Response to Wolever

We thank M.S. Wolever (1) for his letter asking about the process used to develop the American Diabetes Association (ADA) nutrition principles and recommendations. As with all ADA technical reviews and position statements, the process is determined by the ADA as outlined in the ADA Clinical Practice Recommendations 2002 introduction (2), which is used for all new and revised ADA position statements. Members of the task force reviewed the literature with emphasis on research published since the last nutrition review completed in 1994. After completion of the technical review nutrition principles (3), nutrition recommendations were developed and classified according to the system outlined by the ADA for position statements (4).

In regard to the concern that “nonglycemic carbohydrates” will not raise blood glucose, you make an important point. Carbohydrates such as fiber and sugar alcohols have minimal effects on blood glucose. In the recommendation that total amount of carbohydrate in meals or snacks is more important than the source or type, it is implied that the carbohydrate is digested and absorbable. Thus, fiber should not be considered, and sugar alcohols should be considered at a reduced level because of their partial absorption. Perhaps this should have been stated rather than implied. The recommendation would be clearer if it were changed to state that the total amount of “available” carbohydrate in meals or snacks is more important than the source or type.

Your biggest concern appeared to be that a person eating a chocolate bar sweetened with the polyol lactitol might be confused as to the amount of available carbohydrate and administer too much insulin. However, you might presume that the lactitol-sweetened chocolate bar was selected because the person wanted the reduced sugar and caloric intake and would take this into account. Consultation with a dietitian would be useful to clear up any confusion in this regard.

Incidentally, in other polyol-sweetened foods, such as ice cream or cookies, the difference in the total amount of carbohydrate in the alcohol-sweetened foods, compared with foods sweetened with sucrose, is small, even when the amount of sugar alcohol is subtracted from the total carbohydrate.