We welcome the European perspective, although we do not completely share it. We agree with the statement of Mann et al. (1) that “meticulously conducted and controlled human studies of people with diabetes that involve dietary manipulations over a period of weeks or months… provide the most powerful evidence.” However, we take issue with several concerns they express. First, we take issue with the statement that it is important to consider how recommendations are likely to be interpreted by health professionals and patients. Second, we continue to believe that the total amount of carbohydrate is more important than the source or type. Third, we continue to believe that sucrose does not need to be restricted, relative to other carbohydrates, because of concern about aggravating hyperglycemia.

It was an initial determination of the American Diabetes Association Task Force that it was our task to write, as accurately as possible, evidence-based nutrition principles and recommendations. The implementation of these principles and recommendations was to be determined by health professionals in their individualized nutrition counseling with patients. Furthermore, we concluded that patients have the right to read and know accurate nutrition information. With this information, it is then their right to make decisions about their own food choices. Too often in the past, health professionals have taken a parental approach, such as “do this because it is good for you,” or a “food police” approach, such as “don’t eat sugar.” These approaches have not led to successful outcomes. Table 1 outlines this well.

With respect to amount and source of carbohydrate, we stand behind our original recommendation. However, as stated in our response to Wolever (2), our recommendation about the amount of carbohydrate might be more clear if it were changed to say the total amount of “available” carbohydrate is more important than the source or the type. In type 1 diabetic subjects, the amount of carbohydrate in test meals influenced the amount of insulin necessary to control glycemia, whereas glycemic index, fiber content, and caloric content did not (3).

With regard to the concern about sucrose, it is clearly stated in our introduction that “basic to the nutrition recommendations is the underlying concern for optimal nutrition through healthy food choices and an active lifestyle” (4). The section on sucrose, as noted by Mann et al. (1), also states that “sucrose and sucrose-containing foods should be eaten in the context of a healthy diet” (4,5). Mann et al. states that they know of no medium or long-term studies where the practice of focusing on total carbohydrate was shown to be compatible with good glycemic control. Please note that, in the 20 studies quoted, when total carbohydrate came from a variety of starches or starches plus sucrose, the sucrose intake represented approximate usual intake, and only Peterson et al. (6) made an attempt to use sucrose with fiber-containing foods. In most of the studies, rigorous control of the nutrients under study was established by providing meals to subjects. One of the studies provided 23% and another 30% of energy from sucrose. Two of the studies lasted 28 days. If the total carbohydrate intake was kept similar, the responses were also similar. Was the European perspective that both sucrose and starch should be restricted in the diabetic diet because both aggravate hyperglycemia generated with these studies in mind? If so, does this not affirm the concept that the total amount of carbohydrate is more important than the source or type?

The headline “U.S. relaxes sugar ban for people with diabetes,” which appeared in the British Medical Journal (7), surprised us. The relaxation of the restriction on sucrose was nothing new, having been recommended in 1994 (8).

With regard to the statement by Mann et al. (1) that a “high intake of sugary beverages has been convincingly shown to be related to subsequent risk of obesity in children,” we would call attention to another study (9) in which added sugars were found to be relatively unimportant when it came to overall diet quality in individuals between 2 and 19 years of age.

With regard to the glycemic index, the study by Jarvi et al. (10) did find benefit, but as noted in the previous reply to the letter by Irwin (11), other studies (4) have not confirmed long-term benefit from low-glycemic index diets. One study is not “impressive evidence.” The same applies to fiber. Whereas some intervention studies have reported benefit (12,13), others have not (1416). Moreover, the study by Chandalia et al. (13), which compared 24 g fiber with 50 g fiber, would support our statement that it “appears that ingestion of large amounts of fiber is necessary to confer metabolic benefits. It is unclear whether the palatability and gastrointestinal side effects of fiber in this amount would be acceptable to most people” (5,6). The control arm of the study used 24 g dietary fiber and had no beneficial effects on glucose, lipid, or insulin levels. This amount of fiber is clearly at the upper end of usual intake for most Americans and would, by itself, require major lifestyle changes for most Americans to achieve. The 50-g dietary fiber diet included two servings of oatmeal (15 g carbohydrate/serving), six slices of whole wheat bread, six to seven servings of fruit (15 g carbohydrate/serving), and three servings of vegetables (15 g carbohydrate/serving). For many individuals, this type of food plan would require very dramatic changes in eating habits.

In conclusion, we stand behind our original recommendations, as we believe they are evidence based.

