It’s National Diabetes Month, and U.S. Plans Will Lead to…More Diabetes
Administration Seeks to Expand a Nutrition Policy that Allows Donuts and Nachos
President Biden recently issued a proclamation for National Diabetes Month, which follows upon his historic White House Conference last month, on Hunger, Nutrition & Health. He is right to focus on the crushing load of diabetes, which costs $1 billion dollars a day to treat and afflicts more than 37 million Americans, including nearly one third of people aged 65 years-plus. And our children: the number of young people under age 20 with type 2 diabetes grew by an astonishing 95% from 2001 to 2017. These trends have all been moving fast in the wrong direction, ever since the first Diabetes Awareness Month, back in 1975. Awareness is nice, but clearly it hasn’t brought results. And tragically, the current administration’s proposals are based on precisely zero hard science.
It didn’t look great in April of this year, when Biden rescinded Trump’s executive order to cap the cost of insulin to $35 per month for low-income patients. In May, Congress passed the cap as part of the Inflation Reduction Act, but only for people 65 years and older. This leaves out at least 20 million people with diabetes, about one quarter of whom are estimated to be self-rationing insulin, due to its high cost, despite the potentially fatal consequences
To be clear: We should aim to make insulin not just more affordable, but obsolete. That may sound crazy, but reversal of diabetes is now known to be possible, for people with type 2 (type 1 occurs when the body can no longer produce insulin, a condition that cannot be cured). People with type 2 can dramatically reduce or eliminate the need for insulin and swivel their condition into reverse within a matter of weeks—mainly by cutting back on foods that spike blood sugar. Multiple clinical trials, including one with 5-year results, have demonstrated this breakthrough treatment and shown it to be safe. Thus, type 2 diabetes, long considered the unstoppable slow-train to death, has a new gear: reverse. This is undoubtedly headline news, yet not a single person involved in the research or practice of diabetes reversal was invited to talk at the White House conference.
Instead, the policies announced at that meeting will almost certainly worsen the diabetes epidemic. That’s because all the proposals aim to expand upon a program shown to be a failure. It’s like doubling down orders on a dysfunctional plane that can’t fly.
To be clear, nutrition should be a non-partisan issue. Both parties have neglected to take meaningful steps towards combatting obesity, diabetes, or other chronic diseases. Pledges to end cancer, fund new research, or reduce drug prices have been proposed by Republicans and Democrats alike, but tackling the root of the problem, which requires taking on the ultra-processed food manufacturers that generate chronic diseases as well as the pharmaceutical companies who treat them is a challenge that has thus far eluded politicians on both sides of the aisle. A high-water goal for both parties is therefore to make prescription pills more affordable but do nothing to eliminate their necessity.
Biden is no different. His “whole government” approach, laid out in this 44-page National Strategy, promotes better nutrition, via more education, more training, and more school meals for more kids. Yet all of these programs would build upon more of the U.S. Dietary Guidelines for Americans (DGA), our nation’s top nutrition policy—with 10% of calories as sugar and 3 servings of refined grains daily—or, arguably a meal plan for more diabetes. In other words, more of the same.
Can the dietary guidelines combat type 2 diabetes?
We have to assume the White House plans are well-intentioned, but federal programs are required by law to follow the Dietary Guidelines. This policy was the elephant-in-the-room at the White House conference, because despite all the hopeful talk and many creative ideas, everyone’s hands are tied by this all-controlling behemoth policy that dictates anything the federal government might do.
There’s a longstanding debate over the guidelines: whether anyone actually follows them and if they’re based on rigorous science. The question for today is whether there’s any evidence that the guidelines can fight diabetes. If the White House is urging more of the guidelines, the first line of inquiry should be: do they work? Can they successfully treat diet-related diseases?
The short answer is no, because the guidelines aren’t actually intended for treatment. They’re designed for the prevention of disease, in healthy people--only. Once you become one of the 93.2% of Americans in poor metabolic health, in need of advice on how to get healthier, the guidelines are not for you.
This is like having an education policy designed for only A++ students. The original rationale for these healthy-people-only guidelines was that treatment protocols should be the domain of doctors who specialize in various conditions. This idea made sense at the outset of the guidelines, in 1980, when rates of chronic disease were low. Now, however, the policy is an obvious mismatch for the vast majority of the public.
In the whole database for the dietary guidelines, there’s a single systematic review1 on diabetes. which covers studies only through 2013. Our current guidelines were therefore 7 years out of date when published in 2020, leaving out a revolution in diabetes treatment that has occured during those years. 23
The review itself was conducted by the office at the U.S. Department of Agriculture (USDA) in charge of the guidelines’ science, and like virtually all of the USDA reviews on key topics, had significant shortcomings. For a start, it includes a mere 11 studies, of which only 2 are clinical trials (the kind of studies required for policy, because only these data can show cause-and-effect relationships). And the two trials did not test the government’s diet, rendering them irrelevant.4 For perhaps this reason, the review rightly concludes that the evidence should be judged as “limited,” or “Grade III” (Grade III is the lowest rating granted when evidence is available).
