Category: Nutrition

Glycaemic Index: is it a joke?

Jennifer / / Nutrition

The wonderful Barry Groves was trying not to laugh when talking about the glycaemic index: “Another oddity is that slicing bread appears to increase its GI. Gluten-free white bread, unsliced…. has a GI of 71 and exactly the same bread made with the same ingredients, sliced, is 80.
“You couldn’t make it up, could you?”, he says with amusement.

I have often wondered why it took me so long to realise that the Glycaemic Index is rubbish and how I could ever have believed the GI peoples’ nonsense that they are measuring a property of foods that influences blood glucose levels INDEPENDENT of the person eating it. 

Last year I made a submission to the WA parliamentary committee looking into the role of diet in type 2 diabetes prevention and management and followed up with a letter about the GI recently.

Here’s an edited version.

Dear Minister

I have read the transcript of Jennie Brand-Miller’s evidence to the WA inquiry in regards to the role of diet in the prevention and management of type 2 diabetes and would appreciate the opportunity to comment on her evidence.

Brand-Miller’s contribution to the inquiry largely concerns the role of the Glycaemic Index (GI) in diabetes management and in the transcript she talks about “common sense” in relation to the GI. 

I would like to follow her “common sense” line of thinking by asking you and the committee members to consider how the GI of a food is calculated and applied and to decide for yourselves if there is ANY sense to it at all.

I would like to explain why I consider the GI ranking of foods to be one of the most inane concepts in the world of nutrition, despite reasonable competition. Being ludicrous does not equate with being harmless. The harm caused to people with diabetes in putting their faith in the GI as a way to make food choices that will help manage their condition, instead of a method with a sound physiological basis and proven benefits eg reducing carbohydrate intake, is potentially immense. 

What is GI? 

According to the GI people:“The glycemic index (or GI) is a ranking of carbohydrates on a scale from 0 to 100 according to the extent to which they raise blood sugar (glucose) levels after eating. Foods with a high GI are those which are rapidly digested, absorbed and metabolised and result in marked fluctuations in blood sugar (glucose) levels. Low GI carbohydrates – the ones that produce smaller fluctuations in your blood glucose and insulin levels – is one of the secrets to long-term health, reducing your risk of type 2 diabetes and heart disease. It is also one of the keys to maintaining weight loss.”

Example of a low GI meal plan

The following is a meal plan based on low GI foods, and according to Brand-Miller “Low GI foods, by virtue of their slow digestion, absorption and/or metabolism, produce a less pronounced rise in blood glucose and insulin levels, and have proven benefits for health.”

Breakfast: Sanitarium UP&GO™ Choc Ice Flavour GI 38

MT: Chocolate cake made from packet mix with chocolate frosting (Betty Crocker) GI 38

Lunch: Instant two-minute noodles, Maggi (Nestlé, Australia) GI 46

AT: Apple muffin, made with sugar GI 44

Evening meal: Pizza, Super Supreme, pan (Pizza Hut, Sydney, Australia) 

GI 36

Supper: Corn chips GI 42

If you have a niggling doubt that eating these low GI foods would achieve the benefits claimed by advocates of GI, I hope I can convince you that your intuition is right.

Brand-Miller and colleagues claim that the GI is ” ….a property of a food…” and that “People have glycemic responses; foods have GI values.“ In other words, the GI people appear to have somehow concluded that their method for determining the GI of foods is able to eliminate individual variables of the test subjects such as health status, physiology, digestion, age, genetics, fitness level etc., leaving a “property of a food” that determines the extent to which blood glucose levels will be raised after eating. Ummm …….. really?

In addition, they appear to believe that the resulting GI ranking for every food that they have tested, on …… wait for it ……. approximately TEN people, can be a guide to making what they consider “healthier” food choices for everyone? Around 7,000,000,000 of us?  

