WOW!!! The Western Australian Government is holding an inquiry into the role of diet in type 2 diabetes prevention and management, to be completed in early 2019.
I experienced some unexpected hope and optimism when I heard this news. In spite of my natural skepticism, I don’t feel that this inquiry is being held to give the appearance of doing something about the rising incidence of diabetes but rather that the motivation may actually be to find out if diet has a role in preventing or managing the condition.
Imagine the consequences if the members of this government committee come to understand that low carb diets have the potential to not only prevent, but also reverse, type 2 diabetes.
The news will spread worldwide and millions of people will be saved from the ravages of this preventable and treatable metabolic disorder. I’ve allowed myself to be swept away by my optimism to the extent of thinking this inquiry could be a game changer.
So, I put in a submission. It was supposed to be short, but once I started I couldn’t shut myself up.
Here it is with added pictures and some tweaks. (It’s an annoying fact that ideas for improvements only come after the closing date.)
“Dear Committee Members
RE: SUBMISSION FOR THE INQUIRY INTO THE ROLE OF DIET IN TYPE 2 DIABETES PREVENTION AND MANAGEMENT
I have been a dietitian for nearly 40 years, with a particular interest in the management of type 2 diabetes, Metabolic Syndrome and insulin resistance.
Even though I have been recommending carbohydrate restriction to clients with these conditions for many years, this was not my practice in the early days.
When I graduated in 1979 the Australian Dietary Guidelines had just been released. We were taught that these guidelines were the basis of a healthy diet for everyone and for many years I believed this.
My practice changed because of the experience of having a child with a weight problem, despite a very healthy diet and lifestyle. She gained weight around the tummy at an early age, seemed to have less energy than her siblings, was a mouth-breather, suffered with reflux and could be moody at times. All signs I now recognise as relating to insulin resistance.
At around 12 years of age she gained a lot of weight quite quickly and by age 14 was borderline obese. And I was at loss to explain why.
I luckily met a GP whose family situation was remarkably similar to mine; 3 slim, high energy, eat-what-they-like children and one with a weight problem. After hearing about the presence of insulin resistance in young, seemingly healthy children, and not just in people with diabetes as she had been taught, this GP had her daughter tested and suggested the same for my daughter.
A two-hour Glucose Tolerance Test with the addition of 5 insulin measures showed normal blood glucose levels but a high insulin response, fitting the diagnostic criteria for insulin resistance.
I have been researching everything I can about insulin resistance and its relationship to diabetes, obesity and numerous other conditions ever since.
Noting the terms of reference of your inquiry, I would like to focus primarily on the adequacy of prevention and intervention programs.
In Australia, nutrition programs designed to prevent many health related disorders or to manage such disorders once they have developed, are almost exclusively based on the Australian Dietary Guidelines, a set of principles for healthy eating that have been with us for over 40 years.
I believe that the ADGs as a guiding set of principles for good health are a failure and have contributed to the obesity and diabetes epidemics that we are currently facing.
The ADGs are not, and have never been, based on good science. If they were, it would not be possible for the 2003-2013 edition have come up with the advice for Australian adults to eat the equivalent of 6-24 slices of bread per day.
The ADGs have failed to keep the population healthy, and programs based on them have largely failed to treat/manage obesity and diabetes once developed.
To understand why this is the case, I’d like to present some background to the development of the ADGs and propose reasons not only for their failure to keep Australians healthy, but how they may actually contribute to people becoming overweight and diabetic.
History of the ADGs
The ADGs started as a compilation of “ideas” about healthy eating that were accepted and became policy without ever being tested. The first edition in the 70s recommended reducing fat intake and eating plenty of carbohydrates such as breads and cereals and this advice has continued with all subsequent revisions.
A history of the ADGs can be found at http://blog.babyboomersandbellies.com/?p=17
The advice to reduce fat intake to help maintain a healthy weight or for weight loss is based primarily on the fact that fat contains more energy than other macronutrients eg fat has twice the energy content of carbohydrate. (1tsp fat/oil = 36 cals; 1 tsp sugar = 16 cals). Coupled with the common, but erroneous, belief that weight gain is simply a case of eating too much and exercising too little, cutting calories by reducing fat intake seemed like a good idea.
Similar guidelines were being considered for implementation in the U.S. but with more opposition than we saw in Australia. A respected lipid researcher urged caution in the low fat recommendation, saying that if such advice were given to the American population, it would be equivalent to conducting a large-scale experiment, the consequences of which were unknown.
The consequences of demonising fat and recommending “plenty of carbs” for the last 40 years are no longer unknown.
Carbohydrate metabolism and insulin resistance.
