Chapter 10. Whole of System Reform: Health Coaching Central to Reversal & Remission of Metabolic & Mental Illness.

We welcome your use of this resource but please cite:

PSGRNZ (2026) Reclaiming Health: Reversal, Remission & Rewiring. Understanding & Addressing the Primary Drivers of New Zealand’s Metabolic & Mental Health Crisis. Bruning, J.R., Physicians & Scientists for Global Responsibility New Zealand. ISBN 978-1-0670678-2-3

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New Zealand is an early adopter of integrative health coaching, involving goal setting with values and a sense of purpose. This is distinct from a medical model.[1] Long-term dietary changes are not conventionally viewed as clinical treatment, in the way that pharmaceutical drugs are regarded. An increasing volume of scientific data challenges this perspective.

Health coaching has evolved to predominantly support patients with T2DM and/or other metabolic and brain-related conditions to change food habits and behaviours to reduce carbohydrate intake and increase healthy fat and protein intake. The use of continuous glucose monitoring (CGM) in glycaemic and weight control (discussed later in this section) in addition to health coaching, may potentiate patient improvements.[2]

Coaching involves food and nutrition education, and the attainment of skills to support individuals to navigate daily challenges. Individuals can be assisted to make small and large changes, often revolving around attainment of long-term goals, that gradually become healthy habits and which become embedded as praxis. Coaching and support groups often focus on the management of environmental triggers and behaviour associated with food addiction and recognising the role of wrap-around, complimentary services. [3] [4]

New Zealand Primary Health Organisations (PHOs) offer community-based services under an integrated primary mental health and addiction services (IPMHA) that has the aim of building ‘people’s motivation and capability to better understand and actively manage their physical and emotional wellbeing needs’. [5] In 2025 PHO Health Improvement Practitioners and Health Coaches were more likely to be predominantly directed toward general social or life-coaching’ functions. People working within the IPMHA framework may support skills development, but they are not specifically tasked with addressing diet and nutrition in ways that would reduce risk for prediabetes, diabetes, cardiovascular disease and improve brain health.[6]

The Te Whatu Ora documentation defining the scope and requirements of Health Coaching, including training standards and learning outcomes, does not include reference to diet or nutrition.[7] [8]

However, in January 2026, Health New Zealand appointed Collaborative Aotearoa, a membership-based network of primary and community health organisations and partners, in partnership with Prekure, a New Zealand-based health coach training provider, as a provider for the Integrated Primary Mental Health and Addiction (IPMHA) Health Coach Training programme.[9] Prekure’s core focus is nutritional science and behaviour change to support health. As a result, the content and orientation of IPMHA health coach training may shift towards a stronger emphasis on dietary nutrition.

A recent study, Redefining Diabetes Care in New Zealand reported significant health improvements, including weight loss, reduced medication burden, and increased energy with a health coach model.: [10]

An increasing number of GPs are now able to refer patients to health coaches and wellbeing advisors, called Health Improvement Practitioners. These healthcare providers are now employed either within a GP clinic or in a Primary Health Organisation (a cluster of clinics which work together to care for patients who are registered with them).[11]

Figure 11. Zinn C, Campbell JL, Po M. et al. (2024) Redefining Diabetes Care: Evaluating the Impact of a Carbohydrate-Reduction, Health Coach Approach Model in New Zealand. Journal of Diabetes Research.

Low-Carb Approaches in New Zealand: 2025 Audit of Three Primary Care Practices.

Audits of clinical data can provide real-world insight into the outcomes of clinical interventions. U.K.-based Dr David Unwin has argued that clinical audits should not be a poor cousin to other forms of research:

They both start with a question, both expect the answer to inform, change or influence clinical practice, both require formal data collection on patients and both depend on using an appropriate method and design to reach sound conclusions.[12] [13]

Lead author Caryn Zinn of the Redefining Diabetes Care paper, together with colleagues specialising in low-carbohydrate interventions, subsequently conducted a retrospective, observational, real-world clinical audit across three New Zealand-based primary care practices, as a service evaluation, to assess models of care and clinical outcomes. The audit aimed to:

Describe changes in glycosylated haemoglobin (HbA1c) and diabetes status;

Identify factors associated with HbA1c improvement; and

Examine changes in related cardiometabolic outcomes. [14]

The three primary care practices utilise a three-pronged approach as a model of care that seeks to manage and potentially reverse prediabetes and T2DM which integrates (a) whole-food, carbohydrate-reduction, (b) a health-coach approach, and (c) supportive community initiatives.