Not only have many scientists rightly questioned this lunacy but also plain common sense can be a good guide in assessing the validity of the concept. Just think for a moment how likely it is that a healthy, lean 20 year old athlete and a 70 year old sedentary person with insulin resistance and type 2 diabetes would both have a similar “smaller” fluctuation in blood glucose and insulin levels after eating a ‘low GI’ Snickers Bar containing 36 gm carbohydrate, equivalent to approximately 9 teaspoons of sugar?

Or that having a teaspoon of low GI sugar in a cup of tea will result “…in a slower release of energy, which can help curb hunger cravings.” ? (More on that later)

Putting common sense aside: what about the science?

If the GI of a food was really a property of a food, it would follow that individual GIs for a food would be the same, or at the very least fairly consistent, between people.

However, as Maryanne Demasi reports, one group of researchers testing the GI of bread using the established testing protocol, found a huge span of individual GI values from 63 people, ranging from 35 to 103. The “official” GI of a food is determined by averaging the individual results from approximately 8-10 people.  Based on the results above, the GI of this particular bread could be low, medium or high depending entirely on which 10 peoples’ results were used.

These results contradict the assertion that the GI is ” a property of a food”. And averaging the results from 10, 100 or 1000 people will still not give a figure that will be meaningful to one individual, let alone 7.5 billion.

Brand-Miller and colleagues saw a comparable degree of variation for themselves in their 2003 study testing the reproducibility of GI values for foods.  

According to Dr Richard Feinman,  Professor of Cell Biology (Biochemistry) at the State University of New York Downstate Medical Center, Brooklyn NY, “The GI values reported in the Brand-Miller paper are so widely distributed that the conclusion must be that there is nothing at all to the glycemic index.”

“We all thought the GI values that are in published literature must reflect a high degree of consistency between individuals for there to be anything of value to the GI.

It turns out from this paper by supporters of glycemic index that this is not true at all. This seems a scandal — really beyond self-delusion.”

“If my lab had made the measurements reported by Brand-Miller in 2003 we would have concluded that they provided strong evidence against the concept of glycemic index. We would never publish something like this claiming it was of scientific value.”

 “The problem with glycemic index is that it is completely meaningless — not measurement error here, limited accuracy there — but completely wrong.”

An excellent critique of GI and Brand-Miller’s et al’s 2003 paper by Dr Jon W. DeVries concludes: “The inability of the GI method to differentiate between foods on eating occasions leads to the conclusion that the food itself is a minor contributor to a given GI measurement, and therefore the GI method does not measure a meaningful property of a food.“

Jennie Brand Miller on GI controversies

On page 1, the Chair stated that Diabetes Australia recommends that people with diabetes follow the “Australian Dietary Guidelines” and that the guidelines do not mention GI at all.  Brand-Miller answered that other countries mention the GI of foods and that it provides a benefit beyond looking at carbohydrate alone. She was then asked to explain why this controversy exists.

As reported by Maryanne Demasi, “Despite Prof Brand-Miller’s defence of GI, official guidelines do not endorse low GI diets.

“For example, Health Canada has stated that “the inclusion of the GI value on the label of eligible food products would be misleading and would not add value to nutrition labelling and dietary guidelines in assisting consumers to make healthier food choices.”

“In response to the question of whether low GI foods are healthier, UK’s National Health Service (NHS) states “using the glycaemic index to decide whether foods or combinations of foods are healthy can be misleading”.

“Closer to home, our National Health and Medical Research Council (NHMRC) dietary guideline’s committee, also does not officially endorse the low GI diet. And despite the GI Foundation lobbying the NHMRC to change its mind, the response was a direct one;

“The Committee agreed that there was insufficient significant evidence to support change. It was noted that this is a physiologically based classification, with large variability and several limitations.”

GI controversies part 2.

Further to the “GI controversy” question, Brand-Miller answered that there are a lot of opinions, often polarised, in nutrition. 

This is definitely true in regards to the GI concept and here are just a few examples from scientists not involved in the GI industry.


1. “Long-term weight changes were not significantly different between the HGI and LGI diet groups; therefore, this study does not support a benefit of an LGI diet for weight control.”

