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Practice, People & Policy

OPINION

Fad diets

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he last edition of Nursing Review contained an


article called Fad diets: what do dietitians say
about the latest crop? that looked at some of
the 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

countrys leading advocate for the LCHF approach,


and has a background in psychology.
Nursing Review offered Schofield and
colleagues an opportunity to write an opinion
piece in response to the Fad diets article. Nursing
Review also offered the opportunity to the Heart
Foundation, Diabetes NZ and the convenor of
Dietitians NZs Diabetes Special Interest Group to
review and respond to Schofield et al. The resulting
four pieces are published here.

OPINION ONE: Grant Schofield et al.


The use of the word fad to describe therapeutic
diets, some with long histories of clinical
usefulness, which enjoy popularity beyond the
medical community, is lazy and misleading. This
review, despite its commendable focus on real,
unprocessed food, contained factual errors with
regard to low-carbohydrate, high-fat diets, as well
as Paleo and sugar-free diets.
We have summarised only major errors* for
comment. The most important correction* for the
readership of Nursing Review, is that restricting
dietary carbohydrate is an effective option for
diabetics.
Myth: Low-carbohydrate, high-fat diets, Paleo,
or sugar-free diets can cause hypoglycaemia and
ketoacidosis in diabetics
Diabetes medication dosage usually needs to be
adjusted downwards on low-carbohydrate diets.
However, there are clear advantages to reducing
medication 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 of
symptomatic hypoglycaemic episodes. A typical
result is a reduction of hypoglycaemic events by
80 per cent. Thus diets in which carbohydrate
is sufficiently restricted allow better control of

blood glucose, often including sustained normal


glucose and HbA1c readings in type 1 diabetes,
and remission or reversal of diabetes altogether
in type 2 diabetes. A 2015 review authored by
25 diabetes experts outlines 12 robust reasons
why low-carbohydrate diets should be the first
option for diabetes treatment1.
Drugs that can be reduced or stopped include
GSLT2 inhibitors, which have been shown
to cause diabetic ketoacidosis in America2.
Conversely low-carbohydrate diets have never
been shown to cause ketoacidosis.
The use of small amounts of glucose
to correct hypoglycaemia caused by the
unpredictability of insulin dosing still forms
part of managing type 1 diabetes, even on a
low-carbohydrate diet. This does not mean that
there is a requirement for sugar in the diet.
Myths: Low-carbohydrate, high-fat diets
cut out fruit; Paleo diets eliminate starchy
vegetables; not eating grains is a danger
to health. Fruits are not removed on lowcarbohydrate diets, rather high-sugar fruits are
limited; the degree of restriction depending on
an individuals level of insulin resistance. Paleo
diets do not eliminate starchy vegetables, and
may allow some dairy products or legumes.
Grain avoidance is more than compensated for

REFERENCES
1.

2.

30

Feinman R, Pogozelski W, Astrup A et al. (2015). Dietary carbohydrate restriction as the first
approach in diabetes management: Critical review and evidence base. Nutrition 31:1-13
http://dx.doi.org/10.1016/j.nut.2014.06.011
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.

Nursing Review series 2015

nutritionally by increased consumption of nuts,


seeds, fish and vegetables.
Myth: People will get half the message.
Randomised controlled trials of various diet
regimes show low-carbohydrate, high-fat eating
is superior in short and medium-term weight loss
in free living populations and has reasonable
adherence, superior to the low-fat approach,
showing that consumers can understand
and implement this diet effectively when it is
communicated clearly3.
Myth: Saturated fat causes heart disease.
Replacing saturated fat with carbohydrate does
not reduce the risk of heart disease, and may
increase it. Polyunsaturated fats found in fatty
foods are associated with a lower risk of heart
disease, whether they replace carbohydrate or
saturated fats4. This evidence does not suggest
that saturated fats are harmful in the context of
diets 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? Fats
in, Sugars out); and George Henderson, AUT
research officer.

Editors note:
This opinion piece has been published as submitted. Publication means that
Nursing Review is 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 whole
grains 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.

Practice, People & Policy


OPINION

OPINION two: Heart Foundation


It is great to see the Fad diets: what do
dietitians say about the latest crop? article in
Nursing Review has 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/highfat (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

intakes but share common features. These


features include: fewer processed foods; plenty
of vegetables and fruit; other plant foods such as
legumes, 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 type
of 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, the


promotion of healthy cardio-protective fats from
foods like nuts, seeds and plant oils, and the fat
message in the context of healthy dietary pattern,
has been missing from some of these stories.
Confusingly, during a presentation at the
2014 Dietitians NZ National Meeting, those
same LCHF advocates highlighted that cream,
butter, and bacon were not key fats as part of
the LCHF way of eating, whereas the previously
mentioned cardio-protective fats were. Therefore,
we believe the current LCHF messages being
delivered to health professionals and the general
population are incomplete, inconsistent and may
lead to people making poor dietary choices.
In summary, we continue to emphasise that
the quality of carbohydrate and fat in the diet
is key. People need to choose an eating pattern
that works for them, and that is based on foods
that the best available evidence shows reduces
the risk of heart disease and diabetes.
Author: Dave Monro is a dietitian and the
nutrition spokesman for the Heart Foundation.

REFERENCES
1.

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.

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.

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

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 Journal 321:405-12.

3.

