top of page
Library Book Shelves

Our research project

logo-hrc-og-image.png

Our Research Project

Scale of the problem

Type 2 diabetes (T2D) represents one of the largest global epidemics in human history (1). Within New Zealand, high rates of both T2D and prediabetes (PD) present an enormously inequitable and costly health problem that is projected to worsen over the next two decades (2, 3, 4), placing the health service under considerable stress. Despite this, PD and T2D are largely preventable, manageable, and reversible through lifestyle changes.

Evidence

Therapeutic carbohydrate reduction (TCR) is now an established approach for the management and treatment of T2D (5, 6, 7, 8, 9, 10, 11, 12, 13). While a range of dietary approaches may be beneficial (14, 15, 16, 17, 18, 19), carbohydrate reduction shows the largest evidence base for improving diabetic control (20) and may be adapted to fit a range of different dietary patterns and preferences. Accordingly, TCR is recognised in national guidelines around the world, including in the United States (The American Diabetes Association (ADA), the United Kingdom, Australia, Canada, and Scandinavia (Sweden) (21, 22, 23). We expect that New Zealand will follow these examples in future.

​

Studies over timescales of up to five years have confirmed that TCR can lead to improved glycemic control, reduced need for medications, and significant weight loss, in addition to improved blood lipid profiles (5, 6, 7, 8, 10, 11, 12, 18, 24, 25, 26, 27, 28). Further, defined as a glycated haemoglobin (HbA1c) <48 mmol/mol and sustained for >3 months in the absence of diabetes medication (29), diabetes remission has been demonstrated in several studies using TCR (5, 11, 12, 28). Despite historical concerns, reduced carbohydrate diets can easily be formulated to be replete in fibre, vitamins, and minerals when focussed on whole foods (30). TCR exists on a sliding scale and may look different for each individual. While some patients may reduce their carbohydrate intake to as low as 20-30g per day, for others they may make more modest reductions with total carbohydrate intakes of <130g per day (6)

NZ's Primary Care Context

New Zealand’s primary care setting is rapidly changing. We have an ageing, burnt-out primary care workforce; significant change is needed as GP and nurse numbers dwindle. Given the success of TCR, we have a cost effective and efficacious solution in primary care for New Zealand’s metabolic and T2D crisis. We propose a holistic three-pronged primary care healthcare delivery model which:

​

  • emphasises a multidisciplinary team approach, incorporating well-trained health coaches as behaviour change agents into clinics nationwide.

  • is dominated by lifestyle medicine interventions, and complemented by pharmaceuticals where appropriate, the latter being supportive, not the focus. The dietary approach is based on whole foods and minimises ultra-processed food while also reducing overall glycemic load.

  • embeds a suite of comprehensive and culturally responsive support initiatives tailored to the local needs of the community.

​

The goal sounds aspirational, yet this work is already underway in NZ, with several primary care clinics reorienting their funding structures to allow for this holistic model. To date, diabetes has been successfully reversed in up to 64% of patients in a local practice over a two-year period (28). More data is currently being analysed for a further three practices, but preliminary analysis suggests HbA1C reductions in approximately 90% of patients across these three practices.

Getting Started

We currently have government funding for research to progress this work further and support more practices in transitioning to this model of healthcare delivery.

 

While some patients can safely start a reduced carbohydrate approach immediately, others will need medication reviews and more support, depending on their baseline level of diabetic control and health. Accordingly, depending on the needs of each patient population, primary care centres/health care professionals will require training and ongoing support to a greater or lesser degree before transitioning to the new model of care. We can help with this; we don’t want to add to a busy workload so will only offer support where it is wanted. Our traffic light guide below might help you decide what you might need.

​

Broadly speaking, patients can be divided into three groups when thinking about beginning lifestyle interventions for diabetes management:

​

Green – Ready to go

  • Patients with prediabetes or type 2 diabetes but without any medications or metformin

  • Carbohydrate reduction is incredibly safe for this group

  • Very little GP input is needed 

 

Amber – Health professionals need a little assistance / training before starting

  • Patients with type 2 diabetes on medications (other than SGLT2 inhibitors, see below) or those with very poorly controlled diabetes 

  • Patients will need some supervision and a review of medications

 

Red – Health professionals need more assistance / training before starting

  • Patients on insulin, SGLT2 inhibitors, and sulphonylureas

  • Patients will need closer supervision and medication reviews to avoid ketoacidosis

Join us in our endeavour to help produce a more efficient, effective, and sustainable healthcare system, benefiting those that are most vulnerable, such as our Māori and Pacific communities with diabetes and more broadly chronic disease.

References

1.         Zimmet PZ. Diabetes and its drivers: the largest epidemic in human history? Clinical diabetes and endocrinology. 2017;3(1):1-8.

2.         Ministry of Health. Prediabetes: Ministry of Health 2021 [Available from: https://t2dm.nzssd.org.nz/Section-98-Prediabetes.

3.         Ministry of Health. Living Well with Diabetes: A plan for people at  high risk of or living with diabetes 2015–2020. Wellington.: Ministry of Health.; 2019.

4.         Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. Diabetes research and clinical practice. 2019;157:107843.

5.         Athinarayanan SJ, Vantieghem M, McKenzie AL, Hallberg S, Roberts CG, Volk BM, et al. Five-Year Weight and Glycemic Outcomes following a Very-Low-Carbohydrate Intervention Including Nutritional Ketosis in Patients with Type 2 Diabetes. Diabetes. 2022;71(Supplement_1).