2.“Thus, the new information in the present study is that composing a DASH-type diet with low–glycemic index foods compared with high–glycemic index foods does not improve CVD risk factors and may in fact reduce insulin sensitivity and increase LDL cholesterol.”

3. “. Lowering the glycemic index of high carbohydrate, low fat diets …….. in subjects with type 2 diabetes with low glucose tolerance …….has little effect on glycemic control.”

4.“In conclusion, dietary GI and GL were not associated with diabetes risk and substitutions of lower GI carbohydrates for higher GI carbohydrates were not consistently associated with lower diabetes risk.”

5. “In summary, our data indicate substantial variability in G.I. value determinations …….. thus invalidating the practical applicability of the GI value.” and that GI “is unlikely to be a good approach to guiding food choices.” 

Controversy or consensus?

You would never know there was controversy about GI if you relied on the conclusions of a recently published paper: 

Glycemic index, glycemic load and glycemic response: An International Scientific Consensus Summit from the International Carbohydrate Quality Consortium (ICQC) published in 2015

The outcome of the summit was a “scientific consensus statement” which recognized “the importance of postprandial glycemia in overall health, and the GI as a valid and reproducible method of classifying carbohydrate foods for this purpose. There was consensus that diets low in GI and GL were relevant to the prevention and management of diabetes and coronary heart disease, and probably obesity.” 

Furthermore, members of the Summit recommended that:

“Given the high prevalence of diabetes and pre-diabetes worldwide and the consistency of the scientific evidence reviewed, the expert panel confirmed an urgent need to communicate information on GI and GL to the general public and health professionals, through channels such as national dietary guidelines, food composition tables and food labels.”

“Consensus Summit” participants

The affiliations of some of the participants at the “consensus summit” are as follows:

1. Alan Barclay 
Former CEO and consultant to the Glycemic Index Foundation, an organization whose stated aims are to promote public awareness of both the Glycaemic Index and the GI Symbol. The Foundation receives payment via licence fees from food companies to display the GI symbol on packaging. In the 2017 financial year the GI Foundation received $576,686 (tax free) in licence fees.
Barclay is also a co-author of books about the glycaemic index of foods.

2. Jennie Brand-Miller, also known as GI Jennie

President of the Glycemic Index Foundation. She leads the International Glycemic Index (GI) Database and website at the University of Sydney, where she also manages a glycemic index testing service. She is the author or co-author of over 30 books about the glycaemic index (her books have sold over 3.5 million copies since 1996) for which she receives royalties.

3. Furio Brighenti 
Affiliated to a department of the University of Parma that does Glycemic Index analysis as a service to third parties.

4. David Jenkins 
One of the pioneers of the GI and married to the president of the Glycemic Index Laboratories, Toronto.

5. Alexandra Jenkins
 David Jenkins’ wife and president of the Glycemic Index Laboratories, Toronto, Ontario, Canada, a private testing lab for GI value of foods.

6. Thomas Wolever

He reports to be part owner and receives payment as the President and Medical Director of Glycemic Index Laboratories, Inc. (GI Labs, a contract research organization) and Glycaemic Index Testing, Inc. (GI Testing, which supplies services to GI Labs) Toronto, Canada. He has authored or co-authored several books on the glycemic index for which has received royalties from Philippa Sandall Publishing Services and CABI Publishers. 

7. John L Sievenpiper

He reports to have received travel funding, speaker fees, and/or honoraria from International Life Sciences Institute (ILSI) North America, International Life Sciences Institute (ILSI) Brazil, and The Coca-Cola Company. He is an unpaid scientific advisor for the International Life Sciences Institute (ILSI) North America, Food, Nutrition, and Safety Program (FNSP).


The following acknowledgment is near the end of the paper: “The Glycemic Index, Glycemic Load and Glycemic Response: an International Scientific Consensus Summit” was supported by: ………. Glycemic Index Foundation, Glycemic Index Laboratories, Kellogg Europe, SUGiRS (Sydney University Glycemic Index Research Service), Enervit, Meal Garden.


