Evidence based Nutrition Therapy: who decides?

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.