Category: Dietary Guidelines

Hope on the Horizon?

Jennifer / / Dietary Guidelines, Nutrition

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.

Source: Baby Boomers, Bellies and Blood Sugars : the key to successfully managing type 2 diabetes, pre-diabetes and metabolic syndrome

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

 A Reduced Carbohydrate Diet Results in Weight Loss and Improved Glycaemic Control in a Patient with Poorly Controlled Type 2 Diabetes.

Jennifer Elliott

Dietitians Association of Australia: Judge, Jury and Executioner?

Jennifer / / Deregistration, Dietary Guidelines, Dietitians Association of Australia

This post focuses on a complaint that was made against me for my recommendation of low carb diets in diabetes management. It was made by another dietitian, lodged with my workplace and later forwarded to the DAA.

In particular, I’d like to highlight how the DAA complaints process worked in my case. It’s important to note that the DAA is a self regulated organisation that is not under the jurisdiction of any independent agency, including the Federal  Government (Federal Health Ministry, COAG, Ombudsman, AHPRA etc) that I could find. It sets it’s own rules, make decisions which may result in personal and financial loss to individuals, all with apparent impunity.

So here’s a chance for the DAA to shine as I take a look at our time together during the investigation into my practice.

The Beginning

A letter from DAA dated 10 September 2014, was sent to me giving notice that the DAA was “in receipt” of a complaint made by another dietitian.

The issues of the complaint were:

A. That my recommendation of a very low carbohydrate diet for type 2 diabetes management is inconsistent with Evidence Based Practice.

B. That a letter from a patient indicates that I dismissed previous evidence based advice* given to this patient and provided contradictory advice, resulting in a confused and disgruntled consumer.

*which happened to be from the dietitian making the complaint

C. The use of patient testimonials on my website for my book. (I promptly removed these and the matter was not brought up again by DAA as an issue of concern.)

In this letter I was also informed that the “complaint” had been referred to the Vice President who had “….. determined that there is a need for investigation under the Complaints and Disciplinary process.”

It was a really unnerving letter to receive because it seemed to imply more than the issues the complainant had raised. For example, the DAA mentioned “….breaches of the Code of Professional Conduct and Statement of Ethical Practice….”. I was unsettled by the tone but nevertheless happy to answer what the DAA saw as “areas of concern”.

Response sent

I thought I did a pretty good job with my response, particularly in providing evidence for the use of low carb diets in diabetes management as asked. I was surprised, however, that I had to point out to the DAA that they themselves, by deferring to American guidelines by the ADA, must also support low carb diets as one  of the options in diabetes management.

But apparently the DAA was not satisfied.

I am not sure why my response was considered inadequate but I received a letter from CEO Claire Hewat on 19.11.2014 saying that, “…you will still be required to provide a response regarding the two areas of concern highlighted already by the Vice President.”

I wanted to reply: “I’ve already provided responses. Haven’t you read them?” but dutifully sent off two further replies: One, Two with more details.

I did however have to ignore what I considered an unnecessarily menacing tone in the DAA letter. In view of the fact I had responded promptly to every request, I think it was unnecessary for the DAA to write, “A general response is not sufficient. If no satisfactory response is received, DAA will progress this case as allowed by our By-laws. You will have deemed to have disengaged from the process and

the material will be sent to a Hearing and Assessment Panel for consideration with or without your input.”

WHOA!!! Where did that come from? A friendly bit of advice to assist a member or barely veiled intimidation?

Oh, but on a more positive note, CEO Claire Hewat finished her letter with the lovely offer that if I required support, “please do not hesitate to contact me”.

Possibly one of the greatest comedic lines in the DAA joke book.

Did I receive a fair hearing?

It has been suggested to me recently that the DAA may have contravened it’s own By-Laws in the handling of my case.

The By-Law for Complaints and Disciplinary Procedures clearly sets out the steps to be followed after a complaint is made.

Firstly, the Chief Executive Office completes an initial assessment of the material gathered concerning the Complaint.

According to the relevant By-law, the INITIAL ASSESSMENT OF THE EVIDENCE states that:

“5.1  The Chief Executive Officer must assess all the information and material provided by the Complainant, the Respondent, itself and any other third party in relation to the Complaint.”

After gathering this information, the CEO is then supposed to discusses the issues with the Vice President, who then determines whether the complaint should be dismissed or proceed.

“All the evidence” referred to is stated to include both the complaint and the response, otherwise it would only be one side of the story. Obviously. And how could the Vice President be expected to make a decision about what is to happen next if she doesn’t have all the information?

Well………..

In my case, CEO Claire Hewat appears to have had a discussion with the Vice Pres after receiving the complaint but BEFORE I’d even been informed that there was a “complaint” against me. Not only that, the Vice President made her decision that there was a need for an investigation rather than any other course of action BEFORE having received, and therefore read, my response.