There are many scientists who have questioned the utility of the GI who didn’t attend the “International Scientific Consensus Summit“. I wonder how many, or even if any, were invited? On the plus side, it may have been quicker to reach consensuses on so many topics supporting the GI without them there.

The Australian Paradox

No examination of the GI business would be complete without mention of the “Australian Paradox”, a name coined by Brand-Miller and Barclay in 2011:

The Australian paradox: a substantial decline in sugars intake over the same timeframe that overweight and obesity have increased.Nutrients. 2011 Apr;3(4):491-504. Barclay AW1, Brand-Miller J.

In this paper Brand-Miller and Alan Barclay assert that there was a “consistent and substantial decline” in the per-capita consumption of added sugar and sugary soft drinks by Australians between 1980 and 2010, in the timeframe that obesity ballooned. Their claim was that there exists “an inverse relationship” between added sugar consumption and obesity and went so far as to propose that a literal interpretation of this association suggests that reductions in sugar intake may have contributed to the rise in obesity.

As far as I know, they haven’t elaborated on this as yet.

Economist Rory Robertson has pointed out some flaws in this study, one being that the authors appear to have misread their own graphs.

As Robertson reports, the authors’ “finding” of a decline in sugar consumption by Australians over 30 years is contradicted by their own charts ie “…four of the authors’ own published charts – each showing a valid if imperfect indicator of per-capita sugar consumption – trend up not down in the 1980-2010 timeframe.”

Referring to the Brand-Miller and Barclay paper, Robertson says:

“The bottom line is that there is no “Australian Paradox”, just an idiosyncratic and unreasonable assessment – and avoidance – of the available sugar data by those who coined the term. Dr Barclay and Professor Brand Miller’s conclusion obviously was a big winner for the low-GI industry while others took it seriously, yet it stands contradicted by the underlying facts of the matter.”

The food industry and GI: Low-GI sugar

The following is an example of the development, testing and marketing of a low GI sugar ie CSR® LoGiCane™ Sugar, developed by spraying a molasses extract onto raw sugar.

The Sydney University Glycemic Index Research Service (called SUGiRS on their website), for which Brand-Miller is the principal researcher, tested* it. The GI Foundation certified the product, allowing the GI symbol to be displayed on the packaging.

*Note: the number of test subjects is not reported as is usually the case but they are encouragingly described as “normal”.

CSR advertises its product in this way: “By having a low GI, CSR LoGiCane® takes longer to be digested, resulting in a slower release of energy, which can help curb hunger cravings.”

The PR company in charge of launching this product was aware of certain challenges they faced. They stated, “in a media environment focused on highlighting the nation’s increasing rate of obesity“, various experts were “unlikely to support a ‘healthier alternative’ sugar”. As they said, “…the launch required a strategic PR campaign for its success“.

The campaign included Brand-Miller’s support of the launch and collaboration with the Dietitians Association of Australia, for which Barclay has been a spokesperson since 2004, to develop and distribute material to over 3,000 members. End result was that the PR company surpassed targets and won an award.

It may be obvious that I’m not a fan of GI but it goes much further. I’m furious that people who are looking for help to prevent the ravages of diabetes may trust what advocates of the GI advise and choose to use the GI as the basis for their diet choices. And when it doesn’t work, they may give up looking for a diet approach that could be of real benefit.

Substantial evidence supports reducing carbohydrate intake as the first choice in diabetes management.

But from this GI Foundation Position Statement written by Brand-Miller, it seems that she may not agree:

“Low carbohydrate diets have little to offer – they may actually increase the risk of chronic disease.”

And so her advice is to choose low GI options instead.

Fruity Quinoa Porridge, with 54 g carbohydrate per serve (equivalent to approximately 13 teaspoons of sugar) as a breakfast choice to help manage blood sugar levels anyone?

GI is unfortunately not a joke. Laughable maybe but certainly not funny.