6.         Hallberg SJ, Gershuni VM, Hazbun TL, Athinarayanan SJ. Reversing type 2 diabetes: a narrative review of the evidence. Nutrients. 2019;11(4):766.

7.         Kelly T, Unwin D, Finucane F. Low-Carbohydrate diets in the management of obesity and type 2 diabetes: a review from clinicians using the approach in practice. International journal of environmental research and public health. 2020;17(7):2557.

8.         Mckenzie AL, Athinarayanan SJ, Vantieghem M, Volk BM, Adams RN, Roberts CG, et al. 59-OR: Long-Term Sustainability and Durability of Diabetes Prevention via Nutritional Intervention. Diabetes. 2022;71(Supplement_1).

9.         Snorgaard O, Poulsen GM, Andersen HK, Astrup A. Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes. BMJ Open Diabetes Research and Care. 2017;5(1):e000354.

10.       Stern L, Iqbal N, Seshadri P, Chicano KL, Daily DA, McGrory J, et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Annals of internal medicine. 2004;140(10):778-85.

11.       Unwin D, Delon C, Unwin J, Tobin S, Taylor R. What predicts drug-free type 2 diabetes remission? Insights from an 8-year general practice service evaluation of a lower carbohydrate diet with weight loss. BMJ Nutrition, Prevention & Health. 2023:e000544.

12.       Unwin D, Khalid AA, Unwin J, Crocombe D, Delon C, Martyn K, et al. Insights from a general practice service evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes mellitus and prediabetes: a secondary analysis of routine clinic data including HbA1c, weight and prescribing over 6 years. BMJ Nutrition, Prevention & Health. 2020;3(2):285.

13.       Wheatley SD, Deakin TA, Arjomandkhah NC, Hollinrake PB, Reeves TE. Low carbohydrate dietary approaches for people with type 2 diabetes—a narrative review. Frontiers in Nutrition. 2021;8:415.

14.       Aronica L, Landry MJ, Rigdon J, Gardner C. Weight, Insulin Resistance, Blood Lipids, and Diet Quality Changes Associated with Ketogenic and Ultra Low-Fat Dietary Patterns: A Secondary Analysis of the DIETFITS Randomized Clinical Trial. Frontiers in Nutrition. 2023;10:1220020.

15.       Lim EL, Hollingsworth K, Aribisala BS, Chen M, Mathers J, Taylor R. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia. 2011;54(10):2506-14.

16.       Rock CL, Flatt SW, Pakiz B, Taylor KS, Leone AF, Brelje K, et al. Weight loss, glycemic control, and cardiovascular disease risk factors in response to differential diet composition in a weight loss program in type 2 diabetes: a randomized controlled trial. Diabetes care. 2014;37(6):1573-80.

17.       Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. New England Journal of Medicine. 2008;359(3):229-41.

18.       Tay J, Luscombe-Marsh ND, Thompson CH, Noakes M, Buckley JD, Wittert GA, et al. Comparison of low-and high-carbohydrate diets for type 2 diabetes management: a randomized trial. The American journal of clinical nutrition. 2015;102(4):780-90.

19.       Trapp C, Barnard N, Katcher H. A plant-based diet for type 2 diabetes. The Diabetes Educator. 2010;36(1):33-48.

20.       Evert AB, Dennison M, Gardner CD, Garvey WT, Lau KHK, MacLeod J, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes care. 2019;42(5):731.

21.       Davies MJ, D’Alessio DA, Fradkin J, Kernan WN, Mathieu C, Mingrone G, et al. Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes care. 2018;41(12):2669-701.

22.       Diabetes UK. Position statement: low-carb diets for people with diabetes. Diabetes UK: London, UK. 2017.

23.       Association AD. 5. Facilitating behavior change and well-being to improve health outcomes: Standards of Medical Care in Diabetes—2020. Diabetes care. 2020;43(Supplement_1):S48-S65.

24.       Tay J, Luscombe-Marsh ND, Thompson CH, Noakes M, Buckley JD, Wittert GA, et al. A very low-carbohydrate, low–saturated fat diet for type 2 diabetes management: a randomized trial. Diabetes care. 2014;37(11):2909-18.

25.       Westman EC, Yancy WS, Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutrition & metabolism. 2008;5(1):1-9.

26.       Roberts C, Athinarayanan S, Vantieghem M, Mckenzie A, Volk B, Adams R, et al. 212-OR: Five-Year Follow-Up of Lipid, Inflammatory, Hepatic, and Renal Markers in People with T2 Diabetes on a Very-Low-Carbohydrate Intervention Including Nutritional Ketosis (VLCI) via Continuous Remote Care (CRC). Diabetes. 2022;71(Supplement_1).

27.       Athinarayanan SJ, Adams RN, Hallberg SJ, McKenzie AL, Bhanpuri NH, Campbell WW, et al. Long-term effects of a novel continuous remote care intervention including nutritional ketosis for the management of type 2 diabetes: a 2-year non-randomized clinical trial. Frontiers in endocrinology. 2019;10:348.

28.       Hawkins MA, Zinn C, Delon C. The application of carbohydrate-reduction in general practice: A medical audit. Journal of Metabolic Health. 2023;6(1):11.

29.       Riddle MC, Cefalu WT, Evans PH, Gerstein HC, Nauck MA, Oh WK, et al. Consensus report: definition and interpretation of remission in type 2 diabetes. The Journal of Clinical Endocrinology & Metabolism. 2022;107(1):1-9.

30.       Zinn C, Rush A, Johnson R. Assessing the nutrient intake of a low-carbohydrate, high-fat (LCHF) diet: a hypothetical case study design. BMJ open. 2018;8(2):e018846.

bottom of page