Table 1—

Comparison of traditional and empowerment viewpoints regarding diabetes medical nutrition therapy

Traditional viewpointPatient-centered viewpoint
Food choices affect physical health, including diabetes management. Food choices affect psychosocial quality of life as well as physical health. 
The professional is the expert in nutrition and is therefore in charge of developing a meal plan based on assessed needs. The professional is the expert in nutrition, and patients are the experts about themselves and their life circumstances. 
The focus is on metabolic goals, such as weight and blood glucose levels. The professional provides instruction on an appropriate meal plan and teaches clients how to follow it. Desired metabolic outcomes shape behavior change plans but are not in themselves behaviors that clients can control. The focus is on behavioral goals, i.e., specific action steps that clients can control. 
The professional feels effective and successful when clients follow nutrition recommendations. The professional teaches behavior change skills so clients can achieve their own nutritional goals. The professional feels effective and successful when clients become skilled at making informed choices and solving problems. 
Traditional viewpointPatient-centered viewpoint
Food choices affect physical health, including diabetes management. Food choices affect psychosocial quality of life as well as physical health. 
The professional is the expert in nutrition and is therefore in charge of developing a meal plan based on assessed needs. The professional is the expert in nutrition, and patients are the experts about themselves and their life circumstances. 
The focus is on metabolic goals, such as weight and blood glucose levels. The professional provides instruction on an appropriate meal plan and teaches clients how to follow it. Desired metabolic outcomes shape behavior change plans but are not in themselves behaviors that clients can control. The focus is on behavioral goals, i.e., specific action steps that clients can control. 
The professional feels effective and successful when clients follow nutrition recommendations. The professional teaches behavior change skills so clients can achieve their own nutritional goals. The professional feels effective and successful when clients become skilled at making informed choices and solving problems. 

From Maryniuk MD: Counseling and education strategies for improved adherence to nutrition therapy. In American Diabetes Association Guide to Medical Nutrition Therapy for Diabetes. Alexandria, VA, American Diabetes Association, 1999, p. 369

1
Mann J, Hermansen K, Vessby B, Toeller M, the Diabetes Nutrition Study Group of the European Association for the Study of Diabetes: Evidence-based nutritional recommendations for the treatment and prevention of diabetes and related complications: a European perspective (Letter).
Diabetes Care
25
:
1256
–1258,
2002
2
Wolever TMS: American Diabetes Association evidence-based nutrition principles and recommendations are not based on evidence (Letter).
Diabetes Care
25
:
1263
–1264,
2002
3
Rabasa-Lhoret R, Garon J, Langelier H, Poisson D, Chiasson J-L: The effects of meal carbohydrate content on insulin requirements in type 1 patients with diabetes treated intensively with the basal bolus (ultralente-regular) insulin regimen.
Diabetes Care
22
:
667
–673,
1999
4
Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson J-L, Garg A, Holzmeister LA, Hoogwerf B, Mayer-Davis E, Mooradian A, Purnell JQ, Wheeler M: Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications (Technical Review).
Diabetes Care
25
:
148
–198,
2002
5
American Diabetes Association: Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications (Position Statement).
Diabetes Care
25
:
202
–212,
2002
6
Peterson DB, Lambert J, Gerrig, Darling P, Carter RD, Jelfs R, Mann JI: Sucrose in the diet of diabetic patients: just another carbohydrate?
Diabetologia
29
:
216
–220,
1986
7
Josefson D: US relaxes sugar ban for people with diabetes.
BMJ
324
:
70
,
2002
8
American Diabetes Association: Nutrition recommendations and principles for people with diabetes mellitus (Position Statement).
Diabetes Care
17
:
519
–522,
1994
9
Forshee RA, Storey ML: The role of added sugars in the diet quality of children and adolescents.
J Am Coll Nutr
20
:
32
–43,
2001
10
Jarvi A, Karlstrom B, Granfeldt Y, Bjorck I, Asp NG, Vessby B: Improved glycemic control and lipid profile and normalized fibrinolytic activity on a low glycemic index diet in type 2 diabetic patients.
Diabetes Care
22
:
10
–18,
1999
11
Irwin T: New dietary guidelines from the American Diabetes Association (Letter).
Diabetes Care
25
:
1262
,
2002
12
Giacco R, Parillo M, Rivellese AA, Lasorella G, Giacco A, D’Episcopo L, Riccardi G: Long-term dietary treatment with increased amounts of fiber-rich low-glycemic index natural food improves blood glucose control and reduce the number of hypoglycemic events in type 1 patients with diabetes.
Diabetes Care
23
:
1461
–1466,
2000
13
Chandalia M, Garg A, Luthohann D, von Bergmann K, Grundy SM, Brinkley LJ: Beneficial effects of a high dietary fiber intake in patients with type 2 diabetes.
N Engl J Med
342
:
1392
–1398,
2000
14
Lafrance L, Rabasa-Lhoret R, Poisson D, Ducros F, Chiasson J-L: The effects of different glycaemic index foods and dietary fibre intake on glycaemic control in type 1 diabetic patients on intensive insulin therapy.
Diabet Med
15
:
972
–978,
1998
15
Hollenbeck CB, Coulston AM, Reaven GM: To what extent does increased dietary fiber improve glucose and lipid metabolism in patients with noninsulin-dependent diabetes mellitus (NIDDM)?
Am J Clin Nutr
43
:
16
–24,
1986
16
Nuttall FQ: Dietary fiber in the management of diabetes.
Diabetes
42
:
503
–508,
1993

Address correspondence to Marion J. Franz, MS, RD, CDE, 6635 Limerick Dr., Minneapolis, MN 55439. E-mail: marionfranz@aol.com.