nr fad diet feedback

7/24/2019 NR Fad Diet Feedback

1/3

The use of the word fad to describe therapeuticdiets, some with long histories of clinical

usefulness, which enjoy popularity beyond themedical community, is lazy and misleading. Thisreview, despite its commendable focus on real,

unprocessed food, contained factual errors withregard to low-carbohydrate, high-fat diets, as wellas Paleo and sugar-free diets.

We have summarised only major errors* forcomment. The most important correction* for thereadership of Nursing Review, is that restrictingdietary carbohydrate is an effective option fordiabetics.

Myth: Low-carbohydrate, high-fat diets, Paleo,or sugar-free diets can cause hypoglycaemia and

ketoacidosis in diabetics

Diabetes medication dosage usually needs to beadjusted downwards on low-carbohydrate diets.However, there are clear advantages to reducingmedication when high doses are not needed and

stopping it when no longer required.When blood glucose falls on a ketogenic

diet, ketone bodies provide the brain with an

alternative fuel source, decreasing the risk ofsymptomatic hypoglycaemic episodes. A typicalresult is a reduction of hypoglycaemic events by

80 per cent. Thus diets in which carbohydrateis sufficiently restricted allow better control of

Fad diets

article feedbackT

he last edition of Nursing Reviewcontained anarticle called Fad diets: what do dietitians sayabout the latest crop? that looked at some ofthe latest dietary trends; in particular, the Paleo

diet, the 5:2 intermittent fasting diet, the no-sugar

approach and the low-carb, high-fat (LCHF) approach.

The article gave a brief summary of each diets key

focus (a number of variations exist for three of the four

diets) and asked a Diabetes NZ dietitian and Heart

Foundation nutrition spokesperson for what they

consider to be the pluses and minuses of these diets

for people with long-term conditions.

The article gave a thumbs-up to the recent shift in

dietary trends away from processed foods towards

cooking whole food from scratch, expressed caution

about a number of them for people with diabetes

and had a general focus on eating a moderate,

balanced diet. The article can be viewed at

http://bit.ly/1DYABOf.

Amongst the responses positive, mixed and

negative was that of Professor Grant Schofield of

AUT, co-author of What the Fat? Fats in, Sugars

Out. Schofield is a professor of Public Health for

AUT, director of AUTs Human Potential Centre, the

OPINION ONE: Grant Schofield et al.

REFERENCES1. Feinman R, Pogozelski W, Astrup A et al. (2015). Dietary carbohydrate restriction as the first

approach in diabetes management: Critical review and evidence base. Nutrition31:1-13

http://dx.doi.org/10.1016/j.nut.2014.06.011

2. FDA Drug Safety Communication: FDA warns that SGLT2 inhibitors for diabetes may result in a

serious condition of too much acid in the blood. Retrieved 15 July 2015 from

www.fda.gov/Drugs/DrugSafety/ucm446845.htm

3. Nordmann A J, Nordmann A, Briel M et al. (2006). Effects of Low-Carbohydrate vs Low-Fat Diets

on Weight Loss and Cardiovascular Risk Factors: A Meta-analysis of Randomised Controlled Trials.

Archives of Internal Medicine.166(3):285-293. doi:10.1001/archinte.166.3.285.

4. Jakobsen M, OReilly E, Heitmann B et al. (2009). Major types of dietary fat and risk of coronary

heart disease: a pooled analysis of 11 cohort studies.American Journal of Clinical Nutrition

89:1425-32. doi: 10.3945/ajcn.2008.27124.

This opinion piece has been published as submitted. Publication means that

Nursing Reviewis open to publishing counterviews on the issues raised and does not

denote agreement that the original article contained errors.

The original article did not say LCHF cut out fruit it noted that some versions of the

diet included people being encouraged to reduce or cut out their fruit intake.

It also did not say that not eating grains was a danger but rather said that wholegrains have been shown to protect against heart disease. The founder of the Paleo

diet concept, Loren Cordain, excludes potatoes, legumes and dairy products. The

article noted that a number of variations of the Paleo diet exist, including some

involving three non-Paleo meals a week.

Nursing Reviewseries201530

OPINION

Practice, People & Policy

blood glucose, often including sustained normalglucose and HbA1c readings in type 1 diabetes,and remission or reversal of diabetes altogetherin type 2 diabetes. A 2015 review authored by25 diabetes experts outlines 12 robust reasonswhy low-carbohydrate diets should be the firstoption for diabetes treatment1.

Drugs that can be reduced or stopped include

GSLT2 inhibitors, which have been shownto cause diabetic ketoacidosis in America2.Conversely low-carbohydrate diets have neverbeen shown to cause ketoacidosis.

