This is my first guest blog post. It is written by Jennifer Elliott, an Australian dietitian who has become well known this year, in the diet and health on line community, for having been de-registered by her professional body: the Dietitians Association of Australia (DAA). Her case has led to her employer taking the extraordinary position that “Nutritional advice to clients must not include a low carbohydrate diet…” Even more extraordinary when you discover that Jennifer’s advice was being given in the context of insulin resistance and type 2 diabetes and she was merely suggesting that people with an inability to handle glucose/carbohydrate (i.e. diabetics) may benefit from consuming less of it. Here Jennifer shares her story, with links to her blogs, for those who would like to know more.
In Jennifer’s own words…
“I have been a dietitian for 35 years and for over 10 years have recommended carbohydrate restriction to clients with type 2 diabetes (T2D) and insulin resistance (IR).
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.
I converted my parents to a low-fat, almost vegetarian diet, with plenty of wholegrain carbs, fruits and vegetables. I was part of the new generation of dietitians who were spreading the word about healthy “complex carbohydrates”, as they were then known.
When I started a family, I took it a step further by moving to the country for the best lifestyle possible for my children; home grown/ home cooked vegetarian meals, little processed foods, plenty of outside play and TV time limited to what my now adult children refer to as deprivation levels.
Two of my children thrived in this environment – healthy, energetic and lean – but my middle daughter, Jeanne, was different. 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 (IR).
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 am forever grateful for what happened next. I was in the right place at the right time to meet a GP whose family situation was remarkably similar to mine: three slim, high energy, eat-what-they-like children and one with a weight problem. After hearing about the presence of IR 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 Jeanne. A two-hour Glucose Tolerance Test (GTT), with the addition of five insulin measures, showed normal blood glucose levels (BGLs) but a high insulin response, fitting the diagnostic criteria for IR.
Fifteen years ago, my knowledge about IR was limited to its connection with type 2 diabetes. The significance for a 14 year old with normal BGLs was a mystery to me.
The research begins
I started with a Google search of IR, which brought up 1.3 million entries and the accompanying question of why hadn’t I been taught any of this?
I narrowed my search down a little and started reading. It wasn’t like researching for a school assignment that I had no interest in. This was finding out what was happening biochemically to my daughter, as well as five million other people in Australia with this condition. It was fascinating. Answers to all the pieces of the puzzle were in the literature and I found explanations for Jeanne’s mouth breathing and snoring; why the weight went on predominantly around her tummy; why she seemed not to have an off-switch when it came to eating at times; her mood swings, reflux and lack of energy.
Carbs and insulin
It was clear that higher than normal insulin levels were to blame and that a diet designed to reduce these levels is what was needed. It was also clear that a reduced carbohydrate diet was the way to go. We started experimenting with different diet approaches, and, with instant feedback available from what I jokingly called my live-in guinea pig, I learnt more than would ever be possible from just the literature or in a clinical setting. This experience was invaluable.
The diet we settled on was very low carb during the day, but allowing some carbs in the evening meal. For Jeanne, the eating plan was generally eggs, bacon, tomato, avocado for breakfast; protein and salad at lunch; protein and veggies for the evening meal with some carbohydrate in the form of fruit, yoghurt or dark chocolate, etc.
This worked well: no excessive hunger, good energy levels, even moods, no reflux and easily maintained healthy weight. Jeanne has now been eating this way for many years and has maintained all those positive changes. She doesn’t think of herself as being “on a diet”, because as she says, “This is just the way I eat”.
Advising clients on low carb (LC) diets
Before I started advising clients on a lower carb approach for IR and T2D, I anticipated the FAT problem. One of the main arguments against LC is that such diets are higher in fat, particularly saturated fat, and the belief that this will increase the risk for heart disease. Although this is not bourne out in clinical trials, where an improvement in lipid profiles is generally observed, I realised that I didn’t know enough to argue a case for a higher fat diet if I was taken to court (my benchmark).
To be fully confident in recommending my new LC diet approach to clients, I started researching what I, and I believe all dietitians who have qualified since, have never been taught: the basis for the diet/heart hypothesis.
The end result was the publication of my paper: Flaws, Fallacies and Facts: Reviewing the Early History of the Lipid and Diet/Heart Hypotheses and confidence that the diet/heart hypothesis is so flawed that it should not be used as the basis of diet recommendations.
