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Australian Dietary Guidelines submission

ID: 
72
Personal Details
Organisation Name: 
Australian Diabetes Council
Online comments
Specific comments: 
Chapter 1- Introduction
  • Australian Diabetes Council (ADC) recognises the extensive evidence base that these guidelines have been based on, but are concerned that recent studies from 2010 onwards have not been considered in a systematic way. Furthermore, ADC eagerly awaits the results of the Australian Health Survey 2011-13 and question how these findings may affect the guidelines as the average Australian's dietary habits and the Australian food supply have likely changed significantly since 1995.
  • ADC recommend the Australian Dietary Guidelines (ADG) and the Australian Guide to Health Eating (AGTHE) - report consistent age groups when discussing recommended number of serves of different food groups.

  • ADC welcome the revision of food group serve sizes and the recommended number of serves, but would appreciate further explanation on how these were determined within the guidelines.
  • ADC appreciate the well presented document but suggest the following edits be made:

                  - Type 2 diabetes should not be referred to as “Diabetes” as done several times in this document e.g. page 189

                  - Numerous references to “complex carbohydrates”.  This term is outdated; since 1997 The World Health Organisation have recommended using “starch”. Furthermore The World Health Organisation is against using the terms "extrinsic and intrinsic sugars"(1). ADC suggest revising terminology.

                  - Thorough editing required amending several typos and inappropriate repetition of information e.g. page 49 displays serve size of bread twice in the same table.

  • ADC recognises this document is aimed at healthy Australians, not those with chronic diseases such as diabetes. ADC highlights the need for a specific document targeting the nutritional management of diabetes, similar to the document currently being developed ‘NHMRC Clinical Practice Guidelines for the Management of Overweight and Obesity'

 References

(1) Carbohydrates in human nutrition. Rome, Italy: Food and Agriculture Organization of the United Nations; 1997. Report No.: FAO Food and Nutrition paper - 66.
 
 
Chapter 2- Eat a wide variety of nutritious foods

2.1 Eat a wide variety of nutritious foods

  • Australian Diabetes Council (ADC) agrees in general with that statement “Eat a wide variety of nutritious foods from these five food groups everyday”
  • ADC agrees that consuming a wide variety of nutritious foods may help decrease the risk of diet-related chronic disease and promote Australian’s health and well-being.
  • ADC suggests the inclusion of a sixth food group for monounsaturated (MUFA) and polyunsaturated fatty acid sources including healthy oils, nuts, and seeds. The fine printed text in the Australian Guide to Healthy Eating states "* Includes an allowance for unsaturated spreads or oils, nuts or seeds (4 serves [28-40g] per day for men less than 70 years of age; 2 serves [14-20g] per day for women and older men)." The text should be larger or included in the table as a separate column.
  • ADC suggests when mentioning alternatives to different food groups, examples need to be supplied.

2.2 Plenty of vegetables, including different types and colours, and legumes/beans, and eat fruit

  • Australian Diabetes Council (ADC) agrees with the suggestion for the Australian population to increase the variety of vegetables eaten of varying colours. Currently no guidance on the recommended daily servings of different coloured vegetables has been provided, but would be a valuable edition for practical application.
  • ADC recommends amending the inappropriate references to starchy vegetables as “complex carbohydrates” – this term is outdated.
  • ADC is concerned that the consumer version of the guidelines singles out potatoes as a starchy vegetable to limit. Provided they are not fried, potatoes are as nutritious as rice (2) yet there is no specific recommendation to limit rice consumption. ADC suspects that the intent of this guideline was to decrease potato chip and crisp consumption, which accounts for 60% of potato consumption in Australia, as removal of the potato skin, deep frying and the generous addition of salt detrentally affect the potatoes nutrient profile (2). This should be stated in the guidelines, rather than vilifying all potatoes.
  • ADC disagree with the comment that some processed fruit and vegetables are ok as long as it is ‘without added sugar’ (page 43). Small amounts of added sugar are considered acceptable in a healthy balanced diet. Furthermore, sugar can be useful in small amounts to improve the palatability of nutritious foods and therefore increase the likelihood of consumption.
  • ADC suggest including a statement in regards to canned foods to discourage tinned vegetables that are high in sodium and tinned fruit in syrup. Rather encourage Australians to choose tinned vegetables with lower sodium levels and fruit tinned in natural juices.
  • ADC recommend including guidance on choosing healthy low GI fruit and vegetables. There is very strong evidence for the benefits of choosing low GI foods in assisting with weight loss (3-5), preventing type 2 diabetes (6) and certain cancers (6, 7).