There is increasing scientific evidence that the idea of overweight simply being the result of too much food and not enough exercise, best managed by a low fat diet/energy reduced diet, is inadequate. It has been demonstrated that there are differences in the way people metabolise foods, particularly carbohydrates, and while many people are able to metabolise carbohydrates well and thrive on a reduced fat diet, this is not the case for all.
Carbohydrate foods such as bread, potato, rice, pasta, cereals, fruit, milk, sugar etc are broken down to simple sugars, predominantly glucose.
Glucose is absorbed into the blood and the subsequent rise in the blood glucose level triggers the pancreas to release insulin. Insulin aids in the transport of glucose into cells where it is either stored as glycogen or used to provide energy.Many people are able to metabolise carbohydrate foods in this way. They are likely to release the right amount of insulin in response to a rise in their BGL, glucose is quickly cleared from the blood into cells, BGLs remain in the ideal range, our person has lots of energy and doesn’t gain weight easily.
However insulin resistant people have a different metabolic response after eating carbohydrates. If their muscles are resistant to the action of insulin, glucose does not enter muscles quickly and an enhanced insulin response may be precipitated in an attempt by the body to maintain glycaemic control.
High insulin levels may maintain ideal glucose levels for many years but at a cost.
In the scientific literature, there is documentation that high insulin levels are associated with high triglycerides, low HDL, fatty liver, sleep apnoea, excessive hunger, weight gain, central adiposity, difficulty losing weight, tiredness, reflux/ indigestion, type 2 diabetes, gout, hypertension, anxiety, depression, loss of muscle mass, micro albuminuria, inflammation, CHD, poorer breast cancer prognosis and memory impairment. (I can provide references for all these associations if asked)
To put this into real-life context, a person who has an excessive insulin response after eating carbs is likely to have hormonal responses triggered that make them excessively hungry, crave more carbs, experience mood changes associated with comfort eating and/or binge eating, tiredness/lethargy that make them less inclined to exercise and reduced satiation after meals so that they eat more without feeling full.
In addition to these effects on hunger and appetite, high insulin levels promote weight gain by increasing the conversion of glucose to fat in the liver and stimulating visceral fat receptors to take up this fat, resulting in central obesity. And weight loss is made difficult by the effect of high insulin levels on inhibiting lipolysis (fat breakdown).
These are more likely to be the issues that explain the lack of success of the usual practice of focusing on energy and fat restriction, without regard to carbohydrate intake. For insulin resistant people, this advice sentences them to a struggle of cravings, excessive hunger, low energy, reduced satiation and difficulties maintaining a healthy weight.
Development of type 2 diabetes.
Type 2 diabetes and pre-diabetes are often diagnosed at the end of a process that has been developing over many years. The high insulin response at the start of the process may keep the blood glucose level at an appropriate level for a while but over time, insulin levels can change as the disorder progresses. The stage may be reached where there is a decline in β-cell function and the pancreas is unable to maintain adequate insulin production. Blood glucose levels rise as a consequence and the diagnosis of type 2 diabetes is made at this stage.
When a person is first diagnosed with type 2 diabetes they are often advised that it can be managed with diet and exercise. If diet and exercise are not successful in lowering blood glucose levels then medication is given. Often insulin injections are introduced at a later stage if blood glucose levels remain high. The sequence of events from treatment with diet and exercise only, to the addition of oral medications and finally of insulin, is commonly observed.
With the current management approach, blood glucose levels appear to become harder to control over time and increasing doses of medication and insulin are prescribed.
I believe that the reasons optimum blood glucose levels are not achieved is due to poor understanding of the underlying cause, resulting in incorrect dietary advice being given at the very beginning.
The adequacy of prevention and intervention programs
Generally the diet advice provided by diabetes organisations for people with type 2 diabetes follows similar guidelines. It’s appropriate in this submission to look at those from Diabetes W.A. in more detail.
As detailed on their website, Diabetes W.A. makes the recommendation to follow the ADGs as a preventive measure https://diabeteswa.com.au/prevention/reduce-your-risk/eating-for-good-health/
I do not believe that this advice is correct. If an insulin resistant person followed the ADGs ie reduced their fat intake and ate plenty of carbohydrate foods, they have a greater chance of their insulin resistance worsening over time and eventually developing diabetes.
In addition, for those who have developed diabetes, Diabetes W.A. says that healthy eating for people with diabetes is no different from what is recommended for everyone else.
The website also provides meal suggestions.
