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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In conclusion, substantial evidence indicates that current dietary guidelines have not stemmed rising rates of metabolic and mental disorders and, in several respects, may be contributing to the progression of illness. Health is complex, multifactorial, and dynamic. As defined by the World Health Organization:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.[1]

The onset of multimorbidity at earlier ages is strongly associated with poorer long-term outcomes. Rising rates of multimorbidity, alongside equity in medication prescribing, are not proxies for improved wellbeing or quality of life.

This Report demonstrates that New Zealand’s health policy has rested on outdated assumptions while nutritional and metabolic science has advanced. Current Ministry of Health positions, echoed by government-aligned organisations, stand in sharp contrast to an expanding body of evidence showing that foundational dietary and supplementary approaches can reverse or mitigate many metabolic and neurological conditions, improving functionality, wellbeing, and quality of life.

Encouragingly, change is already underway. Case and cohort studies consistently show that substantial reductions in refined carbohydrate intake are associated with improvement, remission, and in some cases reversal across a wide range of metabolic and brain-related conditions.[2] [3] There is increasing consensus that compulsive overconsumption of refined carbohydrates, particularly in the form of ultra-processed foods, constitutes a form of substance-use disorder. Health coaching, peer support, and community-based programmes can facilitate dietary change and, in doing so, reduce the burden of metabolic and neurological disorders as well as pharmaceutical dependence.

Dr Jen Unwin, co-partner of the UK clinic that has pioneered approaches to reversing metabolic syndrome, reducing prescribing rates, and improving mental health outcomes, has described counselling, coaching, and support as ‘fantastically cheerful medicine’. Yet conventional therapeutic frameworks do not treat long-term dietary change as a clinical intervention in the same way pharmaceutical treatments are regarded.

The protection and promotion of health require officials to remain abreast of contemporary science concerning the central role of diet and nutrition in metabolic regulation, hormonal balance, and homeostasis. Vulnerable groups, including infants, children and adolescents, pregnant women, and those with elevated metabolic risk, have received insufficient attention. Indeed, agencies currently lack a clear understanding of what constitutes optimal nutrition by age and life stage. Government bodies have consistently failed to examine the relationships between diet quality, nutrient insufficiency, and the physiological demands imposed by age, sex, ethnicity, genetic variability, socioeconomic context, pregnancy, and inflammatory status.

Historic alignment with international dietary frameworks used in Australia, the United States, and Nordic countries has not succeeded in halting or reversing the rise of prediabetes, diabetes, metabolic syndrome, or mental illness. In the decades following the adoption of current guidelines, multimorbidity in younger age groups has increased markedly. Current policy frameworks emphasise the LDL cholesterol marker, minimise the importance of key macronutrients, fat and protein, and fail to link micronutrient sufficiency with optimal physiological function and resilience.

Public-good research in nutrition science, including the investment required to update regulations and policies through transparent reviews of the scientific literature, has been neglected, deprioritised, and underfunded. As a result, independent scientists that can challenge current assumptions are rare, and government policy remains largely silent on the carbohydrate–insulin pathway and insufficiently responsive to individual metabolic risk.

The technology to detect elevated risk for prediabetes is readily available, and the capacity to screen for nutrient deficiencies in people presenting with mental-health conditions is well established. Yet these interventions remain underutilised, restricted, or unrecognised. Over the same period, funding for pharmaceutical access has expanded, while research into drug risks and adverse effects has been comparatively underfunded. Drug trial data are difficult to access, if not opaque, and governments have not provided adequate funding to independently evaluate industry claims or to systematically assess harms alongside benefits.

In these knowledge gaps, officials appear disproportionately focused on potential risks associated with nutritional supplements, despite long histories of safe use and contradictory evidence, while adverse drug risks are largely left to voluntary disclosure by manufacturers. This reflects a deeper contradiction: the Ministry of Health has the authority to set clinical limits for nutrients, yet is not positioned as an authority on optimal nutrition or its role in sustaining metabolic and mental health.

Suboptimal diets and nutrient insufficiencies amplify risk across a broad spectrum of chronic conditions, including metabolic syndrome and complex multimorbidity, yet when knowledge is absent or incomplete, clinicians, families, and patients are denied meaningful choice. Informed consent cannot be achieved when upstream dietary options are neither explained nor endorsed.

This Report, together with the forthcoming companion report on micronutrients and mental health, demonstrates that a longstanding governance culture has placed carbohydrate science, the carbohydrate–insulin model, and nutritional sufficiency outside the scope of formal health policy for decades. Without system-wide correction, continued institutional reticence and gaps in nutritional understanding will perpetuate poor policy and poor outcomes.

There is, however, strong cause for optimism. Current metabolic and mental-health trends are not inevitable. They are reversible. With evidence-based, nutrition-centred health policy, the trajectory of chronic disease in New Zealand can be changed, and health reclaimed. This Report sets out practical pathways to address the primary drivers of the metabolic and mental-health crisis and to reclaim health.

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REFERENCES

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

[1] World Health Organization. Health and Well-being. https://www.who.int/Data/Gho/Data/Major-Themes/Health-and-Well-Being

[2] Zheng, Q., Gao, X., Ruan, X. et al. (2025) Are low-carbohydrate diet interventions beneficial for metabolic syndrome and its components? A systematic review and meta-analysis of randomized controlled trials. Int J Obes DOI:10.1038/s41366-025-01822-5

[3] Athinarayanan SJ, Roberts CGP, Phinney SD et al. (2025). Effects of a continuous remote care intervention including nutritional ketosis on kidney function and inflammation in adults with type 2 diabetes: a post-hoc latent class trajectory analysis. Front. Nutr. Sec. Nutrition and Metabolism, Vol 12 – 2025, DOI: 10.3389/fnut.2025.1609737

We welcome your use of this resource but please cite:

PSGRNZ’s proposals for reform involves the implementation of high-level strategic science, regulatory and science system shifts, in addition to community and practitioner led wrap-around policies that directly support people in the short-term to pivot long-term to dietary habits that support metabolic health.