The use of small amounts of glucoseto correct hypoglycaemia caused by theunpredictability of insulin dosing still formspart of managing type 1 diabetes, even on alow-carbohydrate diet. This does not mean thatthere is a requirement for sugar in the diet.

Myths: Low-carbohydrate, high-fat dietscut out fruit; Paleo diets eliminate starchyvegetables; not eating grains is a dangerto health.Fruits are not removed on low-carbohydrate diets, rather high-sugar fruits arelimited; the degree of restriction depending onan individuals level of insulin resistance. Paleodiets do not eliminate starchy vegetables, andmay allow some dairy products or legumes.Grain avoidance is more than compensated for

nutritionally by increased consumption of nuts,seeds, fish and vegetables.

Myth: People will get half the message.Randomised controlled trials of various dietregimes show low-carbohydrate, high-fat eatingis superior in short and medium-term weight lossin free living populations and has reasonableadherence, superior to the low-fat approach,

showing that consumers can understandand implement this diet effectively when it iscommunicated clearly3.

Myth: Saturated fat causes heart disease.Replacing saturated fat with carbohydrate doesnot reduce the risk of heart disease, and mayincrease it. Polyunsaturated fats found in fattyfoods are associated with a lower risk of heartdisease, whether they replace carbohydrate orsaturated fats4. This evidence does not suggestthat saturated fats are harmful in the context ofdiets in which fat replaces carbohydrate.

Authors: Professor Grant Schofield, AUT;Dr Caryn Zinn, registered dietitian and senior

lecturer AUT (co-author of What the Fat? Fatsin, Sugars out); and George Henderson, AUTresearch officer.

Editors note:

countrys leading advocate for the LCHF approach,and has a background in psychology.

Nursing Reviewoffered Schofield andcolleagues an opportunity to write an opinionpiece in response to the Fad diets article. NursingReviewalso offered the opportunity to the HeartFoundation, Diabetes NZ and the convenor ofDietitians NZs Diabetes Special Interest Group toreview and respond to Schofield et al. The resultingfour pieces are published here.


2/3

It is great to see the Fad diets: what do

dietitians say about the latest crop? article in

Nursing Reviewhas been widely distributed,stimulating much interest and debate. After all,

it is encouraging to see that so many Kiwis are

interested in what they should be eating. Given

how divided the current nutrition landscape is, it

is no surprise the article has been greeted with

hostility by various commentators, even though

it noted many positive elements about the diets

being discussed.

As we stated in the article, if elements of a

new diet (e.g. no-sugar, low-carbohydrate/high-

fat (LCHF) or Paleo) help to kick-start, or move

someone towards a healthier eating pattern

then that is positive. However, we maintain

that people do not need to resort to extremes

to achieve a cardio-protective dietary pattern.We recommend an approach that works for the

individual, is sustainable, and is based on foods

shown by the best evidence to reduce the risk of

heart disease.

Dietary patterns that support heart health

reflect a range of fat, carbohydrate and protein

REFERENCES1. Heart Foundation. Dietary patterns and the heart position paper (2014). www.heartfoundation.org.nz/

uploads/Dietary_patterns_position_statement_2014.pdf. Accessed 24 July 2015.

2. Jakobsen M, OReilly E, Heitmann B et al. (2009). Major types of dietary fat and risk of coronary heart

disease: a pooled analysis of 11 cohort studies.American Journal of Clinical Nutrition89:1425-32.

doi: 10.3945/ajcn.2008.27124.

3. Mozaffarian D, Micha R, Wallace S (2010). Effects on coronary heart disease of increasingpolyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomised

controlled trials. PLOS Medicine7(3):e1000252.

Diabetes NZ offers support and information

to help people take charge of their health and

live well with their diabetes. We do not provide

clinical advice we complement the services

of other healthcare providers. The dietary

information we give is in keeping with national

and international diabetes dietary guidelines.Lower carbohydrate diets:People

with diabetes currently using insulin or

sulphonylurea medication who choose to

reduce the carbohydrate in their diets will

need advice and guidance from diabetes

specialists. This support will help them with

carbohydrate counting and medication

dose reduction/withdrawal while adapting

from their previous eating pattern. Without

adequate advice and guidance, the risk of

hypoglycaemia is high.

REFERENCES

1. Coppell K, Kataoka M, Williams S et al. (2010). Nutritional intervention in patients with type 2diabetes who are hyperglycaemic despite optimised drug treatment Lifestyle Over and Above

Drugs in Diabetes (LOADD) study: randomised cont rolled trial, British Medical Journal341 doi:

http://dx.doi.org/10.1136/bmj.c3337

2. Joint WHO/FAO Expert Consultation (2003). WHO Technical Report Series 916 Diet, Nutrition,

and the Prevention of Chronic Diseases. Geneva.