For information on managing type 2 diabetes with a low carb approach visit:

http://www.babyboomersandbellies.com

https://www.eattobeatdiabetes.com.au

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

Evidence based Nutrition Therapy: who decides?

Jennifer / / Nutrition

Did low carb (or I) stand a chance?

In July 2014 a complaint was made by a dietitian concerning my recommendation of low carbohydrate diets in diabetes management.

This complaint was lodged with my workplaces and forwarded to the DAA office. Specifically it was in regards to what the dietitian considered “..the use of non-evidence based Medical Nutrition Therapy”, in particular the recommendation of “…….very low carbohydrate diets for the treatment of metabolic syndrome, pre-diabetes and obesity.”

Before I get to the nitty gritty of the complaint process and outcome in my next blog, I’d like to explore the question of who actually decides the evidence for Evidence Based Medical Nutrition Therapy, at least in Australia.

Setting the scene

Presently, and for some years, the DAA has had control of the dietetic curriculum at universities, which may help explain why the Australian Dietary Guidelines are still taught even though they do not reflect current science; step out of line and the DAA can suspend accreditation. Which apparently it has done.

A strong evidence base in the teaching of nutrition and dietetics will be a welcome change if and when it happens. A good start may be putting the curriculum in the hands of universities rather than with an organisation that hasn’t moved on much from the ideas expressed in its little pamphlet, “Stop and Think before you Eat and Drink” from the 1970s. Back then the DAA recommended to “Increase your intake of …..breads and cereals” and for 40 years the organisation continued to stick to their “carbs are good” position.

Evidence for this comes from the DAA’s website over the last few years, including the years 2014-2015 when the DAA was investigating the complaint against me that my recommendation of low carb diets for diabetes was not evidence based. Here are some examples of the DAA’s recent views on a variety of topics, downloaded from the DAA website around 2015.

DAA’s views on carbohydrate:

“Carbohydrate is an important nutrient found in many foods.

Carbohydrate is an important source of energy for the body. Try to eat carbohydrate-containing foods in every meal to provide the body with energy throughout the day.”

 

 

DAA’s Smart eating ideas for brekkie:

“A bowl of whole grain cereal with reduced-fat milk and sliced fresh fruit

English muffins or crumpets with some reduced-fat cheese, baked beans or avocado

Untoasted muesli or rolled oats”

DAA’s opinion: Are carbohydrates fattening?

“Foods rich in carbohydrate are an important part of a healthy diet – they’re a source of energy for our body, and fuel for our brain. Many people fear that eating carbohydrate-rich foods will make them gain weight, but if you’re choosing smart*, high quality carbohydrate foods in the right amounts, there’s no need to worry about weight gain.”

*I wonder what the DAA considers a “smart” carbohydrate food?

DAA’s Healthy eating tips for insulin resistance:

“Eat wholegrain foods everyday such as high fibre breakfast cereals, multigrain bread, oats, barley and cracked wheat.”

DAA’s views on carbohydrate and diabetes:

“Foods containing carbohydrate include bread, rice, pasta, noodles, breakfast cereal, potato, corn, legumes, fruit, milk and yoghurt. It is important to include some of these foods with each meal.”

DAA’s views on low carb/ high fat diets for diabetes:

“An argument for the use of the diet can potentially be supported by ‘established principles in biochemistry and physiology’3, however long-term randomised controlled trials with consistent dietary methodology are lacking.

Therefore, this diet type remains controversial – and DAA believes more research is required on the safety and efficacy of such as diet, in people with diabetes and the general population.”

I sought Professor Feinman’s* response to the DAA’s comments on his paper (3) quoted above.

* Richard David Feinman is Professor of Cell Biology (Biochemistry) at the State University of New York (SUNY) Downstate Medical Center  in Brooklyn

Professor Feinman: “It appears that the DAA has superficially read my article and flippantly chosen to dismiss it. As the article pointed out, “the benefits of carbohydrate restriction in diabetes are immediate and well documented. Concerns about the efficacy and safety are long term and conjectural rather than data driven. Dietary carbohydrate restriction reliably reduces high blood glucose, does not require weight loss (although is still best for weight loss), and leads to the reduction or elimination of medication.”