While the methods were consistent (GP oversight, carbohydrate-reduction guidance, and access to health coaching), approaches differed, such as session frequency, content, mode of delivery, and cultural tailoring. These differences were associated with funding models, community-based education opportunities, and the extent of group or peer-support initiatives available at each site which were also a function of local demographics and cultural context. [15]

While the authors acknowledged limitations, including its retrospective design and lack of a control group, the study provided important insight into the consistency of outcomes across diverse settings that flexibly accounted for local culture, practice variation, and community resourcing. Importantly, the study included substantial Māori and Pasifika representation, key groups that experience elevated risk of prediabetes and T2DM. One practice that serves a high Māori and low socio-economic population multiple patients experienced substantial improvements in HbA1c levels, including to under the T2DM range.

44.4% of patients with PD achieved normal HbA1C levels at follow-up, 32.1% of those with T2D at baseline were able to reverse their condition.

The paper noted the importance of long-term support:

Anecdotal clinician feedback suggests that adherence often fluctuates, with patients cycling between engagement and lapses before re-committing. This aligns with findings from Unwin et al., where longer time on a low-carbohydrate programme correlated weakly with smaller HbA1c improvements, likely reflecting reduced adherence rather than loss of intervention efficacy.

The study provides evidence of the importance of support in communities that experience high risk of prediabetes and T2DM due to ethnicity and/or low-socioeconomic status.

These findings highlight the importance of culturally and systemically aligned models of care in populations facing longstanding inequities in access to effective T2D management. Such diversity and pragmatic design enhance generalisability compared with tightly controlled trials.

The Zinn et al 2025 paper joins an increasing group of case studies which demonstrate that the health coach model can be rolled out in general practice clinics, in the private sector and in communities, and that the resultant dietary changes produce improvements in metabolic and mental health and reduce dependency on medication.[16] [17] [18]

Proof of the health coaching for remission of T2DM concept had been earlier demonstrated by a UK-based medical (general practitioner) Norwood NHS Surgery, spearheaded by Drs David and Jen Unwin. There is now sufficient published evidence that: [19]

Type 2 diabetes remission (defined as an HbA1c < 48 mmol mol) should be considered as a treatment goal for people living with T2DM (especially for those within 6 years from being diagnosed). The ability to achieve this may be influenced by duration of diabetes, weight loss and gender.

Based on the evidence from clinical trials weight loss (typically 15 kg or greater) is the main driver and predictor of remission.

Drug expenditure can be expected to decline as risk indicators improve. UK case study: average Norwood surgery spend was £4.94 per patient per year on drugs for diabetes compared with £11.30 for local practices. In the year ending January 2022, Norwood surgery spent £68 353 per year less than the area average.

The UK-based Unwin clinic commenced low-carbohydrate health coaching in 2013 after Dr David Unwin recognised that without intervention, the 27% diabetes practice population rate would continue to expand. The goal was to achieve T2DM remission and address food addiction. Resistance in the practice was so severe that the dietician left, and the other doctors wanted to have nothing to do with it. By 2024, the entire practice was on board with the programme. The clinic has become a global case study for the reversal and remission of T2DM with clinicians across the UK have since adopted the principles initiated by the Unwin clinic. [20]

Patients could elect to adopt the programme, which included dietary advice, food addiction counselling and a weekly support group meeting. After a decade people in the initial group remain, to support new entrants. Dr Jen Unwin, a former NHS clinical psychologist, joined the team to address food addiction challenges.