 2.3 Grain (cereal) foods (mostly wholegrain)

  • Australian Diabetes Council (ADC)  - calls for greater clarity in defining “wholegrain”. The current explanation is confusing and unclear.
  • ADC agrees with the recommendation for the Australian population to increase their daily intake of wholegrain foods, but ADC recommends this be quantified and that an accompanying statement be included to decrease refined grain/starch consumption as there is evidence that people misinterpret this guideline and consequently consume more total starch (8).
  • ADC recommends using the preferred terminology of ‘starch’ in place of ‘complex carbohydrates’, as this term is out-dated.
  • ADC supports the revised serve sizes for grain foods, which are now closer to a carbohydrate exchange (1 exchange = 15g carbohydrate) making interpretation easier for people living with diabetes.
  • ADC is concerned the large reduction in recommended number of serves for grain foods could inappropriately encourage a low carbohydrate intake, as Australians already eat a relatively small proportion of carbohydrates (9). ADC would appreciate further explanation on how these recommendations were developed within guidelines.
  • ADC recommends including guidance on choosing healthy low GI grain products. There is very strong evidence that healthy low GI diets assist with weight loss (3-5), the prevention of type 2 diabetes (6) and certain cancers (6, 7).

2.4 Lean meat and poultry, fish, eggs, nuts and seeds, and legumes/beans

  • Australian Diabetes Council (ADC) questions the appropriateness of increasing the recommended number of serves from this group, while data shows Australians are already consuming more protein than required (9, 10).
  • ADC suggests including further advice on the number of serves of each protein food over the course of the week. e.g. eggs? as there is evidence that high egg consumption may increase the risk of developing type 2 diabetes and cardiovascular disease (11-15).
  • ADC suggests using a consistent serve size for legumes since they appear in both the meat and vegetable group.

2.5 Milk, yoghurt, cheese and/or alternatives (mostly reduced fat)

  • Australian Diabetes Council (ADC) agrees with specifying serve size of hard and soft cheeses separately to highlight the reduced calcium content of soft cheeses.
  • ADC recommends including a specific mention to ensure when choosing milk substitute products, choose those fortified with calcium.
  • ADC recommends adding serving sizes of custard, salmon with edible bones and almonds as alternatives (as done in 2003 ADG).

2.6 Water

  • Australian Diabetes Council (ADC) agrees with the promotion of tap water, but suggests further emphasis on clean and fresh tap water.
  • ADC would prefer emphasis be given to the benefit of maintaining a healthy lifestyle (diet and physical activity) in the prevention of type 2 diabetes, rather than the promotion of coffee consumption.

 References

(2) Department of Community Services and Health. NUTTAB95 nutrient data table for use in Australia. Canberra: Australian Government Publishing Service; 1995.

(3) Thomas DE, Elliott EJ, Baur L. Low glycaemic index or low glycaemic load diets for overweight and obesity. Cochrane Database Syst Rev 2007 Jul 18;(3):CD005105.

(4) Papadaki A, Linardakis M, Larsen TM, van Baak MA, Lindroos AK, Pfeiffer AF, et al. The effect of protein and glycemic index on children's body composition: the DiOGenes randomized study. Pediatrics 2010 Nov;126(5):e1143-e1152.

(5) Larsen TM, Dalskov SM, van Baak M, Jebb SA, Papadaki A, Pfeiffer AF, et al. Diets with high or low protein content and glycemic index for weight-loss maintenance. N Engl J Med 2010 Nov 25;363(22):2102-13.

