My initial response

Dear Claire

In response to the complaint by Dietitian X

The specific areas highlighted by the Vice President are:

  1. That my recommendation of a very low carbohydrate diet for type 2 diabetes management is inconsistent with Evidence Based Practice.

In reference to diet recommendations for type 2 diabetes, the Dietitian’s Association of Australia does not give specific advice but refers to the American Diabetes Association for this.

In the Nutrition Therapy Recommendations for the Management of Adults with Diabetes published in 2014, the ADA notes that there is no “one-size-fits-all” eating approach in diabetes management and that the chosen eating pattern should be designed to improve glucose, blood pressure, and lipids.

The document states:

  • Evidence suggests that there is not an ideal percentage of calories from carbohydrate,

protein, and fat for all people with diabetes B; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.

. Although numerous studies have attempted to identify the optimal mix of macronutrients for the meal plans of people with diabetes, a systematic review (88) found that there is no ideal mix that applies broadly and that macronutrient proportions should be individualized.

. A variety of eating patterns have been shown modestly effective in managing diabetes including Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH) style, plant-based (vegan or vegetarian), lower-fat, and lower-carbohydrate patterns.

Carbohydrates

  • Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes.

Therefore, collaborative goals should be developed with the individual with diabetes.

  • The amount of carbohydrates and available insulin may be the most important factor influencing glycemic response after eating and should be considered when developing the eating plan.
  • Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycemic control.
  • For good health, carbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy products should be advised over intake from other carbohydrate sources, especially those that contain added fats, sugars, or sodium.

I believe my recommendations are in line with these suggestions.

The document also says: Evidence is insufficient to support one specific amount of carbohydrate intake for all people with diabetes. Collaborative goals should be developed with each person with diabetes. Some published studies comparing lower levels of carbohydrate intake (ranging from 21 g daily up to 40% of daily energy intake) to higher carbohydrate intake levels indicated improved markers of glycemic control and insulin sensitivity with lower carbohydrate intakes (92,100,107–111). Four RCTs indicated no significant difference in glycemic markers with a lower-carbohydrate diet compared with higher carbohydrate intake levels (71,112–114). Many of these studies were small, were of short duration, and/or had low retention rates (92,107,

109,110,112,113).

Some studies comparing lower levels of carbohydrate intake to higher carbohydrate intake levels revealed improvements in serum lipid/lipoprotein measures, including improved triglycerides, VLDL triglyceride, and VLDL cholesterol, total cholesterol, and HDL cholesterol levels (71,92,100,107,109,111,112,115). A few studies found no significant difference in lipids and lipoproteins with a lower-carbohydrate diet compared with higher carbohydrate intake levels. It should be noted that these studies had low retention rates, which may lead to loss of statistical power and biased results (110,113,116). In many of the reviewed studies, weight loss occurred, confounding the interpretation of results from manipulation of macronutrient content.

Despite the inconclusive results of the studies evaluating the effect of differing percentages of carbohydrates in people with diabetes, monitoring carbohydrate amounts is a useful strategy for improving postprandial glucose control. Evidence exists that both the quantity and type of carbohydrate in a food influence blood glucose level, and total amount of carbohydrate eaten is the primary predictor of glycemic response (55,114,117–122).

2.

“The patient letter indicates that I dismissed previous evidence based advice given to this patient and provided contradictory advice, resulting in a confused and disgruntled consumer.”

The letter from the client to the complainant I believe indicates a gross misrepresentation of our interview.

In line with how I conduct my interviews, I explained to the client pathways of carbohydrate metabolism and the rationale for regular exercise and to find a level of carbohydrate intake that is suitable to the individual. Also, that this is different for different people and can best be ascertained by trial and error of different regimens.

The client told me that she understood what I had explained but that it was different to what she had read and had been previously told. I should stress that what I had explained was the physiological response to carbohydrate intake and the rationale for engaging in regular exercise and monitoring carbohydrate intake.

I then suggested that an eating plan that was consistent with her usual eating pattern, but which also suggested some limitation of carbohydrate foods ie the CSIRO Wellbeing diet, may be suitable. I asked if she would like to trial the eating plan, went through the guidelines with her and provided her with a copy of page 3 from the Wellbeing diet booklet.

As is my practice, I said that I recommended trialing the eating plan for 2 weeks to see how it suited her and we could discuss this at a review apt in 2 weeks. The appt was made at the end of the interview and later cancelled by the client.

I would also like to address specific allegations made in the letter of complaint from the patient to DX.

  1. That I do not support what the Diabetic Dietitians say.

My response to clients who question why my approach may be different to what they have heard or been taught, is that there is not a ‘One size fits all ’ approach when it comes to managing diabetes. This is in line with ADA guidelines that state,

“ A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another.”

I provide people with information about the possible underlying causes of the disorder, so that they have the knowledge and tools to evaluate different diet approaches and find what works for them.

 

If a client said to me that they had seen another dietitian and the advice given suited them, I would encourage them to follow that advice. If a client said to me that they had received advice from another dietitian but that they wanted to seek my advice as well, then I would do as I explained above.

I agree with and follow the principle of not a one-size-fits-all approach; therefore I do not denigrate the practices of others. I provide information and encouragement to the client to help them decide which approach best suits them. I suggest that they trial different approaches to inform this decision.

  1. That I tried to put her on a Low Carb diet

I suggested that she trial the CSIRO Well being diet for 2 weeks and that we would discuss it at her next visit. If she had said that she did not want to trial this approach or that she wanted to follow advice received elsewhere, I would have encouraged her to do that.

  1. That I said to “throw low GI out the window.”

This is language that I never use.

My response to questions about GI is that it may play some part in the management of BGLs but that the amount of carbohydrate eaten at meal has the most significant impact on postprandial BGLs.

I believe this to be in line with ADA guidelines, which state under the heading Glycemic Index and Glycemic Load:

Substituting low–glycemic load

foods for higher–glycemic load foods

may modestly improve glycemic

control. c*

The ADA recognizes that education about glycemic index and glycemic load occurs during the development of individualized eating plans for people with diabetes. Some organizations specifically recommend use of

low glycemic index diets (124,125). However the literature regarding glycemic index and glycemic load in individuals with diabetes is complex, and it is often difficult to discern the independent effect of fiber compared with that of glycemic index on glycemic control or other outcomes. Further, studies used varying definitions of low and high glycemic index (11,88,126), and glycemic response to a particular food varies among individuals and can also be affected by the overall mixture of foods consumed (11,126).

Some studies did not show improvement with a lower-glycemic index eating pattern; however, several other studies using low-glycemic index eating patterns have demonstrated A1C decreases of -0.2 to -0.5%. However, fiber intake was not consistently controlled, thereby making interpretation of the findings difficult (88,118,119,127). Results on CVD risk

 

measures are mixed with some showing

the lowering of total or LDL cholesterol

and others showing no significant changes (120).

*Level c evidence is described as: Supportive evidence from poorly controlled or uncontrolled studies

  1. Use of testimonials on my website.

I was unaware of this standard and had the testimonials removed as soon as was possible after receipt of the letter.

If you would like to discuss these or other issues with me in my detail, I will be happy to do so.

Yours sincerely Jennifer

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