Breakfast: 2 slices wholegrain raisin toast with a thin spread of poly or monounsaturated margarine
Carb content: 30 gm carb = approx. 7 tsp sugar
Lunch: 2 slices wholegrain bread spread with 1⁄4 avocado, 2 slices low-fat cheese, lettuce, cucumber and sliced tomato
Carb content: 30 gm carb = approx. 7 tsp sugar
Dinner: 100g lean stir-fried lamb strips served in 1⁄2 wholemeal Lebanese flat bread with sliced tomato, cucumber, onion, 1 cup tabouleh and 2 tablespoons hummus
Carb content: 40 gm = apprx. 10 tsp sugar
Snacks include fruit, crackers and bread, all of which contain around 15 gm carbohydrate each, which will be broken down to 3-4 teaspoons glucose.
Essentially the advice from the Diabetes W.A. is encouraging people who have high blood glucose levels as a result of a problem with carbohydrate metabolism, to eat the very foods that lie at the heart of the problem.
When such diet advice is followed, blood glucose and insulin levels are likely to be raised over the entire day. Over the longer term, these higher levels may lead to weight gain, high blood fats, poor sleep and possibly to the development of other diseases such as gout, kidney and heart disease. The resulting lack of success in reducing blood glucose levels with such diet advice is often interpreted as “the diet not working”. The truth is that high blood glucose levels and weight gain are exactly what should be expected from following advice to eat carbohydrates at each meal and for snacks. Quite simply, such advice is illogical and counter productive.
A marked difference can be seen when contrasted with a lower carbohydrate meal plan.
Such an example could be:
Breakfast: 3-egg omelette with tomato, onion and cheese; pan-fried mushrooms
Lunch: Chicken, avocado and macadamia salad with whole egg mayonnaise
Dinner: Beef in creamy mushroom sauce, cauliflower rice and grilled asparagus.
Small serve berries and cream or full fat yoghurt
Snacks: celery, capsicum, cucumber, cheese, low carb dips
Low carbohydrate meal plans such as this have been shown in clinical trials to result in lower blood glucose levels, improved diabetes markers, improved lipid levels, reduced need for medication and to be well accepted by patients.
A recently published joint position paper from the American Diabetes Association and the European Association for the Study of Diabetes includes approval of Low Carbohydrate diets for use in the management of Type 2 diabetes and recognised that they are both safe and effective. They added that no benefit of moderate carbohydrate restriction (26–45%) was observed.
I would also like to comment on effective diabetes self-management with reference to Aboriginal communities. I note that on the Diabetes W.A. website that diet advice for Aboriginal people with diabetes is to have approximately 50% of the diet as carbohydrate foods. These are suggested to be mainly grains and cereals such as bread, flour, damper, breakfast cereals, rice, pasta and couscous. Also advised are low fat dairy, lean meats, tofu, margarine, vegetable oil and soy milk.
With regard to Australian Aborigines and type 2 diabetes, it is clear that a pre-European diet was a very low carbohydrate diet; however as talked about in this blog (by a West Australian) we have simply tweaked the Australian Dietary Guidelines to apply to all.
http://macrofour.com/prof-andrikopoulos-paleo-pringle-australian-diabetes
This is despite the fact that a traditional diet (which could be regarded by dietitians today as restrictive) was shown in the 1980s to reverse diabetes in people in the Kimberley region however it was not fashionable to continue with that solution because low-fat dietary guidelines were being introduced as a public health initiative. This is described in this blog post by the same author who also takes a look at the diet of Southwest aborigines.
http://macrofour.com/nyungar-diabetes-australian-dietary-genocide
As a dietitian, I find it unfathomable that a guide to healthy eating for indigenous Australians would ignore the body of work by Prof. O’Dea. Should your committee perhaps think about WA producing its own guidelines for healthy eating based upon traditional eating, ignoring dietetic diets based on inappropriate evidence which are inconsistent with the macronutrient composition of a traditional diet?
Finally, noting that other traditional people have the same issue and are using a grass-roots approach to solve it themselves, are we empowering Australians with good information to be able to take their health in their own hands? See this post by the same author about a Tongan in New Zealand using a restrictive low carbohydrate diet and keeping it’s cost low and the food culturally appropriate.
http://macrofour.com/kiwi-tongan-joseph-finau-daphnis
I believe that it is time to reassess the advice currently given to people with diabetes, and to critically evaluate the role of the Australian Dietary Guidelines in contributing to the current high rates of obesity and diabetes.
I hope that Western Australia can lead the way and the rest of Australia follows.
Yours sincerely
Jennifer Elliott
Submission attachment
Jennifer Elliott
Nicely done! Let’s hope they read and think rather than just blaming meat and eggs which seems to be the current (vegan) fashion.
I knew an elderly Type 2 diabetic who was put on a low carb diet because that was accepted at the time (over 50 years ago) and curiously never taken off it again. His diabetes failed to progress in the expected way for the next 42 or 43 years until he died of old age (89). There are others, do you know any? Compare and contrast with the current crop put on low fat high carb and progressing through increasing drugs onto insulin within five to ten years with ever failing health then dying young from diabetes complications.