(6) Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T, Mitchell P, et al. Glycemic index, glycemic load, and chronic disease risk--a meta-analysis of observational studies. Am J Clin Nutr 2008 Mar;87(3):627-37.

(7) Dong JY, Qin LQ. Dietary glycemic index, glycemic load, and risk of breast cancer: meta-analysis of prospective cohort studies. Breast Cancer Res Treat 2011 Apr;126(2):287-94.

(8) Brownlee IA, Moore C, Chatfield M, Richardson DP, Ashby P, Kuznesof SA, et al. Markers of cardiovascular risk are not changed by increased whole-grain intake: the WHOLEheart study, a randomised, controlled dietary intervention. Br J Nutr 2010 Jul;104(1):125-34.

(9) ABS. National Nutrition Survey: Nutrient intakes and physical measurements, Australia 1995. [ABS Catalogue no. 4805.0]. 1995. Canberra, Commonwealth of Australia.

(10) National Health and Medical Research Council. Nutrient reference values for Australia and New Zealand including Recommended Dietary Intakes. Canberra: Commonwealth of Australia and New Zealand Government; 2005.

(11) Djousse L, Gaziano JM, Buring JE, Lee IM. Egg consumption and risk of type 2 diabetes in men and women. Diabetes Care 2009 Feb;32(2):295-300.

(12) Djousse L, Kamineni A, Nelson TL, Carnethon M, Mozaffarian D, Siscovick D, et al. Egg consumption and risk of type 2 diabetes in older adults. Am J Clin Nutr 2010 Aug;92(2):422-7.

(13) Hu FB, Stampfer MJ, Rimm EB, Manson JE, Ascherio A, Colditz GA, et al. A prospective study of egg consumption and risk of cardiovascular disease in men and women. JAMA 1999 Apr 21;281(15):1387-94.

 (14) Feskens EJ, Kromhout D. Habitual dietary intake and glucose tolerance in euglycaemic men: the Zutphen Study. Int J Epidemiol 1990 Dec;19(4):953-9.

(15) Liese AD, Weis KE, Schulz M, Tooze JA. Food intake patterns associated with incident type 2 diabetes: The Insulin Resistance Atherosclerosis Study. Diabetes Care 2009 Feb;32(2):263-8.

(16) Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low-sodium diet vs. high-sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride (Cochrane Review). Am J Hypertens 2012 Jan;25(1):1-15.

(17) Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database Syst Rev 2011 Jul 6;(7):CD009217.

(18) Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 2011 Jun 23;364(25):2392-404.

 

 

Chapter 3- Limit intake of foods and drinks containing saturated and trans fats, added salt, added sugars and alcohol

3.1 Limiting intake of foods and drinks containing saturated and trans fat

  • Rather than simply limiting saturated and trans fats, Australian Diabetes Council (ADC)  recommends further emphasis be made on the importance of including small amounts of unsaturated fats in a balanced diet. The document encourages "only a small amount of unsaturated fat” (page 80), ADC suggests omitting the word ‘only’ to read  “Include small amounts of unsaturated fats”.
  • There is no systematic literature review to support the recommendation to limit saturated and trans fats.
  • ADC is concerned with the document discussion on the Australian population’s intake of total fat remaining constant, but now constituting a lower proportion of total energy intake due to increased carbohydrate intake (page 80). ADC is concerned this comment may inappropriately discourage the consumption of healthy carbohydrate foods.
  • This document refers to ‘invisible fat’ (page 80), ADC feel this terminology is potentially confusing and suggest rewording or including a definition in the document glossary.
  • ADC suggests including examples of oily fish.
  • ADC recommends including an explanation of ‘discretionary’ foods and inclusion of serve sizes for these foods.

3.2 Limit intake of food and drinks containing added salt

  • Australian Diabetes Council (ADC)  agrees with encouraging the public to limit intake of food and drinks containing added salt, but not to avoid products containing important nutrients such as bread, cereals and cheese.
  • ADC agrees with encouraging the public to read food labels.
  • ADC notes that two Cochrane reviews have been published since the systematic literature review process was formerly completed; one on risk factors for cardiovascular disease (16) and the other CVD (17). The evidence from these papers needs to be considered in the final drafting of this guideline.