31Nursing Reviewseries2015

OPINION


3. Moynihan P and Petersen P (2004). Diet, nutrition and the prevention of dental diseases,Public Health Nutrition: 7(1A), 201-226.

Saturated fat:Diabetes NZ affirms its viewthat people with diabetes should not have a diethigh in saturated fat. Saturated fat has beenshown to have a negative impact on heart healthand people with diabetes have a well-recognisedincreased risk of cardiovascular disease. A 2010

study by Otago University researchers found thatpatients with type 2 diabetes benefited from areduction in saturated fat as part of a sensiblemoderate eating pattern1. These benefitsincluded reductions in HbA1c, weight, andBMI, and some people reduced their diabetesmedicine dose.

No-sugar diets:While popular versionsof these diets discourage the use of sucrose(table sugar), other sugars such as glucose anddextrose are commonly used in recipes. Thesesugars are unsuitable for people with diabetes.

Diabetes NZs overall message is for people withdiabetes to reduce their intake of free sugar inall forms. Free sugar is defined by the WorldHealth Organisation and the UN Food andAgriculture Organisation in multiple reports asall monosaccharides and disaccharides added

to foods by the manufacturer, cook, or consumer,plus sugars naturally present in honey, syrups,and fruit juices2,3. It is used to distinguishbetween the sugars that are naturally presentin fully unrefined carbohydrates such as brownrice, whole wheat pasta, fruit, etc. and thosesugars (or carbohydrates) that have been, tosome extent, refined (normally by humans butsometimes by animals, such as the free sugarspresent in honey).

Author:Submitted on behalf of Diabetes NZ.

OPINION THREE: Diabetes NZ

4. Pereira M, OReilly E, Augustsson K et al. (2004). Dietary fibre and risk of coronary heart disease: a

pooled analysis of cohort studies. Arch Intern Med 2004; 164:370-76.

5. Stratton I, Alder A, Neil H et al. and the UK Prospective Diabetes Study Group (2000). Association

of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35):

prospective observational study. British Medical Journal321:405-12.

intakes but share common features. These

features include: fewer processed foods; plenty

of vegetables and fruit; other plant foods such aslegumes, intact whole grains, nuts, and healthy

plant oils; and usually some fish, poultry, lean

meats and reduced-fat dairy1.

Comments relating to the specific points

raised by Schofield et al. follow:

Reducing saturated fat intakes will lower

the risk of heart disease:Our comments in the

previous article refer to reduction in saturated

fat in general, and in fact highlight that a higher

total fat intake is acceptable. Evidence shows a

reduced risk of heart disease when saturated fat

is replaced with polyunsaturated fat2,3. However,

replacing saturated fat with slowly digested,

high-fibre, less-refined carbohydrate foods will

also provide a reduced risk4,5. The key is the typeof carbohydrate. Replacing saturated fats with

highly refined, sugary, carbohydrate-rich foods

will offer little benefit.

People will get half the message:Advocates

of the LCHF approach have recently promoted

cream, butter, and bacon (a heavily processed

meat) through major media stories. Sadly, thepromotion of healthy cardio-protective fats from

foods like nuts, seeds and plant oils, and the fatmessage in the context of healthy dietary pattern,has been missing from some of these stories.

Confusingly, during a presentation at the2014 Dietitians NZ National Meeting, thosesame LCHF advocates highlighted that cream,butter, and bacon were notkey fats as part ofthe LCHF way of eating, whereas the previouslymentioned cardio-protective fats were. Therefore,we believe the current LCHF messages beingdelivered to health professionals and the generalpopulation are incomplete, inconsistent and maylead to people making poor dietary choices.

In summary, we continue to emphasise thatthe quality of carbohydrate and fat in the diet

is key. People need to choose an eating patternthat works for them, and that is based on foodsthat the best available evidence shows reducesthe risk of heart disease and diabetes.

Author:Dave Monro is a dietitian and thenutrition spokesman for the Heart Foundation.

OPINION TWO: Heart Foundation


3/3

Nutritional science is constantly evolving and one

of the key dietary trends that consistently provesits worth in terms of diabetes and cardiovascular

outcomes is the Mediterranean style of

eating1,2,3. This type of diet includes plenty ofvegetables, fruits, legumes, wholegrain cereals,

plus moderate amounts of heart healthy fats and

lean protein. These principles have been widely

incorporated into dietary recommendationsfor the prevention and management of type 2

diabetes around the world4,5.

In New Zealand, we have our very ownNine Steps for Heart Healthy Eating developedby the Heart Foundation6and featured in theMinistry of Health Primary Care Handbook forcardiovascular disease screening and type 2diabetes management7. I have used the 9 Stepswith a number of people with type 2 diabeteswho have gone on to achieve a healthy weightrange (BMI 20-25 kg/m2) and a few have evencome off their diabetes medications altogether.Others may have stayed on tablets or insulin butare feeling confident that they can stick with their

new food plan because it includes a variety ofaffordable foods they can buy locally.