The initial programme was controversial. The Unwin team recorded a wide range of data points, publishing their findings in a series of papers in scientific journals to document progress at the 8-month[21], six[22] and eight-year stages to ensure that key biomarkers were tracked to ensure maximum transparency. Colleagues had expressed concern about the impact of increased protein on kidney function. The clinic tracked renal function, recording that serum creatine markers improved significantly.[23]

Findings included a decrease in health system costs. This included a decrease in medication expenditure, reduction in multimorbidity, and the potential decreased pressure on the public health system with fewer patient visits over time.[24] [25] The intervention:

‘delivered significant improvements in HbA1c with 20% of the practice’s population achieving drug-free T2D remission. There have also been a range of important cardiovascular risk factor improvements. Diabetes drug savings are £68 353 per year compared with the local average. These savings are likely to be dwarfed by cost savings from reduced complications of T2D and days lost from work.[26]

Figure 12. Reversal NZ. Prekure. (August 2022). The Nutrition Ladder. HTTPS://REVERSALNZ.CO.NZ/2022/08/21/THE-NUTRITION-LADDER/

The low-carbohydrate approach has been adapted for New Zealand by local organisations such as Reversal NZ and Prekure. To help patients and clients take dietary steps to reduce their ultraprocessed food and carbohydrate intake, Reversal and Prekure have released a nutrition ladder to highlight different and graduated dietary approaches, and their potential impact on health status.[27]

In Australia, anaesthetist Rod Tayler and fitness professional Jamie Taylor founded the Low Carb Downunder website[28] as an information gateway on the subject of restricting carbohydrate intake for long-term health benefits.

A dietary shift to a low-carbohydrate, higher fat diet in New Zealand may be affordable for the majority of people. A 2019 review concluded that total daily costs were $43.42 (national guidelines) and $51.67 (LCHF) representing an $8.25 difference, or $2.06 per person, with the LCHF meal plan being the costlier option. [29]

Deprescribing Following Improvements in Blood Pressure, Insulin, Weight and Lipid Profile.

Low-carbohydrate diets can result in decreases and changes in blood pressure, lipid profiles and other biomarkers of inflammation. As these markers change, doctors can adjust or deprescribe medication as patient parameters change.[30] Deprescribing is the:

systematic process of identifying and discontinuing drugs when existing or potential harms outweigh existing or potential benefits within the context of an individual patient’s care goals, functional status, life expectancy, values, and preferences.[31]

A Consensus Report (2022) by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) emphasised the individual’s role in T2DM including undertaking glucose lowering interventions, which could incorporate behavioural shifts, low-carbohydrate approaches and shared decision-making, along with traditional medical measures. The Consensus Report recognised the potential for remission, but that an individualised approach for T2DM would reflect personal capacity.

The Consensus Report emphasised the importance of long-term glycaemic management to stem the often-microvascular systemic risks associated with a failure to control glucose, including cardiovascular risk factors, organ degeneration (e.g. kidney) and cognitive decline.[32]

Programmes can support patient-centred change.[33] [34] A Lancet (2025) paper emphasised the need for long-term individualised approaches and cautioned against remission being viewed as a ‘static endpoint’.[35] Author Professor Kamlesh Khunti noted that:[36]

By re-evaluating current definitions, acknowledging the progressive nature of type 2 diabetes, and embracing individualised approaches to glycaemic control, remission can be redefined as a dynamic continuum rather than a static endpoint.

Type 2 diabetes remission could be viewed as a spectrum, from medication-supported to drug-free states. This more flexible and inclusive approach would better reflect real-world care and make remission a more relevant outcome in both clinical practice and research.

Sustained control of hyperglycaemia, along with reducing adiposity [body fat] – whether through surgical, medical, or lifestyle interventions – could be more relevant than remission itself.

Deprescribing can be difficult due to the fear of negative consequences, lack of knowledge relating to choices on how and the timing of deprescribing, and the systemic barriers which encourage prescribing but fail to support deprescribing or acknowledge the problem of multimorbidity and inappropriate polypharmacy. [37]

Chapter 11. Whole of System Reform: Keys to Success.