3.3 Limit intake of foods and drinks containing added sugars

  • Australian Diabetes Council (ADC) recommends amending the inappropriate reference to "extrinsic sugars" and "intrinsic sugars"  as The World Health Organisation is against using the terms (1).
  • ADC questions the large emphasis placed on added sugars being associated with weight gain as this is not evidence based. Evidence suggests it is any excess kilojoules, from a variety of foods and nutrients that is strongly associated with weight gain, and not sugar alone (18).
  • ADC is concerned this guideline may inappropriately discourage Australians to avoid nutritious products containing added sugars, e.g. yoghurt and milk. ADC urges the NHMRC to recognise the importance of small amounts of sugar in increasing the palatability of nutritious foods and in-turn increasing the likelihood of consumption and optimising the populations nutrition status.
  • Since it is difficult for consumers to differentiate between natural and added sugars when reading a nutrition information panel, ADC is concerned this guideline could inappropriately discourage the consumption of foods containing natural sugars, e.g. fruit and milk.
  • The evidence presented in this document refers to ‘sugar-sweetened beverages’ and ‘soft drinks’ being associated with either weight gain, dental caries or reduced bone strength (page 88). Therefore ADC suggest further emphasis be made in the guidelines to ‘limit soft drinks, cordials, fruit drinks and flavoured waters containing added sugars’ rather than foods containing added sugars.

3.4 Alcoholic drinks

  • Australian Diabetes Council (ADC) appreciates the specific reference to people with diabetes to take special precautions and to speak with a health professional (page 100). ADC suggests including a similar discussion addressing people with diabetes under each guideline of this document, not just alcohol.
  • ADC recognises the Australian population’s confusion on what a standard drink is. ADC suggests including an explanation and list of examples of a standard drink, e.g. full strength beer, light beer, spirits, fortified wine.
  • ADC suggests including further discussion about the potential health benefits of abstaining from alcohol.
  • ADC suggests clarifying the level of alcohol intake that prevents 1% of total disease burden (page 93).

 References

(1) Carbohydrates in human nutrition. Rome, Italy: Food and Agriculture Organization of the United Nations; 1997. Report No.: FAO Food and Nutrition paper - 66.

(16) Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low-sodium diet vs. high-sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride (Cochrane Review). Am J Hypertens 2012 Jan;25(1):1-15.

(17) Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database Syst Rev 2011 Jul 6;(7):CD009217.

(18) Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 2011 Jun 23;364(25):2392-404.

 

Chapter 4- Achieve and maintain a healthy weight
  • Australian Diabetes Council (ADC) agrees with the emphasis of terminology on ‘healthy weight’, rather than overweight/obese/underweight.
  • ADC appreciates the inclusion of waist measurement guidelines in signifying overweight men and women (page 106). ADC suggests also including comments on the degree of risk of type 2 diabetes with increasing waist measurements in the executive summary.
  • ADC appreciates the documenting that “many obese-related conditions are preventable and several are at least partially reversible through weight loss achieved by adopting a nutritious dietary pattern and active lifestyle” (page 107). This assists in clarifying an important point that is often misinformed in today’s media with many ‘fad’ diets suggesting a cure for type 2 diabetes.
  • The document advises increased evidence that the relative proportions of macronutrients consumed can affect risk of chronic disease; e.g. proportion of type of fat or carbohydrate. This could potentially encourage people to restrict healthier food sources of macronutrients and impact their overall nutritional health and wellbeing.
  • ADC suggests distinguishing wholegrain carbohydrate foods from refined carbohydrate foods, rather than grouping them together as ‘cereal-based foods’. For example ‘Increased energy consumption in the decade or so to 1995 was largely driven by cereal-based foods, confectionery and sugar-sweetened drinks’ (page 111).
  • ADC suggests quantifying a “moderate” intake of carbohydrate to support the statement “Dietary patterns which tend to be relatively low in total fat and moderately (not high) in carbohydrates are consistent with reduced risk of excessive weight gain” (page 120).
  • ADC is concerned with the comment "protein-rich foods and dietary patterns have a greater effect on satiety than foods and dietary patterns that are high in fat and carbohydrate" (page 120). ADC feels this ignores the distinguishing properties of carbohydrates e.g. low glycemic index and wholegrain.
  • ADC agrees with the comment that “the community as a whole has a social responsibility” to manage the obesogenic environment (page 121), however ADC would also like further emphasis on the government and food industry responsibilities.
  • ADC suggests including a description of the “average size person” (page 123).
  • ADC supports the important role of physical activity in management of chronic disease.
  • ADC agrees with the emphasis on energy rather than macronutrients.
  • ADC would prefer the terminology of ‘monitor’ rather than ‘measure’ (page 103) to avoid inadvertently increasing the risk of eating disorders.
  • ADC suggests including information on the benefits of choosing low glycemic index foods in achieving and maintaining a healthy weight (3-5).