Hopefully we will see more of this kind of thing as the patients (and a small but increasing number of doctors, nurses and dieticians) reject the current orthodoxy. Will they be studied? Probably not, like those in the ADA Forum going back nearly a couple of decades now. Well there’s VIRTA and a few studies now, none of which get to be headline news like the coconut oil will kill you stone dead!!! stuff.
Lowish carb (100- 120g per day) was the usual advice for T2D up until the early 80s i.e. pre dietary guidelines in Australia. Pretty much been downhill since then.
Great that your friend knew that what he was doing was working and didn’t change. And that he was able to live healthily to a good age.
Good article. I met Dr O’Dea a few years back. I had liked her study which showed a return to the land reversed T2DM in Aborigine men. I was surprised, however, when she got quite upset when I suggested that their traditional diet valued fats. This was in a symposium on diabetes among Indigenous people. She got all red in the face and blustery, insisting that it was low-fat while my Aborigine friends were quietly telling me about witchetty grubs and how they preserved the fat pads of kangaroos and discarded lizards that weren’t fat enough.
I found this description of indigenous diets really interesting and it supports what you wrote, Jay.
From Sally Fallon and Mary Enig at https://www.westonaprice.org/health-topics/traditional-diets/australian-aborigines-living-off-the-fat-of-the-land/
“The great challenge for the Aborigine was to obtain enough dietary fat. They were close observers of nature and knew just when certain animals were at their fattest. For example, kangaroos were fat when the fern leaf wattle was in flower; possums when the apple tree was in bloom. Other signs indicated when the carpet snake, kangaroo rat, mussels, oysters, turtles and eels were fat and at their best.11 Except in times of drought or famine, the Aborigine rejected kangaroos that were too lean – they were not worth carrying back to camp.1 During periods of abundance “animals were slaughtered ruthlessly, and only the best and fattest parts of the killed game were eaten.”7 Favorite foods were fat from the intestines of marsupials and from emus.7 Highly saturated kidney fat from the possum was often eaten raw.5 The dugong, a large seagoing mammal, was another source of fat available to natives on the coasts.
Other sources of fat included eggs – from both birds and reptiles – and a great variety of insects. Chief among them was the witchetty grub, or moth larva, found in rotting trunks of trees. These succulent treats – often over six inches long – were eaten both raw and cooked. Fat content of the dried grub is as high as 67%. The green tree ant was another source of valuable fat, with a fat-to-protein ration of about 12 to one. Another important seasonal food in some parts of the country was the begong moth. The moths were knocked off rock walls on which they gathered in large numbers, or smoked out of caves or crevices. They were roasted on the spot or ground up for future use. Moth abdomens are the size of a small peanut and are rich in fat.4”
Oh, my goodness! This is absolutely MARVELLOUS!
All strength to you in your endeavour to effect change, hopefully first here in WA and may your influence then spread further afield…..!
Thank you for your comment, Renee. I’m looking forward to the W.A. committee’s report on this. Fingers crossed it will be a game changer.
Dear Jen
Where are you based?
Are you taking referrals?
Dr Peter Heffernan
Adult ADHD Specialist
Hi Peter. I am in the process of setting up Skype consultations, both for people new to LC and those who need advice and support in getting back/staying on track. Will let you know when it’s up and running.
A balanced effort on a complex issue. Missing was the fructose / fatty liver / Lustig issue that I believe is more at the root of the problem than dietary guidelines.
I found your blog when reading Daryl Ilbury´s book on Tim Noakes, whom I met in Cape Town in 2015 on the large low-carb conference. As a nutritionist I have experienced the intolerance of official advisors when discussing low-carb/high-fat diets, and my professorship at the Harstad College was terminated in 2003 following actions taken by our leading nutrition advisor at the time, head of the Nutrition department at the University of Oslo. In 2010 I established a foundation and started a new health magazine (see vof.no) where we report on all aspects of health, documenting what the Government does not tell us. It would be great to make an interview with you, showing our readers that things happens “on the other side of the world”, in spite of global suppression of how to heal with less carbs in the diet. Sincerely, Dag Viljen Poleszynski, PhD (viljen@vof.no)
Hi Dag. My apologies for the delay in responding; I haven’t been checking notifications from my blog for some time.
Thank you for your comment and the link to Dayl Ilbury’s book.
I had no idea that you experienced such appalling treatment from authorities in your country for discussing LCHF diets.
I would be very happy to discuss what happened to me for your magazine and would also be very interested in your own story.
Looking forward to speaking with you.
Best regards, Jen