ADA 2018 Standards of Care for Diabetics

The  ADA 2018 Standards of Care for Diabetics are out.

A1C targets of <7% (53 mmol/mol)

7% represents a very lax standard of care and results in an unhealthy level of blood sugar. Their own standard notes:

…further lowering of A1C from 7% to 6% [53 mmol/mol to 42 mmol/mol] is associated with further reduction in the risk of microvascular complications, although the absolute risk reductions become much smaller.

The reason they don’t use the smaller number is that the smaller number comes at the cost of too many lows. This is where the Low Carbohydrate diet comes to play since it eliminates the lows the patient can go for the lower number without risk of hypoglycemic (too low a blood sugar) events (as long as medications are adjusted down as blood sugar levels go lower). Their own words are:

Given the substantially increased risk of hypoglycemia … with polypharmacy in type 2 diabetes, the risks of lower glycemic targets outweigh the potential benefits on microvascular complications.

polypharmacy = more than one medication at the same time. The medications that they give you run a risk of dropping your blood sugar too low which is even worse than being too high.

Dietary Guidelines

The Standard of Practice has improved with respect to low carbs but still doesn’t recognize the definitive science in the area. For instance, the Standard clams:

Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive…

That’s just plainly false or deliberately misstated. It may be the case that to solve diabetes requires 20 grams of carbs in one person but another person can tolerate 100 grams of carbs.


…although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose control

This is where it gets really stupid. Monitoring something does absolutely nothing at all to state how much someone should be taking. Monitoring isn’t the answer except to determine how much carbs should be limited.

Here’s the right way to state this.

  1. Monitor carbohydrate intake using glucometer.
  2. Don’t eat foods (type or quantity) which cause your blood sugar to go up more than 10 points over 2 hours.
  3. Test all your food intake and discontinue any carbohydrate sources which cause your blood sugar to raise.

Now that would be useful advice.

The Standard of Care continues:

The role of low-carbohydrate diets in patients with diabetes remains unclear

Could it be clearer than this? My HbA1C went from 8 to 5.2 after a year and a half of Low Carb. That’s pretty darned clear, right?

The idiocy continues:

While some studies have shown modest benefits of very low–carbohydrate or ketogenic diets (less than 50-g carbohydrate per day) (78,79), this approach may only be appropriate for short-term implementation (up to 3–4 months) if desired by the patient, as there is little long-term research citing benefits or harm.

Let’s see. There’s evidence that Low Carb diets reverse diabetes. And diabetes is really bad for you. And they claim there’s no evidence of the long term benefits or harm from Low Carb diets. This begs the question – is there evidence of the damage from the alternate? Clearly, diabetes harms people long term, right?

And the definition of low carb or keto as less than 50 g of carbohydrates flies in the face of the broadly agreed on number of 20 of carbohydrates being at ketogenic levels.

Here’s where the insanity reaches a peak.

Most individuals with diabetes report a moderate intake of carbohydrate (44–46% of total calories) (51). Efforts to modify habitual eating patterns are often unsuccessful in the long term; people generally go back to their usual macronutrient distribution (51). Thus, the recommended approach is to individualize meal plans to meet caloric goals with a macronutrient distribution that is more consistent with the individual’s usual intake to increase the likelihood for long-term maintenance.

The logic is people like to eat carbs and will return to them. They lack self control so why bother telling them that low carb can be the cure for diabetes but they need to stay on the Low Carb diet FOREVER? What’s the alternative for diabetics?

How about showing the patients pictures of amputated body parts? How about taking them to a blind school where many of the patients are blind from diabetes? Why not tell them about diabetic neuropathy and the constant pins and needles that people have?

No, it’s better to give them a pill and send them out the door. Better not tell them that most of them will end up on Insulin.

Why not tell them what can happen with a Low Carb diet? Most people would love to lose weight and maybe even get below their High School Senior year weight, wouldn’t they?

Why is there ZERO support in place for people who really want to do this with Low Carb? Why are all of us on our own and being told that we shouldn’t even bother since we will fail anyway?

The next comment is somewhat useful:

As for all Americans, both children and adults with diabetes are encouraged to reduce intake of refined carbohydrates and added sugars and instead focus on carbohydrates from vegetables, legumes, fruits, dairy (milk and yogurt), and whole grains. The consumption of sugar-sweetened beverages and processed “low-fat” or “nonfat” food products with high amounts of refined grains and added sugars is strongly discouraged

If people did just those things then things would be better. But how good have people shown themselves to be at reducing refined carbohydrates? Why not just say that they need to ELIMINATE refined carbohydrates entirely? Then we can forget about compliance in reducing.

Instead the answer is to educate people to use more Insulin:

Individuals with type 1 or type 2 diabetes taking insulin at mealtime should be offered intensive and ongoing education on the need to couple insulin administration with carbohydrate intake. For people whose meal schedules or carbohydrate consumption is variable, regular counseling to help them understand the complex relationship between carbohydrate intake and insulin needs is important. In addition, education on using the insulin-to-carbohydrate ratios for meal planning can assist them with effectively modifying insulin dosing from meal to meal and improving glycemic control

Why not teach people that over dependence  on Insulin will result in Insulin Resistance and ever increasing dosage needs? Why not tell people that their ability to control their blood sugars will get worse and worse with time on Insulin? Why not tell people that every day they have high blood sugar numbers their own pancreas is dying (beta cell death) and that at some point in time they may not be able to get off Insulin ever?

I need to stop now. This is upsetting me. They really don’t care about diabetics. If they did they would tell them the truth and try to get them cured.

Give them a pill and bring in the next patient…


Author: Doug

I'm an Engineer who is also a science geek. I was pre-diabetic in 1996 and became a diabetic in 2003. I decided to figure out how to hack my diabetes and in 2016 found the ketogetic diet which reversed my diabetes.

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