I cautiously introduced the idea of my new approach to GPs in my area. I explained that I would be trialling restricted carbs to people who fit the diagnostic criteria of Metabolic Syndrome and were therefore likely to be IR (high triglycerides, elevated BGLs, central weight, low High Density Lipoprotein and high Blood Pressure). I asked that recent biochemistry be provided and rechecked after three months to assess effects of the diet and that medications, especially BP and blood glucose lowering meds, be monitored and reduced if required.
The results were as expected; weight loss, improved BGLs and reduction in medications.
One example of the benefits of carb reduction was seen in a man with T2D, who after 7 weeks on a LC diet stopped taking insulin, lost 13 kg and reduced his HbA1c from 10.7 to 7.7 mmol/l.
Charged with using a “non-evidence-based” dietary approach
For the last 10 years, GPs have been referring patients to me because of the diet approach I use and the results they have seen in their clients. That all changed recently when a dietitian initiated an inquiry into my use of LC diets, alleging that they are not evidence based.
My work places and the Dietitians Association of Australia (DAA) conducted investigations into the allegation. I was confident that the verdict would be in my favour, not only because of the positive results clients were achieving, but also because I was following the latest guidelines from the American Diabetes Association, as is recommended practice for dietitians in Australia.
I was deregistered by the DAA in May 2015, for reasons that are not entirely clear. It appears that they didn’t like the way I kept notes on one client.
It is also apparent that the DAA endorses a regular intake of carbohydrate foods for management of various conditions including diabetes and obesity.
Based entirely on my deregistration from the DAA, the Southern New South Wales Local Health District (LHD) dismissed me and have instructed that dietitians in the LHD must follow DAA’s recommendations for diabetic diets, and are prohibited from advising clients on low carb approaches. And if any of the GPs, who used to refer to me, ask for LC advice for their patients, they will be advised “a low carbohydrate intake diet is not currently supported by the DAA”.
Richard Feinman, Professor of Metabolism and Cell Biology at the State University of New York, made an innocent offer of help last year, which morphed into another full-time job for him. He has read all the correspondence and decisions, offered to discuss the science behind LC with the DAA (was refused) and has been as incredulous as myself with the final decisions.
I have written about this fiasco on my blog and have received incredible support from people all over the world. Letters in support of LC diets as well as calls for my reinstatement have been sent to the DAA and Health Ministers. Whereas I was once quite hopeful that these voices would be listened to, it looks like I was a little optimistic.
Loss of employment and being forced out of my comfort zone has led to some unexpected developments. I’m looking at extending the content of my book into a 12-week online program for people with T2D, and there’s a chance a local GP surgery will join with a NSW university in a clinical trial comparing the LC approach I recommend with standard higher carb advice.
When we could see the way it was headed, Professor Feinman asked how I would feel if I didn’t get my job back but my case became a catalyst for change. Increased awareness of the benefits of LC would be a start and perhaps many more people would hear that T2D and IR can be managed and often reversed with carb restriction. I’d definitely be happy with that.”
I first came across Jennifer when I read her paper, referenced above. I highly recommend reading it. Jennifer was working from the other side of the world in a similar area to me – examining the evidence base for our global dietary guidelines. Jennifer found that there was no evidence. I have found the same. We have both challenged our respective governments to show us the evidence. Both have failed.
This was bad enough. What happened next beggared belief. The Dietitians Association of Australia (DAA), declared war on one of their own members; deregistered a highly experienced, research-driven practitioner and took away the job, income and livelihood of a committed professional, whose only crime was to try to improve the health of her clients. And Jennifer didn’t just try; she succeeded. Against all measures that matter: weight; reliance upon medications; blood glucose levels; blood lipid levels; health; energy and so many more.
If the DAA position were evidence based, other approaches that work should still be embraced. Nothing that can help patients should be dismissed. The fact that the DAA position is not evidence based, just makes their stance worse. I think that Jennifer sealed her fate when she wrote that brilliant paper, challenging everything that she had been taught. Credit to her, you would think, but no. The paper was published in October 2014 and the DAA executed their revenge soon afterwards.
I sincerely hope that Richard Feinman is right and that this case will be a catalyst for change. It needs to be. Something good needs to come from this because, as it stands, this has been a lose, lose, lose for everyone: a personal loss for Jennifer; a huge loss of credibility and reputation for the DAA; and an immense loss for patients who are being denied the opportunity to benefit from anything other than conventional advice.
Just as a final thought, here are the sponsors of the Dietitians Association of Australia. Jennifer didn’t stand a chance.