Not so sweet


Guidelines are flawed and must be revised as type 2 diabetes is reversible, says the 2020 Australian of the Year.

Dietary1 and clinical guidelines2 must change along with our love affair with sugar if Australia is to halt our burgeoning type 2 diabetes (T2D) epidemic and escalating costs associated with treating its life-threatening consequences, believes Dr James Muecke, AM. Dr Muecke is a senior lecturer in ophthalmology and visual sciences, University of Adelaide, and the 2020 Australian of the Year.

Dr James Muecke

Dr Meucke founded Sight For All in 2008, to fight blindness in the Aboriginal and mainstream communities of Australia, as well as some of the poorest countries of the world. This commitment to social impact and humanitarian work saw him receive the Order of Australia in 2012, the Australian Medical Association’s President’s Leadership Award the following year, and Ernst & Young’s Social Entrepreneur for Australia in 2015.

Today he uses his platform to share his messages about the ravages of T2D and importantly, the opportunities to reshape how the disease is managed and even prevented by changing what we eat.

In a National Press Club address in December 2020, he explained in detail how he had been “concerned” to discover that the dietary guidelines used to inform public policy and clinical management of T2D were not only out of date, but biased in favour of industry.

“They discourage eating foods containing natural saturated fat—which has led to the production of many low-fat foods, which are highly processed and loaded with sugar and refined carbohydrates. They also state that the link between dietary saturated fat and cardiovascular disease is well established. However, there’s no evidence, whatsoever, to link whole fat dairy, unprocessed red meat, and eggs with heart attacks, stroke or T2D.

“And there’s no evidence to show that the high carb dietary pattern recommended by our guidelines prevents T2D.

“The science is not complex and has been known about for nearly a century,” he told the audience.

“The dietary guidelines, by their own admission, are not for people with diabetes yet GPs are [using them] on people with diabetes. I don’t understand how organisations such as the Royal College of General Practitioners, Diabetes Australia and our government health bodies ignore this critical point? Indeed, our poor diet is responsible for more disease and death than smoking, alcohol and inactivity combined.”

He said the guidelines were born out of weak and unreliable epidemiological data and showed bias on multiple critical levels. This includes conflicts of interests with the food industry which is keen to push foods like sugar-laden breakfast foods.

As a result, the T2D epidemic is also flowing onto our children, with children as young as seven now being diagnosed with “…a disease not so long ago known as maturity-onset diabetes”.

“When are we going to stop pushing cereal for breakfast on kids?”

Children targeted

In March 2021, the Obesity Policy Coalition (OPC) released ‘Brands off our kids!’3 highlighting the tactics used by the processed food industry to target children and called on the government to set higher standards and stop the processed food industry setting its own rules.

At the same time, a survey revealed that seven-in-10 Australians want the government to step in and protect children from unhealthy food marketing.4

The survey revealed strong public support for:

  • an end to unhealthy food marketing on TV at times children are watching (73%) as well as in other areas targeted at children, such as popular characters or cartoons on websites, games or mobile apps (60%);
  • higher standards to stop unhealthy food and drink marketing in public places owned or managed by the government (60%);
  • a stop to unhealthy food and drink marketing near schools (66%); and
  • a stop to unhealthy food marketing targeting children online (76%) and across all social media for users younger than 16 years of age (68%).

Executive manager of the Obesity Policy Coalition, Jane Martin, said all Australian children should be able to grow up in a society that promotes their health and wellbeing.

Martin added the current arrangements around guidelines were like leaving Dracula in charge of the blood bank.

“We know that the processed food industry is getting away with airing three unhealthy food ads every hour during children’s peak TV viewing times; with making apps designed specifically to promote unhealthy brands to very young children; and with saturating digital media with unhealthy food so that Australian children aged 13–17 years are exposed to almost 100 online promotions for unhealthy food every single week.”

Martin said at a time when two thirds (67%) of adults and a quarter (24.9%) of children in Australia are above a healthy weight, the community expects government to prioritise children’s health above the profits of the processed food industry.

“For too long we have left it up to junk food companies to police themselves. [This] report, together with the strong public push for government regulation, adds to the litany of evidence which highlights a need for government action to protect children from the processed food industry’s unhealthy food marketing.”

Not so sweet

At the same time the ‘Full of Crap’ campaign,5 delivered by the Rethink Sugary Drink alliance, targets young males about the ways sugary drink companies promote their products and the health harms associated with drinking them.

Craig Sinclair, head of prevention at Cancer Council Victoria, a partner of Rethink Sugary Drink, said one-in-six teens downs at least 5.2 kilograms of added sugar from sugary drinks alone every year.

