Jen Elliott, a dietitian with 35 years’ experience, has been expelled from the Dietitians Association of Australia (DAA) because of her recommendation to lower carbohydrate diets to people with insulin resistance and type 2 diabetes (T2D) (1). The complaint originated from another dietitian who did not agree with the approach taken by Jen who claimed that the recommendation of:

“a very low carbohydrate diet for type 2 diabetes management is inconsistent with Evidence Based Practice”.

A further complaint was that one of her clients was not happy with an interview.

In response Jen pointed out that:

  • The DAA does not give specific advice but refers to the American Diabetes Association (ADA) for this.
  • The ADA notes that there is no “one-size-fits-all” eating approach in diabetes management and that the chosen eating pattern should be designed to improve glucose, blood pressure, and lipids.
  • ADA documentation suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.
  • Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. Therefore, collaborative goals should be developed with the individual with diabetes.
  • Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycaemic control.
  • Evidence is insufficient to support one specific amount of carbohydrate intake for all people with diabetes.

In the light of these points it would seem that recommending a diet low in carbohydrates is consistent with the DAA policy such as it is. Jen also pointed out that there is extensive evidence to show that the quantity and type of carbohydrate in a food influence blood glucose level, and total amount of carbohydrate eaten is the primary predictor of glycaemic response. There are of course hundreds, if not thousands, of individuals who can confirm this from their own personal experience. As a consequence they have effectively cured their T2D, been able to come off drugs, and improve the quality of their lives.

Although Jen explained to the client the pathways of carbohydrate metabolism and how to determine the appropriate intake for a specific individual, the person alleged she dismissed previous evidence based advice and as a result was left confused and disgruntled. So clearly there are two very different versions of what happened at the interview.

Here is how Jen describes what took place:

“The client told me that she understood what I had explained but that it was different to what she had read and had been previously told. I should stress that what I had explained was the physiological response to carbohydrate intake and the rationale for engaging in regular exercise and monitoring carbohydrate intake. I then suggested that an eating plan that was consistent with her usual eating pattern, but which also suggested some limitation of carbohydrate foods ie the CSIRO Wellbeing diet, may be suitable. I asked if she would like to trial the eating plan, went through the guidelines with her and provided her with a copy of page 3 from the Wellbeing diet booklet. As is my practice, I said that I recommended trialling the eating plan for 2 weeks to see how it suited her and we could discuss this at a review apt in 2 weeks. The appt was made at the end of the interview and later cancelled by the client. I would also like to address specific allegations made in the letter of complaint from the patient to DX. 1. That I do not support what the Diabetic Dietitians say. My response to clients who question why my approach may be different to what they have heard or been taught, is that there is not a ‘One size fits all ’approach when it comes to managing diabetes. This is in line with ADA guidelines that state, “A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another.” I provide people with information about the possible underlying causes of the disorder, so that they have the knowledge and tools to evaluate different diet approaches and find what works for them. If a client said to me that they had seen another dietitian and the advice given suited them, I would encourage them to follow that advice. If a client said to me that they had received advice from another dietitian but that they wanted to seek my advice as well, then I would do as I explained above. I agree with and follow the principle of not a one-size-fits-all approach; therefore I do not denigrate the practices of others. I provide information and insufficient to support one specific amount of carbohydrate intake for all people with diabetes.”

Note: CSIRO is the Commonwealth Scientific and Industrial Research Organisation of Australia.

In response to this Jen was sent a letter specifically asking her to reply to the charges that:

  • Your recommendation of a very low carbohydrate diet for T2D management being inconsistent with Evidence Based Practice
  • The patient letter indicates that I dismissed previous evidence based advice given to this patient and provided contradictory advice, resulting in a confused and disgruntled consumer.

This seems rather peculiar as Jen had already answered these allegations comprehensively in her previous letter.

Nevertheless, Jen responded this time with support from Dr Richard Feinman and Dr William Yancy.

Dr. Feinman is the lead author on the recent review:

“Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base” (2).

The review provides an evidence-based medicine perspective supporting low-carbohydrate diets. The paper has 26 authors with excellent credentials including at least one well-known former critic of low carbohydrate diets.

Dr Yancy is co-author of the ADA guidelines who included the following comment in a letter to Jen:

“The evidence supporting a low-carbohydrate diet is ample at this point. The only data we are missing is a trial with one of the ultimate disease endpoints like mortality or heart attacks. Of course, the low-fat/high-carbohydrate diet does not have evidence showing it improves those outcomes either—the trials that have been done were negative. And, in head-to-head trials with intermediate outcomes, low-carb diets quite clearly do better for improving HDL and triglycerides, and much of the time do better for improving glycemia and weight. Since we did the evidence review for the ADA guidelines, 3 more RCTs in patients with DM have shown greater benefit with the low-carb diet.”

 

Jen also provided a comprehensive response to the second charge, which included detailed comments on the complaint from the other dietitian (DX). Here is an extract:

“DX says ”The dietary advice is not that of the wider scientific community” and “A low carbohydrate diet is not best practice for diabetes care”. DX obviously is unaware of ADA guidelines, which DAA recommends dietitians follow.

 “The diet described by the client with carbohydrate once per day…….” DX should have checked her facts, as she is mistaken in what she believes I recommended to the client. If I had recommended carbs in one meal per day, which I clearly did not, it would nonetheless be supported by ADA’s guidelines.”

All the publicly available information can be accessed at (1).

A subsequent development has appeared on Facebook. In response to the following comment from George Henderson:

I am disappointed by your recent decision to expel Jennifer Elliott for recommending the lower carbohydrate CSIRO Wellbeing diet to a patient with Type 2 Diabetes” (3).

The DAA replied:

“Hi George. Please note that the former DAA member you mention was not expelled for recommending the lower carbohydrate CSIRO Wellbeing diet to a patient with Type 2 Diabetes, as you suggest. In line with DAA’s complaints procedures, we are not able to go into detail about this case – this information is confidential. What we can say is that a complaint was made against the former DAA member regarding professional competence, through DAA’s formal complaints process and this was assessed by DAA’s Complaints Committee. As a result, this person’s DAA membership has been cancelled. It is incorrect to suggest the former member is in trouble because she had certain views on nutrition and dietary approaches. DAA wishes to be clear that the outcome of the complaint against this former member relates to professional competence – and this is the reason DAA’s Complaints Committee revoked this person’s DAA membership.”

This is in direct contradiction to what Jen herself understands which relates to her dietary advice. This must mean that her expulsion was based entirely on the complaint from the client about the way the interview was conducted and the implications of that for professional competence. This seems extraordinary as it depends entirely on who you believe. Jen has presented her account which totally disputes that of the client. So without any corroboration, the DAA decision is inexplicable.

It is obvious that there is a lot more to this than meets the eye. The DAA cannot hide behind confidentiality. On the face of it the behaviour of the DAA is irrational, unjustified and disgraceful.

REFERENCES

  1. http://linkis.com/com/2pNvU
  2. http://www.sciencedirect.com/science/article/pii/S0899900714003323
  3. https://www.facebook.com/dietitiansassociation/posts/10206562152909378?ref=notif&notif_t=like