By Jane Feinmann
Three events I have attended in the last month highlight the fact that the Government’s Eatwell Guide is not just clearly unhealthy but indefensibly so. The Guide, based on recommendations from the Scientific Advisory Committee on Nutrition (SACN)’s 2015 Carbohydrates and Health report, says starchy carbohydrates should make up nearly 50 per cent of our daily calorie intake, including for those with Type 2 diabetes (T2D) – a condition involving a chronic carbohydrate intolerance. The official line is that Eatwell is uncontroversial and unchallenged. The meetings I attended suggest this is not the case.
First up, the Guide came under scrutiny from the authoritative All Party Parliamentary Food & Health Forum on March 28.
The Forum had invited the charity, Diabetes UK’s Director of Research, Dr Elizabeth Robertson, to put the case for the Eatwell Guide. The other side was to be covered by Southport GP, Dr David Unwin. He is the Royal College of General Practitioners’ champion for collaborative care and support planning in obesity and diabetes, who has published research showing the benefits of advising those with T2D to eat a low carb diet.
So how did the debate go? Well it didn’t. Rather than an opportunity for their Lords and Ladyships to hear various options for handling the diabetic crisis, it turned into a one-man show. With the press release printed and just days to go before the event, Dr Robertson pulled out and Diabetes UK failed to offer another speaker.
T2D affects four million Brits who the charity is supposed to be helping. This no-show, not the first one by the charity, was probably a PR disaster for them. It clearly annoyed the members there to hear about an official policy and made it look as if the charity’s policy was indefensible.
Case for low carbs impressive, reports BMJ
The event, however, was a success for the low carb side. Dr Unwin spent the hour explaining the benefits for his patients, and for the NHS, of providing advice that contradicts the Eatwell Guide, among them a significant cut in the drug bill as blood glucose levels become more stable. As the BMJ reported Unwin made an impressive case for GPs to be allowed to keep some or all of the savings on T2D medication – in Dr Unwin’s case, around £38,000 for his practice compared to the average spend by other surgeries in his area, while achieving ‘a significantly better quality of diabetes control’ than they did.
Forum members, including Lord Rea, were clearly impressed. Will we soon see the House of Lords lobby for a fees structure to incentivise GPs who tell their T2D patients to ignore the Government’s dietary guidelines? It could well happen.
Just a week later, there was no mention of the Eatwell Guide at my second event, a meeting of NICE at its plush offices just off the Mall, to discuss an update of its 2012 guidelines for people at high risk of T2D. But the Guide was undoubtedly the starchy carb elephant in the room.
Diabetes Prevention Programme: not yet tested in UK
The purpose of the meeting was to compare the cost effectiveness of the new NHS Diabetes Prevention Programme (at £233 for at least 13 sessions providing advice on nutrition, i.e. the Eatwell Guide, plus exercise) with the cost of prescribing metformin, the gold standard diabetes medication that is currently prescribed for people who have pre-diabetes. .
The results were not at all clear because even after years of a growing diabetes epidemic, the research to support this key plank of the government’s strategy hadn’t been properly done.
So NICE was forced to base its assessment of cost effectiveness on studies of US and Finnish versions of the programme, both of which are more intensive than the, frankly, watered down NHS version.
Secondly, and perhaps more significantly, the evidence-based benefits even of the intensive US and Finnish programmes are not impressive: telling people with pre-diabetes to take more exercise and reduce calories not surprisingly doesn’t work..
DPP not cost-effective for most people at risk of T2D
So as the public part of the meeting drew to a close, NICE was floundering. The only people for whom DPP can be clearly shown to be cost-effective, it appeared, were those under 40 – and then only if there was an assumption that this relatively brief, low cost intervention would bring about changes that would last a lifetime.
Of course that’s nonsense – as GPs on the committee pointed out. Yet the real scandal is that NICE appears to assume that the DPP is the only alternative to medication for people at risk of T2D. There was no mention of the low carb intervention, so wholeheartedly welcomed by an expert group the previous week at the other end of Whitehall.
And it’s not the only occasion that this has happened. In February, the Lancet published a Seminar on T2D outlining the impact of, and potential remedies for this global epidemic, currently affecting 415 million people. It thoroughly assesss the efficacy and safety of diabetic medication and includes a brief reference to very low calorie diets and bariatric surgery as alternatives but no makes no mention at all of low carb diets..