As far as I know there are more studies, including RCT’s, of low-carb diets than any other, and they did well. The constant harping of health organizations that there are insufficient trials is what was called in one of the countries in Gulliver’s Travels “that which is not” because their language did not have a word for lying.

And the continued emphasis on method rather than content is without precedent in science. The seriousness of diabetes requires that we evaluate all of the evidence that is available.

And seriously, what qualifies the DAA, a member organisation for dietitians in Australia, to say that “this diet type remains controversial”.  Former DAA CEO Claire Hewat declined my offer to discuss the science of carbohydrate restriction when in the process of deregistering Jennifer Elliott for using such an approach with her diabetic clients.”

Not only did the DAA support the regular eating of carbohydrate foods generally, it also displayed an unfathomable opposition to the hosting of a conference on low carb nutrition at the University of Sydney in 2014.

The DAA’s CEO Claire Hewat was involved in this infamous episode when she wrote to the University of Sydney voicing the DAA’s opposition to a low carb conference being held in the university grounds.

The response was that Sydney University supported academic freedom, the conference went ahead and researchers and academics working in the area of carbohydrate restriction were able to present their research despite the DAA’s efforts.

Who knows why the DAA would oppose the hosting of a scientific conference on the benefits of carbohydrate restriction with world renowned experts sharing their knowledge?

And why the DAA, which over the years has received thousands of dollars from it’s partnerships with companies such as Nestle, Arnotts and the Australian Breakfast Cereal Forum, has supported the regular eating of carbohydrate foods for all sorts of conditions, including those of carbohydrate intolerance?

There have been suggestions that the DAA is in bed with Big Food and critics who say that the DAA is little more than a front for the food industry. Journalist Marika Sboros explores these accusations in her excellent article IS DOWN UNDER’S DAA REALLY IN BED WITH BIG FOOD? and encourages people to make up their own minds.

 

Pick the odd one out

A possible example of the DAA’s seeming ambivalence to low carb diets in diabetes management can be found in the DAA’s submission to the Royal Australian College of General Practitioners for their publication “General Practice Management of Type 2 Diabetes”, in April 2016.

 

In the Dietary section of the RACGP document the DAA made 5 recommendations, referencing the 2014 American Diabetes Association publication “Nutrition Therapy Recommendations for the Management of Adults With Diabetes” as the source.

There is an obvious exception. See if you can pick it.

Here is a comparison of the recommendations between the two organisations.

1 (a) ADA: The recommendation for the general public to eat fish (particularly fatty fish) at least two times (two servings) per week is also appropriate for people with diabetes.

(b) DAA: Consumption of oily fish at least twice a week is recommended for the general public.

2 (a) ADA: Individuals who have diabetes should receive individualized MNT as needed to achieve treatment goals,

(b) DAA: People with diabetes should receive individualised medical nutrition therapy to achieve treatment goals

3 (a) ADA: For overweight or obese adults with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss.

(b) DAA: For overweight or obese adults with Type 2 Diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss.

4 (a) ADA: The amount of carbohydrates and available insulin may be the most important factor influencing glycemic response after eating …

(b) DAA: The amount of carbohydrate eaten and the available insulin may be the most important factor that influences the glycaemic response after eating.

5 (a) ADA: Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes.

(b) DAA: Evidence does not support a particular macronutrient composition to improve glycaemic control.

So far the DAA is mirroring the ADA, which is no surprise since the DAA made it clear some years ago that they don’t do the work themselves but that the “….recommendations of the DAA Practice Guidelines are based on the US Practice Guidelines due to their rigorous development process and also their transferability to the Australian setting.” ref

But maybe only when it suits them?

6 (a) ADA:

“Multiple …… eating patterns can be effective for achieving metabolic goals.”