“Getting swept up by the beverage industry’s marketing game could mean young Aussies have signed themselves up to unhealthy weight gain, increasing their risk of battling serious health problems such as T2D, heart and kidney disease, stroke and 13 types of cancer later in life.”

Dr Muecke backs moves to restrict the marketing of sugary products and has long called for so-called ‘sugar tax’. He says the abundance of cheap sugary products—including sugar-sweetened drinks—coupled with a sedentary lifestyle, is wreaking havoc on our health.

He adds in Australia and many parts of the world, nearly one in every 10 adults has T2D—and in some parts of the country half of all adults have either diabetes or prediabetes.8

“If a patient has T2D, shouldn’t every single one of them be informed that there are proven methods for putting into remission their life-changing and life-threatening disease and begin given that opportunity?

“There are now more than 100 controlled clinical trials to support that a very low calorie or low carbohydrate diet works to either prevent T2D or put into remission,” he says.

Diet delivers

Dr Muecke says research has shown following simple low-carb advice can result in drug-free diabetes remission in 46% of participants—with cost savings to healthcare providers.7

For example, UK GP Dr David Unwin7 has been at the forefront of practice change. He developed a program in which patients with type 2 and pre-diabetes patients were given a low carbohydrate diet.

Nineteen patients entered the program with just one dropping out in the early stages (though there was weight loss, the diet just didn’t suit the individual). Of the 18 who persisted with the diet, all had substantial weight loss. Initial weight fell from 100.2 ± 16.4 to 91.0 ± 17.1kg (mean weight loss 8.6 ± 4.2kg; p<0.0001). Waist circumference decreased from 120.2 ± 9.6 to 105.6 ± 11.5cm (p<0.0001).

Blood glucose control improved significantly (HbA1c 51 ± 14 to 40 ± 4mmol/mol; p<0.001). Only two patients remained in the abnormal range (>42mmol/mol); but even these two had an average drop of 23.9mmol/mol. Simultaneously, BP improved (systolic 148 ± 17 to 133 ± 15mmHG, p<0.005; and diastolic 91 ± 8 to 83 ± 11mmHg, p<0.05).

Serum GGT (gamma‐glutamyltransferase) decreased from 75.2 ± 54.7 to 40.6 ± 29.2U/L (p<0.005). Total serum cholesterol decreased from 5.5 ± 1.0 to 4.7 ± 1.2mmol/L (p<0.01).

Seven patients were able to come off medication: metformin (one completely and two halved their dose), perindopril and lacidipine, as BP control improved so much. Additionally, metoclopramide, omeprazole and lanzoprazole were reduced.

All 18 participants lost weight and had improved HbA1c, and none had higher cholesterol. The majority reported improved energy and wellbeing, and many began exercising.

Likewise, in the US the ongoing Virta Health8 studies illustrate the benefits of lifestyle interventions, such as ketogenic diets, on diabetes progression and even reversal.

One investigation8 demonstrated that patients could rapidly improve glycaemic control through reductions in fasting blood glucose, HbA1c, and medication use after 10 weeks’ treatment. Patients lost 7% of their body weight on average and reported less hunger.

What’s more there were ongoing benefits. At two years’ treatment, patients still experienced clinically significant improvements in HbA1c, metabolic syndrome rate, and markers of inflammation. More than half of the trial completers met the criteria for diabetes reversal, and a significant portion of those individuals also had partial and complete diabetes remission. Along with these improvements in health outcomes, 67% of diabetes-specific prescriptions were discontinued, and 91% of patients who began on insulin either reduced or eliminated their insulin dosage.9

Remission recognition

Despite this overwhelming evidence for T2D remission, it took lobbying from Dr Muecke to get term the ‘remission’ included in the National Diabetes Strategy.10

“Disappointingly, it was not felt to be worthy of its own goal. Vested interests are not only shaping what we eat and driving chronic disease in our society, they are also shaping how we treat disease,” he told the National Press Club.

He is now calling on authorities to include remission as a major goal in its own right, which he believes would be a major step forward in changing diabetes management.

He also wants more support for all healthcare professionals to guide patients through an effective and clinically proven dietary solution to their diabetes.

“I feel that it’s critical for all in the healthcare sector, including pharmacists, to be aware that the dietary advice we’ve been fed for 50 years is flawed and has been biased by industry. We all need to ‘be singing from the same songbook’—that natural saturated fats are not linked to cardiovascular disease, red meat doesn’t cause cancer, we don’t need cereal for breakfast and that we should minimise sugar and refined carbs and avoid ultra-processed foods,” Dr Muecke tells the AJP.