Anyone smell a rat?

How does that constitute giving due consideration to the complaint and the evidence if I hadn’t yet been given the chance to provide a response to the accusations? Is it possible that I wasn’t being treated fairly?

Anyway, this farce of what could be likened to a Kangaroo Court continued for a while and by the end of the ordeal, DAA’s decision was no surprise.

The Verdict

A letter from DAA dated 21.4.15 informed me of the Board’s decision.

The Board resolved that the complaint from the dietitian had been upheld; they deemed me guilty of professional misconduct (the DAA has refused to specify of what) and I was to be expelled from membership of the DAA.

Also, the Board supported the recommendation to alert relevant authorities such as Medicare, health funds and relevant government departments and  I was informed that my “status” would be noted on the public section of the DAA website. The DAA wrote to the SNSWLHD to inform them of the Board’s finding and I consequently lost the job I had held for over 20 years.

Thanks DAA.

Possible next post:

SNSWLHD directive that “Nutritional advice to clients must not include a low carbohydrate diet”

 

 

Dietary guidelines: where’s the evidence?

Jennifer / / Dietary Guidelines

Dietary guidelines are at the core of dietetic training and practice in Australia.

Ask a dietitian a question about your diet and you’ll likely receive an answer based on the guidelines.

Take for example answers from four dietitians when asked if cheese is bad for us. Thankfully all said “no”, but every answer had disclaimers that invoked the Dietary guidelines, either in terms of allowable quantities (2-4 serves dairy per day/a matchbox size for one serve), or fat content (“This is because fat is an energy-dense nutrient and lots of us are overweight, and because a lot of the fat in cheese is the ‘bad’ saturated fat.”) ref

These comments are made by dietitians involved in training the next generation of dietitians and represent one of the many ways The Dietary Guidelines have influenced “beliefs” about nutrition, in this case, of “experts” in the field.

But should the Dietary Guidelines be afforded such a position of influence? Is the evidence base for them as strong as what many dietitians, and others, believe?

Here’s an overview of how dietary guidelines in Australia came into being, which hopefully will add some clarity to the question of whether or not they have a solid “evidence base”.

 

               Evolution of Australian Dietary Guidelines: 1960-2015

 

1960s

Not official nor government endorsed but I remember these gems from the 1960s:

 

 

  1. drink milk because it is good for your teeth
  2. don’t eat too many lollies because they’re bad for your teeth
  3. eat your crusts so your hair will grow curly
  4. Peter’s ice cream is the health food of the nation

 

Professor Richard Feinman once commented that in view of what we have now, these don’t look so bad.

Until the late 1950s, before Government dietary guidelines were introduced, advice on food was pretty general. Emphasis was on liberal intakes of the ‘protective’ foods such as milk, eggs, fruits and vegetables www.ecodietitians.com.au

The next decade saw the beginning of the downhill slide.

 

1970s

This is the time when I thought it would be a good idea to become a dietitian. I began a science degree in 1976 and completed my Postgraduate Diploma in Dietetics in 1979.

 

At around this time the first dietary guidelines made an appearance in Australia.

“Stop and Think Before You Eat and Drink”  was the name of a pamphlet issued in the 70’s by The Australian Dietitians Association, now known as the DAA. This little pamphlet encapsulated what could be assumed to be the organisation’s “beliefs” about healthy eating. These guidelines cannot be considered as evidence-based as there are neither references nor any documentation to support the scientific legitimacy of statements such as “limit the fat in your diet”, “reduce salt intake” and “increase your intake of ….. bread and cereals.” Also unexplained is the change from “exercise moderation in the amount of carbohydrates eaten” to “increase your intake”.

At the end of a 1978 seminar organised by the DAA, the organisation resolved to set up a committee to develop a national nutrition policy. Few responses were received to serve on the committee and the DAA members and Professor Truswell decided to go it alone and as he said“…. draft ourselves a set of dietary guidelines for Australians” ref

Within a mere eight months, this small group of people had not only written “Dietary goals for Australia” but had had them accepted and ready for presentation by the Commonwealth Department of Health.

Quoting from Truswell, two things stood out to me from his account of this time.

  1. “There was no background review of the scientific literature at the time”

You’re kidding, right?

No review of the scientific literature for a professional body such as the DAA for their 1970 pamphlet isn’t great, but for the DAA to support having dietary guidelines signed off for an entire population without demonstrable evidence…how can we have ignored this action for so long?

It does however explain how the whole exercise was done so quickly; reviewing the science is time-consuming.

2. “The setting was conducive to a positive reaction.”