REFERENCES1. The PREDIMED Study http://predimed.onmedic.net/eng/Home/tabid/357/Default.aspx

accessed 15 Aug 2015.

2. De Logeril M, Salen P, Martin J et al. (1999). Mediterranean diet, traditional risk factors, and the rate

of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study.

Circulation99: 779-85.

3. Esposito K, Maiorina M, Ceriello A, Giugliano D (2010). Prevention and control of type 2 diabetes by

Mediterranean diet: a systematic review. Diabetes Research and Clinical Practice89: 97-102.

4. Dyson P, Kelly T, Deakin T et al. (2011). Diabetes UK evidence-based nutrition guidelines for the

prevention and management of diabetes. Diabetic Medicine28: 1282-8.

5. Evert A, Boucher J, Cypress M et al. (2014). Nutrition therapy recommendations for the management

of adults with diabetes. Diabetes Care37: S120-S143.

6. The Heart Foundation www.heartfoundation.org.nz.

7. New Zealand Guidelines Group (2012). New Zealand Primary Care Handbook2012 (3rd Edition).

Wellington: Ministry of Health.

8. World Health Organisation (2015). Guideline: Sugars intake for adults and children. Geneva.

Nursing Reviewseries201532

OPINION


9. Wolpert H, Atakov-Castillo A, Smith S, Steil G (2013). Dietary fat acutely increases glucose

concentrations and insulin requirements in patients with type 1 diabetes: implications for

carbohydrate-based bolus dose calculation and intensive diabetes management. Diabetes Care36:

810-816.

10. Smart C, Lopez, P, Evans M et al. (2013). Both dietary protein and fat increase postprandial glucose

excursions in children with type 1 diabetes, and the effect is additive. Diabetes Care36: 3897-3902.

11. Bell K, Smart C, Steil G et al. (2015). Impact of fat, protein, and glycemic index on postprandial

glucose control in type 1 diabetes: implications for intensive diabetes management in the continuous

glucose monitoring era. Diabetes Care; 38: 1008-1015.

12. Ministry of Health (2014). Quality Standards for Diabetes Care Toolkit Wellington

www.health.govt.nz/publication/quality-standards-diabetes-care-toolkit-2014.

13. Franz M, Boucher J, Evert A (2014). Evidence-based diabetes nutrition therapy recommendations

are effective: the key is individualisation. Diabetes, Metabolic Syndrome and Obesity: Targets and

Therapy7: 65-72.

14. American Diabetes Association (2015). Standards of medical care in diabetes 2015: summary of

revisions. Diabetes Care38: S1-S94.

Nave to think one diet fits all:It would be

nave to think that any one particular dietarypattern be it the 5:2 diet, LCHF, or the Paleo

approach is an appropriate solution for the

whole population. If only life were that simple! Iagree that free sugars should be limited8, but

extreme restriction of wholegrains, legumes,

starchy vegetables or fruit is unnecessary and

disadvantageous given the role of dietary fibre indisease prevention4,5. I prefer to support people

with diabetes to review whether they are eatingthe right amount of food for a healthy weight

and focus on choosing heart healthy fats, good

quality carbohydrates, and abundant non-starchy

vegetables. If anything needs to be restrictedit would be the heavily processed foods that

add many calories but not much in the way of

nutrition.

Matching insulin to different diets challenging:

Research is still emerging about the impact

of high fat and/or high protein meals onpostprandial insulin secretion and glycaemic

control in adults and children with type 1

diabetes9,10,11. This presents a challenge forthose of us in clinical practice in terms of how

we match the right amount and type of insulin tothese meals, and challenges the assumption thatfollowing a low-carbohydrate diet means peoplewith diabetes will require less insulin.

Personalised advice important:In summary,most experts agree that there are multipledietary patterns that are beneficial forcardiovascular health and it is important

therefore that each person be given personalisedadvice based on their own needs and foodpreferences12,13. It is the position of theAmerican Diabetes Association (ADA) thatthere is not a one-size-fits-all eating pattern forindividuals with diabetes14. Tempting as it mightbe to be swayed by the latest dietary trends,as clinicians we need to stay grounded in ourperson-centred practices and consider a numberof factors that might impact on the efficacy ofany particular dietary pattern as part of ourclinical assessment.

Author:Shelley Mitchell NZRD, MSc. is thediabetes specialist dietitian at MidCentral Healthand convener for the DSIG of Dietitians NZ.

OPINION FOUR: Shelley Mitchell, DiabetesSpecial Interest Group convenor for Dietitians NZ

nr fad diet feedback

Documents