Every year the American Diabetes Associations revises and updates its Clinical Practice Recommendations, a publication upon which many doctors and medical caregivers depend as a primary source of diabetes treatment information.

The current edition reaffirms the ADA's landmark decision in 2008 to accept low carbohydrate diets as one method people with diabetes can use to lose weight in the short term (up to one year).

Previously, the ADA, as well as many other public health organizations, had recommended low fat diets that precluded any more than very light consumption of red meat, eggs, dairy products, and other high protein, high fat foods. Because diabetes increases the risk of cardiovascular disease, the concern was that a high fat intake could lead to arterial plaque and other vascular obstructions.

However, subsequent research has shown that a high carbohydrate intake-even if the carbs rate well on the glycemic scale-may be at fault for excess weight in certain people with diabetes. Excess weight can lead to heart problems and envelope vital organs in fat.

The ADA remains cautious, however, recommending that people with diabetes who go on low carb diets monitor their lipid profiles and renal function and, if they have nephropathy, watch their protein intake. 

Other Updates

The updated recommendations include discussions of treatment approaches, glycemic control, testing and prevention, and addressing complications.

Regarding treatments for type 1 and type 2, the guidelines emphasize general approaches rather than specific drug regimens. For type 1s, the recommendation is for multiple daily injections using both basal and prandial insulins, with anticipated carb intake and post-meal activity in mind. The ADA also advises type 1s to consider using insulin analogs if they have problems with hypoglycemia.

For type 2s, the recommended treatment includes metformin, diet, exercise, and the use of other drugs when needed to keep BG levels as close to normal as possible. While the ADA recommends that doctors consider prescribing insulin soon after diagnosis for patients who experience severe weight loss or hyperglycemia, the guidelines no longer endorse a certain progression of drugs. How a patient moves from metformin to a sulfonylurea or combination product and then on to Januvia, Byetta, or insulin is left up to the medical practitioner.

The ADA's recommendations on glycemic control are unchanged from early 2008. The goal is an A1c of 7% for most patients and an A1c of 6% for patients who are not prone to hypoglycemia. In cases where patients have severe hypoglycemia or have had diabetes for a long time but have suffered few complications, A1c's can go higher.

(The association has taken a wait-and-see stance with its decision to stick with the 2008 glycemic control recommendations. When the acclaimed ACCORD study of strict glycemic control among 10,000 patients was abruptly stopped earlier this year in the wake of an unexpected increase in heart attack deaths among tightly controlled type 2s, the ADA decided not to revise its recommended A1c levels downward. Interestingly, a parallel European study tracking strict glycemic control among a similarly sized population of type 2s showed no increase in mortality from cardiovascular events.)

Regarding prediabetic conditions, the recommendations come down explicitly in favor of testing-and even medicating-individuals who run an apparent risk of developing type 2. Risks include being overweight, suffering from hypertension, being physically inactive, and having a family history of the disease. The ADA also advises everyone 45 years and older to be tested for impaired glucose tolerance and impaired fasting glucose, indicators of vulnerability to the onset of type 2.

Preventive measures include weight loss and increased physical activity. The recommendations call for people under 60 who are obese or at high risk to begin taking metformin, both for its efficacy as a glucose inhibitor and its low cost.