Diabetes Canada has just released a new Position Statement acknowledging that a low carb and very low carb (keto) diet is both safe and effective for adults with diabetes.
Reflecting back on their 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada release in April 2018 and covered in this article, Diabetes Canada clarified in today’s Position Statement that it was not their intention to restrict the choice of individuals with diabetes to follow dietary patterns with carbohydrate intake that were below the consensus recommendation of 45-60% energy as carbohydrate, nor to discourage health-care practitioners from providing low-carb dietary support to individuals who wanted to follow a low-carb meal pattern.
In the new Position Statement, Diabetes Canada acknowledged what I’ve written about previously, that Diabetes Australia, Diabetes UK, and the American Diabetes Association (ADA) in conjunction with the European Association for the Study of Diabetes (EASD) have developed position statements and recommendations regarding the use of low carbohydrate and very low carbohydrate (ketogenic) diets for people with diabetes. They state that from these previous international position statements and recommendations, several consistent themes have emerged — specifically that low carbohydrate diets (defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate) and very low carbohydrate diets (defined as <50 g of carbohydrate per day) can be safe and effective both in managing weight, as well as lowering glycated hemoglobin (HbA1C) in people with type 2 diabetes over the short term (<3 months).
Diabetes Canada explained in the publication that they periodically develop position statements in order to address issues that are important for people living with diabetes, as well as their health-care providers and when there is either insufficient data to perform a systematic review, or there is no high level evidence (e.g. double-blind placebo controlled studies).
Diabetes Canada stated that this new position statement was developed in response to emerging evidence. as well as a shift in international consensus regarding lower carbohydrate diets — with the goal of providing important clarification for people living with diabetes, as well as health-care providers. It is their hope that this update will make effective engagement with multi-disciplinary teams easier, as well as avoid inter-professional tensions, as well as clearly identify areas where there are key safety issues and the need for clinical monitoring.
The purpose of the position statement was to summarize the evidence for the role of low carbohydrate diets (<51-130g carbohydrate/day) or very low- carbohydrate diets (<50g carbohydrate/day) in the management of people diagnosed with type 1 and type 2 diabetes.
Summary of the Evidence – type 2 diabetes
Low Carbohydrate Diets
A review of the evidence found that a low carbohydrate diet (<51-130g carbohydrate/day) may be effective for weight loss, improved blood sugar control including a reduction in need for blood sugar lowering medication (anti-hyperglycemic therapies).
Also noted in the position paper is that while other dietary approaches for managing type 2 diabetes may be effective for weight loss and better blood sugar control, they have not achieved this while also reducing the need for blood-sugar lowering medication. Diabetes Canada calls this a “meaningful outcome”.
Very Low Carbohydrate Diets
Of significance, this new position statement states that a review of the current literature suggests that very low- carbohydrate diets (<50g carbohydrate/day) may be superior to higher carbohydrate diets for improving blood sugar control and body weight, and that it can reduce the need for blood sugar lowering medications in the short term (up to 12 months).
They state that evidence regarding longer-term benefits is limited.
Summary of the Evidence – type 1 diabetes
The new position paper states that “there is very little reliable data and major evidence gaps which make it difficult to make general recommendations with any confidence” for those with type 1 diabetes.
That said, the paper does state that for those living with type 1 diabetes, significant improvements in outcomes such as lower HbA1C, reduced insulin requirements, less variability in blood sugar and weight loss have been reported by individuals who have chosen to follow a low carbohydrate or very low carbohydrate diet.
Diabetes Canada concludes that “in the absence of clear trial evidence to support generalized recommendations, as well as the positive results experienced by people following low- and very low- carbohydrate diets;
- health-care providers will need to work as partners with individuals seeking to identify an optimal and sustainable dietary pattern that fits with their individual preferences.
- Health-care providers will need to recognize that diverse approaches are required to address the complex challenges of diabetes and obesity.
- Health-care providers should strive to engage with patients in supportive relationships which respect shared decision making. “
Cautions and Safety
Diabetes Canada advised that insulin and/or sulphonylurea doses may need to be reduced or discontinued to avoid hypoglycemia (low blood sugar) in those following a low carb or very low carb diet, and that SGLT2 inhibitors may increase the risk of diabetic ketoacidosis in individuals following low carbohydrate diets. As well, Diabetes Canada states that some added caution may be needed to ensure detection and treatment of hypoglycemia.
Diabetes Canada’s Five Recommendations
- Individuals with diabetes should be supported to choose healthy eating patterns that are consistent with the individual’s values, goals and preferences.
- Healthy low carb or very-low-carb diets can be considered as one healthy eating pattern for individuals living with type 1 and type 2 diabetes for weight loss, improved blood sugar control and/or to reduce the need for blood sugar lowering medications. Individuals should consult with their health-care provider to define goals and reduce the likelihood of adverse effects.
- Health-care providers can support people with diabetes who wish to follow a low-carbohydrate diet by recommending better blood glucose monitoring, adjusting medications that may cause low blood sugar or increase risk for diabetic ketoacidosis and to ensure adequate intake of fibre and nutrients.
- Individuals and their health-care providers should be educated about the risk of diabetic ketoacidosis while using SGLT2 inhibitors along with a low carbohydrate diet, and be educated in lowering this risk.
- People with diabetes who begin a low carbohydrate diet should seek support from a dietitian who can help create a culturally appropriate, enjoyable and sustainable plan. A dietitian can propose ways to modify carbohydrate intake that best aligns with an individual’s values, preferences, needs and treatment goals as people transition to- or from a low carbohydrate eating pattern.
Healthy Low Carb and Very Low Carb Diets
Finally, Diabetes Canada underscores that Canadians both with- and without diabetes who choose to adopt a low or very low-carbohydrate dietary
pattern “should be encouraged to consume a variety of foods recommended in Canada’s Food Guide”, and that “regular or frequent consumption of high energy foods that have limited nutritional value, and those that are high in sugar, saturated fat or salt, including processed foods and sugary drinks, should be discouraged.”
As a Dietitian who has been helping individuals in Canada safely follow low carbohydrate and very low carbohydrate diets for the past 5 years, I am delighted that Diabetes Canada shares the consensus of other international groups that have determined that these diets are both safe and effective for adults to follow in order to get much better blood sugar control, and for weight loss.
If you would like more information about how I can help you get started on a low carbohydrate or very low carbohydrate diet, please reach out to me by sending me a note using the Contact Me form on the tab above.
To your good health!
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- Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
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