Eating patterns for achieving metabolic goals include:

  1. Mediterranean style
  2. Vegetarian or Vegan
  3. DASH (Dietary Approaches to Stop Hypertension)/ Low fat diet
  4. Low carbohydrate

 

(b) DAA: Alternative dietary patterns that improve glycaemic control include:

  1. Mediterranean-style dietary pattern
  2. Vegan or vegetarian dietary pattern
  3. Incorporation of dietary pulses (e.g. beans, peas, chick peas, lentils)
  4. Dietary Approaches to Stop Hypertension (DASH) dietary pattern

 

As can be seen, the DAA’s recommendations to the RACGP are pretty much copied from the ADA guidelines, but there is one very obvious omission.

It appears that the DAA do not want Australian GPs to think that Low Carbohydrate diets are one of the “Alternative dietary patterns that improve glycaemic control” as the ADA recommend.

This is despite the ADA going into some detail about the research supporting low carb diets.
“Some published studies comparing lower levels of carbohydrate intake (ranging from 21 g daily up to 40% of daily energy intake) to higher carbohydrate intake levels indicated improved markers of glycemic control and insulin sensitivity with lower carbohydrate intakes (92,100,107–111).

“Some studies comparing lower levels of carbohydrate intake to higher carbohydrate intake levels revealed improvements in serum lipid/lipoprotein measures, including improved triglycerides, VLDL triglyceride, and VLDL cholesterol, total cholesterol, and HDL cholesterol levels (71,92,100,107,109,111,112,115)”

A surprising detour from the ADA guidelines by the DAA? Or not really?

In their submission to the RACGP, the DAA also showed their support for the inclusion of sugar in diabetic diets, and wanted to pass on this “wisdom” to GPs.

On page 8 of their submission, the DAA says: “All sugars do not need to be eliminated. A small amount of added sugar, as part of a mixed meal or food (e.g. 1 teaspoon of sugar/honey added to breakfast cereal), will not adversely affect blood glucose levels.”

I guess when a person with diabetes eats a breakfast along DAA’s guidelines e.g. a bowl of whole grain cereal with reduced-fat milk and fresh fruit, what’s an extra teaspoon of sugar added to the approximately 10 tsp of sugar that will come from the carbohydrates* in their their cereal bowl?

* During digestion, carbohydrates in foods such as cereal, milk and fruit are broken down to sugars, predominantly glucose, which is then absorbed into the blood. Amounts of sugar in the DAA recommended breakfast are: 1 cup of whole grain/high fibre cereal approx. 4 tsp sugar; 1 cup low-fat milk approx. 2 tsp sugar; a small banana approx. 4 tsp sugar.

More details and examples at Eat to Beat Diabetes

Who decides the evidence?

Back to my case. Two different dietitians were enlisted by my workplaces to investigate whether low carb diets are evidence based . The DAA under the leadership of CEO Claire Hewat ran its own investigation.

The DAA has not disclosed the names nor occupations of the people who were on the panel deciding whether or not low carb diets were evidence based, but the DAA board, made up primarily of DAA registered dietitians, had the final say.

At one workplace, one investigator was a DAA registered dietitan and at the second workplace, the investigator was not only a DAA registered dietitian, but also a DAA Board Member at the time.

During the process, Professor Richard Feinman wrote to the DAA CEO Claire Hewat and suggested “…….a discussion, perhaps an online webinar, in which all sides present their case. I and/or my colleagues would be glad to participate.  I have made the point that, analogous to a court of law, evidence must be subject to evaluation of its admissibility. You can’t simply judge the value of your own evidence. I think a real give-and-take would provide both practitioners and patients a chance to truly evaluate the evidence. In this, Ms. Elliott may have given us an opportunity.”

CEO Claire Hewat replied “DAA is interested in and carefully assesses all relevant evidence nor is DAA afraid of debate but this is not the place for it.”

So in answer to the question, “Evidence based Nutrition Therapy: who decides?”, it looks like in Australia it might be the DAA.

Next post: The complaint. The answer. The Verdict.