When I asked the lead author, Dr Sudesna Chatterjee of Leicester University’s Diabetes Research Centre, why low carb had been ignored she said the evidence showed that patients wouldn’t adhere to it. This statement, so frequently made, cannot continue unchallenged. A growing number of trials demonstrate the effectiveness and acceptability of a low carb diet when combined with a program of education.
Dr Unwin has published results from his practice in the BMJ on which I posted a report about for HealthInsightUK 18 months ago.
As he recently told the Lords Health and Food Forum, the diet resulted in weight loss, improvement in blood sugar control and a reduced need for medication. Last month an American study, published in JHR Diabetes, involving 262 patients with T2D obtained similar results (10.2196/diabetes.6981). The key finding of this trial, however, was that the crucial accompanying education program was equally effective when delivered in person or on-line.
Eatwell Guide dairy advice is challenged by The Dairy Council
A third recent meeting I attended gave some cause for hope that change is in sight. On April 5, the Dairy Council held a meeting for journalists to launch its monograph: ‘Dairy and Obesity: What the Science Says’. It wasn’t about T2D as such, but the analysis by leading scientists showed exactly how nutrient-rich dairy foods, notably butter, cheese and full fat milk and butter, are both highly protective of health and able to cut the risk of obesity for all ages.
‘There are many potential mechanisms by which dairy can modulate fat balance and there is a good rationale for including dairy products in the diet to assist with fat loss whilst also maintaining lean body mass,’ explained leading researcher, Dr Javier Gonzalez of the University of Bath. In other words, dietary fat doesn’t make you fat.
This was no political rally. It was a well-mannered, low-key event. But there was no doubting the serious intent of the Dairy Council in highlighting the sheer wrongness of what many see as the infamous Eatwell plate – where butter is shunned in favour of a ‘low fat’ spread and a sliver of cheese and mini tub of ‘low fat’ yoghurt, an option that looks pathetically small and unappealing compared to the glory of the starchy carb section.
‘Let’s start by telling people how many portions of dairy they should be eating every day in the same way as they are told how many portions of fruit and veg to eat,’ Dr Anne Mullen, Director of Nutrition at The Dairy Council told journalists.
She was speaking at the panel stage of the meeting and invited a comment from fellow-panelist, Dr Sheela Reddy, described by the Dairy Council’s programme as ‘formerly of the Department of Health, making her almost someone prepared to be publicly accountable for the Eatwell Guide. And surprisingly Dr Reddy agreed. ‘Yes’, she said. ‘I agree we need to tell the public how many portions of dairy they should eat every day.’
So why are the clear benefits of low carb being ignored?
Straws in the wind? On the one hand, there’s a huge interest in low carb. At the same time, important ongoing discussions that will decide policy for years are ignoring evidence that it could dramatically improve people’s health and save NHS funds. Such willful blindness is not only unscientific; it is not hard to identify plausible and unedifying reasons. One, professional pride, is understandable. Admitting 40 years of advice was wrong is hard. Another is less forgivable. The links between the diabetes profession and the large food companies has already been described in detail here.
Dietitians often defend their position by saying that it’s excess calories and lack of exercise that make you put on the weight that can lead to diabetes. This is a claim that chimes perfectly with the line taken by food and drink companies. Research published earlier this month in the BMJ found that: ‘Industry money was used to covertly influence journalists with the message that exercise is a bigger problem than sugar consumption in the obesity epidemic’. (BMJ 2017;357:j1638 It’s this advice that many believe has led to the current epidemic of both obesity and T2D.
Now is a time when openness about the evidence base on diet and health is essential
A review of the evidence on saturated fat and health by the government advisory committee SACN is due to appear sometime this year, which perhaps explains the timing of the Dairy Council’s latest monograph. It was one of the scandals of SACN’s carbohydrate and health report two years ago that the Committee refused to consider evidence on fat as an alternative to carbohydrate.
This new SACN report should lead to major shift in UK’s nutritional advice. A new Eatwell Guide might, for instance, encourage the population to consume a minimum of five (or even between five and ten?) portions of healthy dairy daily – instead of a Plate that gives the impression that nutritious dairy food is something best avoided.
Above all it’s time for public debate. Those who are in position to provide influential advice to people with T2D or pre-diabetes must be prepared to discuss their policy publicly. They cannot be allowed to carry on hiding behind cancelled appearances in order to keep the lid on such a critical debate.