References

(3) Thomas DE, Elliott EJ, Baur L. Low glycaemic index or low glycaemic load diets for overweight and obesity. Cochrane Database Syst Rev 2007 Jul 18;(3):CD005105.

(4) Papadaki A, Linardakis M, Larsen TM, van Baak MA, Lindroos AK, Pfeiffer AF, et al. The effect of protein and glycemic index on children's body composition: the DiOGenes randomized study. Pediatrics 2010 Nov;126(5):e1143-e1152.

(5) Larsen TM, Dalskov SM, van Baak M, Jebb SA, Papadaki A, Pfeiffer AF, et al. Diets with high or low protein content and glycemic index for weight-loss maintenance. N Engl J Med 2010 Nov 25;363(22):2102-13.

 

 

Chapter 5- Encourage and support breastfeeding

Australian Diabetes Council supports this guideline.

 

 

Chapter 6- Food safety

Australian Diabetes Council supports this guideline.

 

 

Appendices

Comments on The Australian Guide to Healthy Eating (AGTHE) document

  • Australian Diabetes Council (ADC)  supports the separation of unsaturated fats from saturated fats. However ADC suggests including unsaturated fats as part of the plate model.
  • ADC would prefer all images of bread to be multigrain rather than white to help reinforce the wholegrain message.
  • Margarine tubs are rarely labelled “unsaturated”. Rather than having one tub of margarine labelled “unsaturated”, ADC would be prefer two tubs, one representing “Monounsaturated”, and the other “Polyunsaturated”.
  • ADC recommends using images of real foods only, rather than a mixture of real foods and illustrations.
  • ADC suggests displaying canned legumes in protein section alongside meat, fish, chicken and nuts (similar to vegetable section).
  • ADC recommends breaking the vegetables in to starchy and non-starchy sections to aid education.
  • ADC suggests including an explanation of each food group, along with practical meal or snack to help the Australian population reach their recommended number of serves for each food group.
  • ADC suggests including an explanation on water and fluids.
  • ADC suggests including an explanation of “discretionary” choices and serve sizes.
  • ADC would appreciate the provision of information on how to determine the number of additional serves from the five food groups or discretionary foods for taller or more active Australians as in previous version.
  • ADC suggests providing advice on choosing healthier options to make up additional serves for taller and more active Australians. Without this some groups may inappropriately choose only discretionary foods. For example: a tall and active male aged 19-51 may inappropriately choose three additional serves of high fat (particularly saturated fat), high sodium and nutrient-poor foods.
  • ADC suggests including an explanation of different types of fats, their sources and their effects on health.
  • ADC suggests including directions to choose foods lower in salt (sodium) and to avoid adding salt to cooking and at the table.
  • ADC suggests including information on wholegrain foods and fibre.
  • ADC supports the important role of physical activity in management of chronic disease and weight, and recommends it be mentioned in the AGTHE.

 

Page reviewed: 3 January, 2013