Last week we discussed the ketogenic diet in the management and prevention of diabetes. It is possible that this article may have raised some ire, as the controversy between ketogenic and non-ketogenic dieters sometimes reaches the fervour of a religious war.
I did end off the article saying that people’s metabolism does differ and it does seem that some people do better on the ketogenic diet than a high-carb diet, especially in the short term. But I do believe the ketogenic diet is not normal physiology. It may work well for the Inuit (Eskimo) people in the Northern Polar regions where plants do not grow, but I believe we were designed to live on a plant-based diet, especially when you study our digestive system anatomy and physiology.
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I have noticed over the years that the official national guidelines in many countries has certainly changed in terms of intake of carbohydrates. At one time the suggestions were for significant restrictions in the ingestion of carbohydrates from fruit and whole grains, whereas more recently there has been encouragement of the use of these sources of carbohydrates. What follows is the recommendation by the expert committee of the SA Endocrine, Metabolic and Diabetes Society.
| Characteristics of a High-Quality Dietary Pattern | |
| Food | Nutrient and health benefits/Consequences |
| High intake of fruit and vegetables:
Minimum of 5 portions per day |
Increases intake of fibre that enhances satiety, phytonutrients, vitamins and minerals that combat oxidative stress |
| Starchy foods should be wholegrain:
Corn, barley, rolled oats, unrefined maize, wild/brown rice and wholegrain breads |
Contains B vitamins, vitamin E and fibre that improves glycemic control and enhances satiety |
| Encourage intake of all types of fish:
Especially fatty fish with high omega 3, eg. Sardines |
Low saturated fat content, good source of protein, omega 3 fatty acids, selenium, magnesium and vitamin D |
| Encourage intake of legumes:
Soya beans, various dried beans, lentils and chick peas and dried peas |
Promotes healthy lipid profile, good source of fibre and protein |
| Use of low fat sugar free dairy products:
Low fat plain yoghurt and low fat milk |
Provides calcium vitamin D, and magnesium. Good source of protein with a low saturated fat content |
| Use of vegetable fats:
Such as nuts and seeds avocado pear, olives, plant oils (canola, olive, sunflower, etc. Avoid tropical oils (eg. Coconut and palm kernel oil) |
Replacing saturated fatty acids in the diet with unsaturated fatty acids tends to reduce the risk of cardiovascular disease. Tropical oils contain fatty acids which raise LDL |
| Reduce intake of commercially hydrogenated fats: Commercially deep fried foods, fast foods and baked items contain high amounts of trans fatty acids | Trans fatty acids raise total and LDL cholesterol, decrease HDL cholesterol and increase inflammation |
| Reduce intake of processed meats and fatty red meat:
Bacon, all types of sausages, polony and deli meats |
High content of salt, nitrates, heme-iron and saturated fat |
| Reduce intake of sugars:
Table sugar, honey, sugar-sweetened beverages, fruit juices, sweets, desserts and baked goods |
Poor nutrient content, contributes to poor glycemic control, bad lipid profiles, obesity and inflammation |
| If alcohol is consumed it should be in moderation:
Wine, spirits, beer etc. |
High intake aggravates glycemic control, hypertension and high triglycerides |
(The above table comes from the SAEMDS protocol on management of Diabetes)
Despite the benefits associated with Medical Nutrition Therapy (MNT), lack of adherence is a common problem. One of the possible explanations is the approach provided by health professionals. Providing patients with generic nutritional advice does not constitute MNT, but rather describes the control arm of large studies which offer no improvements in metabolic markers.
Based on the lack of efficacy associated with generic nutritional messages e.g. food plates, handing out pamphlets of ‘foods allowed and foods to avoid’- these should be avoided as they are not a substitute for comprehensive MNT.
The recommendation goes on to emphasise the role of the Registered Dietician (RD) in supporting and individualising adoption of the dietary interventions. “The RD should assess the patient and provide individualized nutrition and behaviour modification education during regular monitoring sessions”. (The above quotations are found on p 26,27 of the recommendations in the on-line document).
An important principle of lifestyle modification, expertly articulated by Lifestyle guru Dr Dean Ornish, is of the Spectrum of intervention.
On one side of the spectrum of lifestyle is the typical western diet which is highly destructive to health and longevity, and on the other side is a somewhat restrictive but highly health-promoting diet consisting of a whole foods, plant-based diet.
Between those opposite poles, any intervention will bring some benefits. The more you shift towards the whole-food diet, the better your outcomes. You have to decide to what point you want to aim and what outcomes you desire. The present recommended dietary Medical Nutrition Therapy is significantly more to the whole-food end of the spectrum than previous recommendations, and certainly very different from the ketogenic (Banting) diet so many people promote.
The problem with consensus statements is that they are by nature a compromise, to pander to the demands of so many interest groups and differing perspectives. Certainly with the statements coming out of the USA, required conflict of interest disclosures indicate that experts are often sponsored by various pharmaceutical industries or agro-business that may very well have vested interests in certain recommendations. The South African document does not provide disclosures of such vested interests. In the USA and possibly other Western countries, organisations like the American Egg Board and other Agro-business lobby groups have major influence through politicians on policies.
For instance in the USA it is the Department of Agricultural that sets national dietary guidelines, thus acting as both player and referee. Those same lobby groups provide funding for research and costs involved in congresses and publications, thus subtly influencing outcomes. I like to believe that our South African experts are not unduly influenced by pressure groups.
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I have been told by various professional colleagues that you will never persuade South Africans to give up their traditional fare of ‘boerewors, braais and shisa nyama’. Of course once people start having heart attacks at 40 and 50 years of age, or suffer with debilitating obesity, diabetes, or arthritis or develop high blood pressure, it may be a bit late to try to undo the damage. But there are enough people around who are waking up to the role we can play in both preventing and reversing this tide of chronic disease sapping the vital force of our beautiful country.
Perhaps it is time for us to not just be satisfied with some change, but to aim for the best outcomes, the best opportunities to live a vibrant life. And that is possible for all of us.
In our next article we will look at the results of research and experience from many sources in the Lifestyle Medicine fraternity, who are offering dramatic improvements in the quality and quantity of life with a diet that is delicious, varied and healthful.
In the mean time take charge of your health. There is a good Biblical injunction about the wide gate and the broad road that leads to destruction and many people follow that route. In contrast the route to life is narrow and takes courage and discipline and only a few people choose that route. Just because the majority goes with the flow of what is nice and easy and cultural doesn’t bode well for their future health.
Choose the path to abundant, healthy life this week.
Dave Glass
Dr David Glass graduated from UCT in 1975. He spent the next 12 years working at a mission hospital in Lesotho, where much of his work involved health education and interventions to improve health, aside from the normal busy clinical work of an under-resourced mission hospital.
He returned to UCT in 1990 to specialise in obstetrics/gynaecology and then moved to the South Coast where he had the privilege of, amongst other things, ushering 7000 babies into the world. He no longer delivers babies but is still very clinically active in gynaecology.
An old passion, preventive health care, has now replaced the obstetrics side of his work. He is eager to share insights he has gathered over the years on how to prevent and reverse so many of the modern scourges of lifestyle – obesity, diabetes, ischaemic heart disease, high blood pressure, arthritis, common cancers, etc.
He is a family man, with a supportive wife, and two grown children, and four beautiful grandchildren. His hobbies include walking, cycling, vegetable gardening, bird-watching, travelling and writing. He is active in community health outreach and deeply involved in church activities. He enjoys teaching and sharing information.
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