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REFERENCES

NB: Number order differs from the original Reclaiming Health publication (PDF).

[1] Wolever RQ, Caldwell KL, Wakefield JP et al. (2011) Integrative Health Coaching: An Organizational Case Study. Explore, 7(1):30-36. DOI: 10.1016/j.explore.2010.10.003

[2] Taylor PJ, Thompson CH, Brinkworth GD. (2018). Effectiveness and acceptability of continuous glucose monitoring for type 2 diabetes management: A narrative review. J Diabetes Investig. 9(4):713-725. DOI: 10.1111/jdi.12807.

[3] Zinn C, Campbell JL, Po M. et al. (2024) Redefining Diabetes Care: Evaluating the Impact of a Carbohydrate-Reduction, Health Coach Approach Model in New Zealand. Journal of Diabetes Research. 2024:4843889, DOI:10.1155/jdr/4843889

[4] Zinn C, Campbell JL, Fraser L. et al. (2025) Carbohydrate Reduction and a Holistic Model of Care in Diabetes Management: Insights from a Retrospective Multi-Year Audit in New Zealand. Nutrients.17(24):3953.

[5] Te Whatu Ora (Feb 2024). Integrated Primary Mental Health & Addictions HCES. Updated practice profile. February 2024. https://d2ew8vb2gktr0m.cloudfront.net/files/Updated-IPMHA-Practice-Profile-Te-Whatu-Ora-Feb-24.pdf

[6] Te Pou (2026). Integrated primary mental health and addiction. https://www.tepou.co.nz/initiatives/integrated-primary-mental-health-and-addiction

[7] Te Whatu Ora (Feb 2024). Integrated Primary Mental Health & Addictions HCES. Updated practice profile.

[8] Te Pou. Health Coaching. https://www.tepou.co.nz/initiatives/integrated-primary-mental-health-and-addiction/health-coaching

[9] Scoop (January 20, 2026). PREKURE And Collaborative Aotearoa Appointed To Build Aotearoa’s "Primary Care-Ready" Health Coach Workforce. https://www.scoop.co.nz/stories/GE2601/S00026/prekure-and-collaborative-aotearoa-appointed-to-build-aotearoas-primary-care-ready-health-coach-workforce.htm?

[10] Zinn C, Campbell JL, Po M. et al. (2024) Redefining Diabetes Care: Evaluating the Impact of a Carbohydrate-Reduction, Health Coach Approach Model in New Zealand. Journal of Diabetes Research. 2024:4843889, DOI:10.1155/jdr/4843889

[11] Zinn C, Campbell JL, Po M. et al. (2024) Redefining Diabetes Care.

[12] Wade DT. (2005). Ethics, audit, and research: all shades of grey. BMJ 330:468–71.

[13] Unwin D. (2024) Reducing overweight and obesity; so how are we doing? BMJ Nutrition, Prevention & Health 0:e000836. DOI:10.1136/bmjnph-2023-000836

[14] Zinn C, Campbell JL, Fraser L. et al. (2025) Carbohydrate Reduction and a Holistic Model of Care in Diabetes Management: Insights from a Retrospective Multi-Year Audit in New Zealand. Nutrients.17(24):3953. Page 3.

[15] Zinn C, Campbell JL, Fraser L. et al. (2025) Carbohydrate Reduction and a Holistic Model of Care. Page 3.

[16] Saner E, Kalayjian T, Buchanan L et al. (2025) TOWARD: a metabolic health intervention that improves food addiction and binge eating symptoms. Front. Psychiatry. Vol.16. DOI: 10.3389/fpsyt.2025.1612551

[17] Zinn C, Campbell JL, Po M. et al. (2024) Redefining Diabetes Care: Evaluating the Impact of a Carbohydrate-Reduction, Health Coach Approach Model in New Zealand. Journal of Diabetes Research. 2024:4843889, DOI:10.1155/jdr/4843889

[18] Unwin J, Delon C, Giæver H, et al. (2022) Low-carbohydrate and psychoeducational programs show promise for the treatment of ultra-processed food addiction. Front. Psychiatry 13:1005523.