I get the sense Truswell may have thought getting dietary guidelines accepted by government so easily without opposition was a positive thing. This “positive reaction” may have been more a reflection of the audience, which consisted of food industry reps, consumer organisations, dietitians and bureaucrats, than an indication of the strength or soundness of the guidelines.

There was one dissenting voice to passing these dietary goals. The Nutrition Society of Australia opposed the guidelines because: “Some of its members considered dietary guidelines are politics, not science.”

Politics vs science was exactly the situation that was playing out in the U.S., where a congressional forum in 1977 to discuss the adoption of dietary goals, opposition was immense. Many researchers and scientists claimed that it was indisputable that no adequate trials had been undertaken to assess the effects, either positive or negative, of the diet changes being suggested.

This was eloquently stated by Prof E.H Ahrens, a lipid researcher from Rockefeller University, who addressed the hearing. On the proposal for Americans to reduce their fat intake, Professor Ahrens stated that this advice “…… on the strength of such marginal evidence was equivalent to conducting a nutritional experiment with the American public as subjects”.

However, politics and not science won the day. See ref for an excellent review of how this happened.

In answer to his own question as to why the Australian guidelines were accepted so well here, and weren’t met with “…… the spate of criticisms of the US dietary goals …. … or opposition like the British criticisms…..”, Truswell ref suggested the following:

  1. “The scientific nutrition establishment was small and new.”
  2. “Introduction of the Australian goals was well staged and tactfully presented.”
  3. “Australians are more receptive to new food ideas than people in the longer established countries.”
  4. “Dietary guidelines answered a deep need for the emerging profession of community nutritionists/dietitians”

 

So ……. not because the science had been settled?

 

1980s

In 1980 I started work at Queen Victoria Hospital, a large teaching hospital in Melbourne. Like many dietitians then and now, I went out into the world prepared to spread the message I had been taught: a low-fat diet with plenty of carbs as bread, cereals and fruits, is the way to good health. My apologies to every patient I counselled and the students I mentored.

 

It took me many years to see through this brainwashing. It wasn’t until the personal experience of having a child with a weight problem that I was forced to “think differently”. I fear that if this hadn’t been the case, I might have remained ignorant to the potential harm in recommending lower fat, higher carb diets to people who are carbohydrate intolerant . This turned out to be the majority of my clients.

The DAA pamphlet appeared in a second edition in this period. The message was the same and absence of evidence was maintained.

1990s

The 1992 edition of Dietary Guidelines for Australia link was produced by a committee of five nutritionists, one food industry representative, a psychologist and two bureaucrats. It was the first to include references, seemingly in an attempt to retrofit the 20 years of “what to eat to be healthy” recommendations.

In many sections of the 1992 Dietary Guidelines, references were far from comprehensive and appeared to be cherry picked to support each guideline. Or were mistakenly quoted as supportive when that wasn’t the case. Take for example Guideline 3: “Eat a diet low in fat and, in particular, low in saturated fat”

The basis of the demonisation of saturated fat is the belief that it raises the blood cholesterol level, and that a high cholesterol level causes atherosclerosis and cardiovascular disease. This is referred to as the diet/heart hypothesis, and has remained a theory lacking confirmation for over 50 years.

Even so, the unnamed author (or authors) of Guideline 3 attempted to back up the claim that “Saturated fatty acids elevate plasma total and LDL-cholesterol.” by citing one reference as proof.

The problem is that the referenced article is actually the OPPOSITE of supportive. Rather than it lending support to the idea that saturated fat increases cholesterol, it is CRITICAL of the methods used to incriminate saturated fat as cholesterol raising!

How could that happen? Did the author(s) not read the article or not understand it? Whichever the case, since 1992 the recommendation for Aussies to reduce saturated fat intake has been embedded in our guidelines, based on disputable evidence.


2000s

Is it possible to go from bad to worse?

The 2003 review of the guidelines suggests yes.

This decade was the golden era for industries that had anything to do with cereals and grains. It is the time when the recommendation of the Australian Dietary Guidelines was to eat “plenty of cereals (including breads, rice, pasta and 
noodles)”

And by eat “plenty”, they really did mean PLENTY. The recommendation was for women aged 19-60 to have the equivalent of 8 to 18 slices of bread and 10 to 24 for men.

Per day, no less.

How was this decision to recommend eating up to a loaf of bread per day reached? Who was responsible?

In the absence of finding anything directly answering this question, I looked at information ref about the person who wrote the chapter on breads and cereals, Peter Williams.

Peter Williams was a University of Wollongong Associate Professor of Nutrition and Dietetics 2006-2011. His publications include a paper called Report on the health benefits of whole grains and legumes for Go Grains Health and Nutrition Ltd, a paper on The benefits of breakfast cereal consumption: a systematic review of the evidence base. Adv Nutr 5:636S‐683S and a book chapter, Williams P (2003). Eat plenty of cereals (including breads, rice, pasta and noodles) preferably wholegrain. In: Food for Health: Dietary Guidelines for Australian Adults. pp31‐49. NHMRC: Canberra.