Mozaffarian D, Micha R, Wallace S (2010). Effects on coronary heart disease of increasing


polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomised
controlled trials. PLOS Medicine 7(3):e1000252.

OPINION three: Diabetes NZ


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.

Saturated fat: Diabetes NZ affirms its view


that people with diabetes should not have a diet
high in saturated fat. Saturated fat has been
shown to have a negative impact on heart health
and people with diabetes have a well-recognised
increased risk of cardiovascular disease. A 2010
study by Otago University researchers found that
patients with type 2 diabetes benefited from a
reduction in saturated fat as part of a sensible
moderate eating pattern1. These benefits
included reductions in HbA1c, weight, and
BMI, and some people reduced their diabetes
medicine dose.
No-sugar diets: While popular versions
of these diets discourage the use of sucrose
(table sugar), other sugars such as glucose and
dextrose are commonly used in recipes. These
sugars are unsuitable for people with diabetes.

Diabetes NZs overall message is for people with


diabetes to reduce their intake of free sugar in
all forms. Free sugar is defined by the World
Health Organisation and the UN Food and
Agriculture Organisation in multiple reports as
all 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 distinguish
between the sugars that are naturally present
in fully unrefined carbohydrates such as brown
rice, whole wheat pasta, fruit, etc. and those
sugars (or carbohydrates) that have been, to
some extent, refined (normally by humans but
sometimes by animals, such as the free sugars
present in honey).
Author: Submitted on behalf of Diabetes NZ.

REFERENCES
1.

Coppell K, Kataoka M, Williams S et al. (2010). Nutritional intervention in patients with type 2
diabetes who are hyperglycaemic despite optimised drug treatment Lifestyle Over and Above
Drugs in Diabetes (LOADD) study: randomised controlled trial, British Medical Journal 341 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.

3.

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

Nursing Review series 2015

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Practice, People & Policy


OPINION

OPINION four: Shelley Mitchell, Diabetes


Special Interest Group convenor for Dietitians NZ
Nutritional science is constantly evolving and one
of the key dietary trends that consistently proves
its worth in terms of diabetes and cardiovascular
outcomes is the Mediterranean style of
eating1,2,3. This type of diet includes plenty of
vegetables, fruits, legumes, wholegrain cereals,
plus moderate amounts of heart healthy fats and
lean protein. These principles have been widely
incorporated into dietary recommendations
for the prevention and management of type 2
diabetes around the world4,5.
In New Zealand, we have our very own
Nine Steps for Heart Healthy Eating developed
by the Heart Foundation6 and featured in the
Ministry of Health Primary Care Handbook for
cardiovascular disease screening and type 2
diabetes management7. I have used the 9 Steps
with a number of people with type 2 diabetes
who have gone on to achieve a healthy weight
range (BMI 20-25 kg/m2) and a few have even
come off their diabetes medications altogether.
Others may have stayed on tablets or insulin but
are feeling confident that they can stick with their
new food plan because it includes a variety of
affordable foods they can buy locally.

Nave to think one diet fits all: It would be


nave to think that any one particular dietary
pattern 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! I
agree 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 in
disease prevention4,5. I prefer to support people
with diabetes to review whether they are eating
the 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 restricted
it 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 on
postprandial insulin secretion and glycaemic
control in adults and children with type 1
diabetes9,10,11. This presents a challenge for
those of us in clinical practice in terms of how

we match the right amount and type of insulin to


these meals, and challenges the assumption that
following a low-carbohydrate diet means people
with diabetes will require less insulin.
Personalised advice important: In summary,
most experts agree that there are multiple
dietary patterns that are beneficial for
cardiovascular health and it is important
therefore that each person be given personalised
advice based on their own needs and food
preferences12,13. It is the position of the
American Diabetes Association (ADA) that
there is not a one-size-fits-all eating pattern for
individuals with diabetes14. Tempting as it might
be to be swayed by the latest dietary trends,
as clinicians we need to stay grounded in our
person-centred practices and consider a number
of factors that might impact on the efficacy of
any particular dietary pattern as part of our
clinical assessment.
Author: Shelley Mitchell NZRD, MSc. is the
diabetes specialist dietitian at MidCentral Health
and convener for the DSIG of Dietitians NZ.

REFERENCES

32

9.

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.
Circulation 99: 779-85.

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 Care 36:
810-816.

10.

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 Practice 89: 97-102.

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 Care 36: 3897-3902.

11.

4.

Dyson P, Kelly T, Deakin T et al. (2011). Diabetes UK evidence-based nutrition guidelines for the
prevention and management of diabetes. Diabetic Medicine 28: 1282-8.

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.

5.

Evert A, Boucher J, Cypress M et al. (2014). Nutrition therapy recommendations for the management
of adults with diabetes. Diabetes Care 37: S120-S143.

12.

Ministry of Health (2014). Quality Standards for Diabetes Care Toolkit Wellington
www.health.govt.nz/publication/quality-standards-diabetes-care-toolkit-2014.

6.

The Heart Foundation www.heartfoundation.org.nz.

13.

7.

New Zealand Guidelines Group (2012). New Zealand Primary Care Handbook 2012 (3rd Edition).
Wellington: Ministry of Health.

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
Therapy 7: 65-72.

14.

8.

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

American Diabetes Association (2015). Standards of medical care in diabetes 2015: summary of
revisions. Diabetes Care 38: S1-S94.

1.

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


accessed 15 Aug 2015.

2.

Nursing Review series 2015