However, with the mojo science often seen in the guidelines process, the experts overseeing the 2015 process decided to upgrade that ranking to Grade II (“moderate” evidence) based on the random inclusion of two extra studies (not clinical trials). This decision was ‘non-systematic,’ meaning it didn’t follow any stated rules and is therefore not replicable. Non-systematic work also opens up the potential for bias—or lobbying interests.
In short, the Biden administration is pinning its diabetes-fighting hopes on outdated nutrition recommendations that have no proven efficacy for fighting diabetes.
US dietary guidelines are no healthier than “SAD”—the standard American diet
But perhaps the guidelines are healthy enough to benefit people with diabetes anyway? Most people eat so poorly, and surely the guidelines are better than the typical junk-food American diet?
The answer to that question lies in the only well-controlled (and double-blind) clinical trial on the guidelines ever conducted, which tested the government’s diet (DGA) against a “typical American diet” (TAD). In this study, the TAD was designed to be higher in refined grains, saturated fat, and sugar, while the DGA contained more fruits, vegetables, and whole grains. All food was provided for the 52 women participating, over 8 weeks.
The DGA women achieved the goal of adhering to the guidelines: they scored 98 out of 100 in the ‘Healthy Eating Index,” a measure for DGA adherence. The TAD women, by contrast, scored 65-69 on this index. These TAD ladies were told to consume 3 ½ additional servings of refined grains per day, including lemon cheesecake, and candy including “Jelly Bellies” as “all day condiments.”
USDA officials have assiduously promoted the idea that Americans are unhealthy because they fail to follow the USDA guidelines. However, in this experiment, the women with a near-perfect HEI scores saw virtually no improvement in their health compared to women on a junk-food diet. Markers for diabetes and heart disease, the outcomes measured, showed no difference, except slightly better systolic blood pressure for the DGA women.5
This trial is reinforced by another, government-funded experiment, called the Women’s Health Initiative (WHI), which has been subject to more debate, since it was less well-controlled. Even so, with nearly 49,000 women, it is the largest clinical trial in nutrition science ever conducted. The women in the intervention group were given a copy of the Dietary Guidelines to follow, while the controls were told to continue with their regular diets. After an average of 7 years, researchers reported in 2006 that they could observe no benefits for the DGA group for rates of fatal or non-fatal heart disease, stroke, diabetes, obesity, or any of the several types of cancer measured.
We can only conclude that according to the most rigorous available data, the USDA diet will not make a dent in the diabetes epidemic. In fact, given what is now known about how type 2 diabetes can be put into remission—by reducing sugars and starches—the US guidelines, with six servings of grain (including 3 refined grains) and 10% of calories as sugar, will almost inevitably worsen this condition.
These are the guidelines that allow donuts and OJ for breakfast in school meals, followed by pizza and Nachos for lunch. Need we say more?
In his remarks at the White House conference, Biden said that people don't like "government programs which are ineffective.” He’s absolutely right. Which is why he should scrap the government’s high-carbohydrate diet and restart, based on the most promising and most recent science. The past decade of studies has revealed to us a path for conquering type 2 diabetes. Now we need leadership unafraid of standing up for this science.
You can expect this URL to change. The USDA has shifted the website locations of its scientific reviews numerous times, with no forwarding addresses. My original BMJ paper on the 2015 Dietary Guidelines updated its footnotes once but could not keep up with the ever-disappearing URLs for the evidence-based of our nation’s nutrition policy.
The American Diabetes Association in 2018 updated its standards of care to include a “very low-carb” diet due to its ability to control blood sugar, which is crucial for treating diabetes.
The lack of rigorous, proper scientific methods for reviewing the science in the Dietary Guidelines has been recognized in two reports by the National Academies of Sciences, Engineering, and Medicine, as well as a peer-reviewed study published in a journal of the National Academies (on which I am one of seven authors).
The two trials are: 1) PREDIMED, a large study in Spain that tested a Mediterranean diet. This diet differed significantly from the U.S. guidelines in at least two ways: It did not reduce red meat, and it advised 40% of calories as fat. By contrast, the U.S. guidelines advise 20-35% of calories as fat and limited amounts of red meat. 2) A trial on 187 men in Norway, which was similar to the U.S. guidelines in its advice to reduce saturated fats and sugars while eating more vegetables but was different in at least 8 other ways (on salt, alcohol, fruits, whole grains, refined grains, types of protein foods, soy foods, and vegetable oils) (Jacobs et al)
The diets were not designed for weight loss, and participants were reported to have kept their weight stable. This factor should not have prevented other health improvements, however, since multiple studies have found that cardiometabolic markers can improve without weight loss.