The American Diabetes Association (ADA) has published guidelines on lifestyle management as part of its Standards of Medical Care in Diabetes for 2019.

The guidelines cover a range of areas including Nutrition, diabetes education and physical activity. One of the points of note is that the ADA recognises the strong evidence for low carbohydrate lifestyles in improving blood glucose control.

The ADA’s guidelines are applicable to people and healthcare providers within the United States. They are also watched by other health organisations and can have an indirect influence on policy in other countries.


The ADA advises that nutrition should be individualised to the individual, and states: “There is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes.”

This is a progression from previous years in which the ADA had encouraged a high intake of carbohydrate. The fact that the new guidelines offer more flexibility to the individual represents a positive step forward.

Carbohydrate intake

A key line in the guidance recognises the power of low carbohydrate approaches to reduce blood glucose levels: “For people with type 2 diabetes or prediabetes, low-carbohydrate eating plans show potential to improve glycemia and lipid outcomes for up to 1 year.”

The ADA takes a cautionary approach with their wording. There have been longer studies showing continued benefit and indeed maintenance of remission over several years.

In addition, they add, “As research studies on some low-carbohydrate eating plans generally indicate challenges with long-term sustainability, it is important to reassess and individualize meal plan guidance regularly for those interested in this approach.”

It is well worth noting that when dietary studies are ru, people are often assigned to a lifestyle they might not have chosen. This is one reason why studies can often report that benefits of a diet tail off after a year or more.

However, when someone is committed to following a new approach, the long-term results are likely to improve. This has certainly been shown on the Low Carb Program, whereby many members have been following the guidance closely for a number of years with continued benefits.

Real-world examples, like the followers of the Low Carb Program, are more reliable indicators of how people respond in daily life, because these people are following the lifestyle in their day-to-day lives and have not been told or financially incentivised to follow the approach. The reasons are much more organic; these people are following the program because they want to improve their health. Furthermore, many people on the program have achieved remission of their diabetes.

Sugar reduction

The guidelines also advise taking care to reduce sugar intake. They place emphasis on avoiding sugar-sweetened beverages and include fruit juices.

The guidance notes that, in addition to risks of high blood glucose levels and weight gain, that excess sugar raises risks of heart and vascular disease and fatty liver disease.

The guidance on sugar in foods is sadly a fairly weak approach from the ADA. They state that people, “should minimize the consumption of foods with added sugar that have the capacity to displace healthier, more nutrient-dense food choices.”

It is disappointing that the guidance does not place emphasis on reducing intake of added sugars to as low a level as possible.

At, we forward the approach of choosing real, whole-foods and avoiding processed foods and those with added sugars as much as one is able to. Families that have followed this approach have noticed very positive benefits soon after cutting out sugary foods.

Physical activity

The guidelines regarding physical activity are closely in line with the NHS’s. At least 150 minutes per week of moderate- to vigorous-intensity activity is recommended for adults. Children and adolescents are advised to take at least 60 minutes per day of moderate- to vigorous-intensity activity.

Prolonged activity should be interrupted with some of form of movement every 30 minutes. For older adults, flexibility and balance training is advised two to three times per week.

Type 1 diabetes

The guidelines highlight that some people with type 1 diabetes may benefit from considering the impact of fat and carbohydrate on blood glucose levels in addition to carbohydrate’s effect.

Whilst carbohydrate has the most significant impact in raising glucose levels, protein and fat can have an influence, albeit a less prominent influence.

People on insulin pumps can use advanced bolus dosing to help with getting excellent control when having meals with larger protein or fat intakes. On injections, it is more difficult, and most people are advised not to account for protein and fats.

Considering the effect of protein and fat requires advanced understanding of glucose management but may be worth some people asking their health tam about if their health team has a strong understanding of this area. is also in the process of readying a structured education program for type 1 diabetes. Head over to register your interest and be informed when it launches at

Small positive advances

It is a sign of positivity that the ADA has not set prescribed macronutrient amounts for people and has understood the need to individualise nutrient intake.

The recognition of the glucose-lowering benefits of low carb is also good to see. We hope that in subsequent years, the ADA may recognise the longer-term benefits, including citing real-world examples, such as results from the Low Carb Program.

What are your thoughts on the guidelines, and which parts of the guidance would you like to have seen more emphasis on? Let us know your thoughts.

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