or saturated fat and that leaner protein sources and meat alternatives are preferred. Often, nutrition therapy isn't given the priority that it should have… It's a lot easier to write a prescription than to have a dialog with the patient about eating behaviors."

Some of the points are good sense and there is some good information when it is carefully analyzed.

Recommendations for Management of Diabetes

I had to look carefully at this area, but again some minor changes. Sugar-sweetened beverages (SSBs) get the blame for obesity and type 2 diabetes. At least they did not change the recommended daily allowance (RDA) for digestible carbohydrate and left this at 130 g/day. This is still high for those in some low carb diets, but is much more realistic that the 200 to 230 g/day they used to recommend.

ADA does make this statement about the 130 g/day, “It is based on providing adequate glucose as the required fuel for the central nervous system without reliance on glucose production from ingested protein or fat. Although brain fuel needs can be met on lower carbohydrate diets, long-term metabolic effects of very low-carbohydrate diets are unclear and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability.”

Yes, if much of the information is taught to people with diabetes by dietitians from the Academy of Nutrition and Dietetics then we will be short of nutrients and the food will not be tasty. Other nutritionists not following the ADA, will work with people with diabetes to balance the nutrition or add supplements for those that are short. They will correctly assess the patients for their needs and work within what the patient will or will not eat and make sure that the patient understands what is happening and what is needed. They will not preach mantras and mandates at the patients.

In the next paragraph, they state the following, “Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol. There is a lack of evidence on the effects of specific fatty acids on people with diabetes, so the recommended goals are consistent with those for individuals with CVD.” This means to me that they are aligning with the American Heart Association when they are talking about cardiovascular disease and do not want people with diabetes on any medium to high fat regimens. I would appreciate it if they were discussing Omega 3 versus Omega 6 and see if they can get the idea.

The medical nutrition therapy (MNT) is again emphasized and again it is to be taught by “a registered dietitian who is knowledgeable and skilled in implementing nutrition therapy into diabetes management and education be the team member who provides MNT.” Again, I say “no thanks,” I will get my nutrition advice elsewhere and avoid having an RD on my team.

The ADA does admit that there is no diabetes diet per se, and there is not a mix that applies broadly (no one-size-fits-all) enough and that regardless of the macronutrient mix; caloric intake must be in line with the individual weight management goal. They even say that metabolic status also applies, meaning lipid profile, renal function, and food preferences. While they don't list all the diets, they are saying that all need to be considered in managing diabetes. For ADA to admit this, means there maybe hope yet for other changes, but the patients need to maintain the pressure and hold their feet to the fire.