[19] Unwin D, Delon C, Unwin J, et al. (2022) What predicts drug-free type 2 diabetes remission?

[20] Kelly, T, Unwin, D, Finucane, F. (2020). Low-Carbohydrate Diets in the Management of Obesity and Type 2 Diabetes: A Review from Clinicians Using the Approach in Practice. Int. J. Environ. Res. Public Health 2020, 17, 2557. DOI: 10.3390/ijerph17072557

[21] Unwin D and Unwin J. (2014). Low-carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice. Practical Diabetes 2014:31;2:76-79. DOI: 10.1002/pdi.1835

[22] Unwin D, Khalid AA, Unwin J, et al. (2020). 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:e000072. doi:10.1136/bmjnph-2020-000072

[23] Unwin D, Unwin J, Crocombe D et al, (2021). Renal function in patients following a low-carbohydrate diet for type 2 diabetes: a review of the literature and analysis of routine clinical data from a primary care service over 7 years. Current Opinion in Endocrinology & Diabetes and Obesity 28(5):469-479, DOI: 10.1097/MED.0000000000000658

[24] Xin Y, Davies A, Briggs A, McCombie L, Messow CM, Grieve E, et al. (2020). Type 2 diabetes remission: 2 year within‐trial and lifetime‐horizon cost‐effectiveness of the Diabetes Remission Clinical Trial (DiRECT)/counterweight‐plus weight management programme. Diabetologia.63(10):2112–22

[25] Brown A, McArdle P, Taplin J, Unwin D, Unwin, J, et al. (2022). Dietary strategies for remission of type 2 diabetes: A narrative review. J Hum Nutr Diet. 35:165–178.

[26] Unwin D, Delon C, Unwin J, et al. (2023). What predicts drug-free type 2 diabetes remission?

[27] Reversal NZ. Prekure (Aug. 2022). The Nutrition Ladder. https://reversalnz.co.nz/2022/08/21/the-nutrition-ladder/

[28] Low Carb Down Under. lowcarbdownunder.com.au

[29] Zinn C, North S, Donovan, Muir C, Henderson G. (2019). Low-carbohydrate, healthy-fat eating: A cost comparison with national dietary guidelines. Nutrition & Dietetics, 22(2):283-291. DOI: 10.1111/1747-0080.12534

[30] Murdoch C, Unwin D, Cavan D et al (2019). Adapting diabetes medication for low-carbohydrate management of type 2 diabetes: a practical guide. British Journal of General Practice 69(684): 360-361. DOI: 10.3399/bjgp19X704525

[31] Scott IA, Hilmer SN, Reeve E, et al. (2015) Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 175:827-34. DOI:10.1001/jamainternmed.2015.0324 pmid:25798731

[32] Davies MJ, Aroda VR, Collins BS, et al. (2022) Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2022 Nov 1;45(11):2753-2786. DOI: 10.2337/dci22-0034.

[33] Wheatley SA, Deakin TA, Arjomandkhah NC, et al (2021) Low-carbohydrate Dietary Approaches for People With Type 2 Diabetes—A Narrative Review. Frontiers in Nutrition vol: 8 year: 2021 doi: 10.3389/fnut.2021.687658

[34] Walker L, Smith N, Delon C (2021). Weight loss, hypertension and mental well-being improvements during COVID-19 with a multicomponent health promotion programme on Zoom: a service evaluation in primary care: BMJ Nutrition, Prevention & Health 2021;4. DOI: 10.1136/bmjnph-2020-000219

[35] Khunti K, Papamargaritis D, Aroda VR et al. (2025) Re-evaluating the concept of remission in type 2 diabetes: a call for patient-centric approaches. The Lancet Diabetes & Endocrinology, 13(7): 615 - 634

[36] University of Leicester News (June 18 2025). Experts urge caution against overemphasis on type 2 diabetes remission. https://le.ac.uk/news/2025/june/diabetes-remission-patients-leicester

[37] Hung A, Kim Y H, Pavon J M. (2024) Deprescribing in older adults with polypharmacy BMJ.