Williams was an invited lecturer at the ILSI Australasia and Grains & Legumes Nutrition council Symposium in 2013, on the topic of “The pros and cons of carbohydrate intake in modern Australia and New Zealand – an overview of health effects.

There were commercial consultancies, which totaled $1,292,349 from 2000‐2016,

Prof Williams has received awards from the DAA for his contributions to the profession and in 2010 received Honorary Life Membership.

Professional activities of Williams include :

2002-2003 President, Dietitians Association of Australia

2000- 2003 Member, NH&MRC Dietary Guidelines Review Working Party

2000-2002 Member, the Go Grains Advisory Committee


I must admit to feeling surprised and a little uneasy when I noticed the overlap of time-frames for some of the professional activities noted above.

According to the blurb from the 2003 guideline review, preliminary work started in 2000 and revisions were finalised in 2002.

From 2000 to 2002 Prof Williams was involved with Go Grains, an advocacy body for the Australian grain industry, at the same time as he was writing the chapter for the guidelines titled “EAT PLENTY OF CEREALS (including breads, rice, pasta and noodles)”, which translated into the National advice for adults to eat the equivalent of 8-24 slices of bread per day.

 

2013 – now

With the foundations of our Dietary Guidelines being shaky, and, uncontested, it was no surprise to me that the 2013 review produced “more of the same”. What was disturbing though, was the number of reviewers, senior advisors, working groups, and consultation rounds, and no one was able to pipe up with even one “hang on a minute….”

There were certainly some missed opportunities for this in the latest review. Take for example the evidence statements in the 2013 guidelines for ‘limit intake of foods high in saturated fat’. Instead of this statement being graded on the strength of evidence, or even having a reference, it was simply described as ‘established’.ref

Table 3.1: Evidence statements for ‘limit intake of foods high in saturated fat’
Established evidence
Saturated fat is the strongest dietary determinant of plasma LDL concentration.

How did the brains behind this go from one reference which they thought supported the guilt of saturated fat, but which didn’t, to deciding a few years later that the matter was done and dusted, no references required?

It should be noted that the antipathy towards saturated fat reflected in the Australian guidelines is not shared by international experts such as Arne Astrup, Head of Department of Nutrition, University of Copenhagen.

In relation to a recent review of the U.S. guidelines he writes:

“The [Dietary Guidelines] committee seems to be completely dissociated from the top level scientific community, and unaware of the most updated evidence. There are now several new meta-analysis of both observational studies and also of randomized controlled trials clearly showing that there is no benefit of reducing saturated fat in the diet. All analyses and research can be criticized, but these meta-analyses have been published in leading scientific journals typically after critical reviews by 3-5 independent scientists (including a statistician), and by expert editors, so they cannot and should not be dismissed so easily….Equally important is that the scientific studies that were the basis for the ‘cut down on saturated fat recommendations have been re-evaluated, and it is quite clear that today we would have concluded that there is no robust evidence to substantiate the advice.”

And James DiNicolantonoi (Saint Luke’s Mid America Heart Institute) wrote:

“Problem three is that there was never any evidence to demonize saturated fat per se back in 1977 in the original Dietary Goals…”

—Quoted in Cardiobrief

                                                                          

Where to next?

I subscribe to the concept “one can criticise without having to offer solutions”, however, I feel it fair I do as a nutritionist, and on behalf of the health of Australians.

 

 

 

My preference is to see the scientific, social, and political communities make an admission the guidelines have been a disaster and to scrap them.

In the event that doesn’t happen and we have a repeat waste of taxpayer’s money for another review in a decade or so, at the very least my hopes are:

  1. The DAA does not win the tender, and has limited involvement in the review.
  2. Any person with ties to the food industry is excluded from participating.
  3. A person who has reviewed a chapter/guideline previously is excluded from future reviews. An exception may be made for those of strong character who are able to admit to stuffing things up in the past and genuinely want to do better.
  4. And most importantly, my wish is for the possibility of harm to be seriously considered for the first time. Not only have these guidelines not met their objective of improving health, there is a good case that they have likely caused harm to hundreds of thousands of people.

Rates of obesity and type 2 diabetes have risen dramatically. Children as young as 10 yrs are being diagnosed with type 2 diabetes. It has to be considered whether the advice to “eat less fat/plenty of carbohydrates” is implicated.

It may be that because the intention behind the guidelines was good ie to improve health, that harm has never been considered. After 40 years and deteriorating health, it’s about time it was.

Coming soon

Undoing the brainwashing: my road to recovery.