“Just eating real fresh seasonal whole foods is the best dietary advice for everyone. If patients with chronic metabolic diseases require dietary advice, they are best referred to a professional who understands that a high-carb eating pattern will not prevent or reverse T2D, a disease of carbohydrate intolerance.

“Also, I would strongly encourage all pharmacies to remove sugary products and ultra-processed foods from their checkouts, where they are preying on people’s addiction to sugar,” he adds.

‘Addiction’ is one of what he calls the ‘5As of sugar toxicity’.

“Addiction, alleviation, accessibility, addition and advertisements around sugar mean people often find it hard to kick it. But with more than 15,000 lives lost to T2D and $20bn spent on the disease every year, we cannot afford to be silent anymore.”


Blinded by sugar

In this free webinar presentation, Dr James Muecke tells the story of Neil Hansell, a man who woke one morning blind in both eyes due to diabetes. He also outlines why T2D is a growing worldwide epidemic and explores a number of strategies to curb the toxic impact of sugar on our health and on our world. Go to: https://www.mdfoundation.com.au/resources/james-muecke-webinar-diabetes/


References

  1. Eat for health: Australian dietary guidelines. Canberra: National Health and Medical Research Council; 2013. https://www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/n55_australian_dietary_guidelines.pdf
  2. Type 2 diabetes: Goals for optimum management. Royal Australian College of General Practitioners. https://www.racgp.org.au/FSDEDEV/media/documents/Clinical%20Resources/Guidelines/Diabetes/Type-2-diabetes-Goals-for-optimum-management.pdf
  3. 7 out of 10 Australians support push to protect children from unhealthy food marketing. Obesity Policy Coalition. https://www.opc.org.au/media/media-releases/aussies-support-push-to-protect-kids-from-unhealthy-marketing.html#_ftn1]
  4. Nuss T, et al. Australians’ support for initiatives to protect children from unhealthy food and drink marketing and advertising. Research brief prepared for: Obesity Policy Coalition. Melbourne, Australia: Centre for Behavioural Research in Cancer, Cancer Council Victoria; 2020.
  5. Rethink sugary drink. https://www.youtube.com/watch?v=ZTXXIPJVMqQ
  6. Diabetes: the silent epidemic and its impact on Australia. Baker IDI Heart & Diabetes Institute and Diabetes Australia; 2012. https://www.diabetesaustralia.com.au/wp-content/uploads/Diabetes-the-silent-pandemic-and-its-impact-on-Australia.pdf
  7. Unwin D, Unwin J. Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre‐diabetes: experience from one general practice. Practical Diabetes. 2014;31(2):76-9.
  8. McKenzie AL, et al. A novel intervention including individualized nutritional recommendations reduces hemoglobin A1c level, medication use, and weight in T2D. JMIR Diabetes. 2017;2(1):e5.
  9. Athinarayanan SJ, et al. Long-term effects of a novel continuous remote care intervention including nutritional ketosis for the management of T2D: a 2-year non-randomized clinical trial. Front Endocrinol. 2019;10:348. doi: 10.3389/fendo.2019.00348.
  10. Australian National Diabetes Strategy 2016–2020. https://www.health.gov.au/resources/publications/australian-national-diabetes-strategy-2016-2020

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1 Comment

  1. Sue Tonakie
    21/10/2021

    Congratulations to Dr Muecke for standing up and challenging the dietary guidelines. Pharmacists can support this move away from processed food & the corresponding overabundance of sugar (which is a 50:50 disaccharide of glucose plus fructose) by giving lifestyle advice to help prevent/treat Metabolic Syndrome and T2DM. As a first step, it is vital that we understand the complex hepatic metabolism that the fructose in sugar undergoes (and how it differs from that of glucose). Products of fructose metabolism include triglycerides/VLDL (via “de novo lipogenesis”) [causing NAFLD/insulin resistance, NASH, fatty pancreas/insulin deficiency, dyslipidaemia and adiposity/obesity], uric acid [linked to gout and reduced nitric oxide (leading to hypertension)], and glucose. Also add upregulation of JNK1 (insulin resistance) and increases in advanced glycated end products (cell dysfunction/aging), reactive oxygen species (oxidative stress), dental caries (poor oral health is linked to chronic diseases) and stimulation of the cerebral reward pathway (addiction) to the list growing list of adverse effects due to sugar, particularly fructose. This is why the “health star” rating of juice had to be lowered.

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