PSGRNZ broadly supports Professor Grant Schofield’s proposal:[1]

Investing in prevention: A minimum 15% of the health budget will be allocated to chronic disease prevention and 5% to mental health services.
Reforming food policy: Stronger nutrition labelling, reduced unhealthy food marketing, and ultraprocessed food tax measures.
Reducing medication reliance: Encouraging ‘social prescribing’ so GPs can refer patients to exercise, nutrition support, and mental health therapy before medication.
Expanding public health workforce: Training more health coaches and lifestyle medicine experts to support behaviour change.
Ensuring accountability: A National Health Reform Taskforce with executive powers will monitor progress, report on key health indicators, and adjust strategies as needed

In addition to the Schofield Proposal, PSGRNZ propose the following:

[I] DIET FIRST APPROACHES IN LOCAL COMMUNITIES.

Implement practitioner and community-led dietary approaches that recognise individual susceptibility to hyperglycaemia and hyperinsulinemia in response to high-glycaemic and refined carbohydrate intake (cumulative carbohydrate burden), and that address the challenge of food addiction, which may co-occur with and reinforce chronic high refined carbohydrate intakes.

1. Formal recognition that so-called prediabetes (HbA1c 39–46 mmol/mol; 5.7–6.4%) is more accurately described as early type 2 diabetes mellitus (Zinn, 2025). HbA1c values in this range reflect impaired blood glucose regulation and represent a precursor state to metabolic syndrome, conferring increased long-term health risk.

2. The right to information on the dietary carbohydrate and consequent blood glucose burden for that individual. From childhood onwards, New Zealanders have the right to be informed of the combinatory role of free sugars and dietary carbohydrates in creating the metabolic conditions which underlie prediabetes, diabetes and which are associated with common chronic metabolic and brain-related conditions. That individual has the right to regular testing to assess that individual’s unique predisposition to the risk of unstable blood glucose, elevated triglycerides and elevated insulin.

3. Right to information and informed consent: Patients must be provided with clear, comprehensive information about the likely progression of common medication pathways associated with metabolic syndrome, inclusive of diabetes. Informed consent should be explicitly strengthened to ensure that patients understand the potential for a progressive cascade into multimorbidity following diagnoses such as prediabetes and diabetes. This requires that patients are fully briefed on the side effects of medications that are likely to be co-prescribed over the course of treatment for metabolic and psychiatric conditions, including the risks of drug–drug interactions.

4. Expand health coaching across general practice, integrating a three-pronged approach (Zinn et al. 2025[2]): Whole food, carbohydrate reduction; a health coach, behaviour-change-based delivery approach; and community- or peer-based initiatives to reduce hyperglycaemia and hyperinsulinemia. Health coaches combine holistic and flexible individual- and community-based nutrition education to support patient dietary transitions away from patterns that provoke hyperglycaemia and hyperinsulinemia. Health coaches incorporate food addiction education and counselling to support patients to adopt behavioural and psychological strategies to optimise nutrient intake and health outcomes.

Recent New Zealand findings corroborate with international evidence that the three-pronged health coach model results in meaningful patient outcomes, improves health equity, and reduces medical prescribing. A small number of early-adopter New Zealand primary care practices have integrated qualified health coaches, a model that can be expanded.[3] [4]
Expand PHO health coach services to integrate the three-pronged approach.
Refer all patients with HbA1c 39–46 mmol/mol+ for health coaching to support long-term reduction in chronic elevated blood glucose levels.

5. Offer subsidised, Pharmac funded continuous glucose monitors (and training) for young people under 25 after diagnosis of prediabetes or diabetes, including T2DM. Automatic provision for the under 25 age group with the choice of access to a CGM device for an initial six-month period.

6. Expand care of dental and general practitioner services to young people under 25 (this aligns with the NZDA’s call to increase affordability of access to dental care). PSGRNZ echo select proposals by the New Zealand Dental Association (NZDA), Roadmap Towards Better Oral Health report which recommended expanding care to young adults and the implementation of dental service models to meet the needs of local communities and high-need population groups.

Free doctors and dental visits to young people under the age of 25.
That pharmacy charges to patients for prescriptions issued by a dentist should be the same as those for prescriptions issued by a medical practitioner in primary care.
That patients attending a dentist should have access to funded laboratory services for histology and routine blood tests on the same basis as primary care.

7. Offer high-dose multinutrient supplementation as an option as an adjunctive, first-line treatment for a spectrum of psychiatric conditions that would automatically be diagnosed as requiring prescription drugs and health coaching as an integrative wrap-around support framework. The Hardy DEN product, and future similarly structured products is sufficiently safe to be offered for retail sale as a general nutrient by healthcare practitioners. (Pharmac funding for the under-25 age group and for individuals who receive work and income benefits).

Automatically enrol people eligible for high-dose multinutrient supplementation, in health coaching as wrap-around, clinician led and community enhanced integrative support framework to enhance nutrient intake, address food addiction, and support the remission of metabolic and brain-related parameters for a period of two years.

8. Re-establish the original Ka Ora, Ka Ako programme. Ensure that meals are locally produced by community contractors. Amendments may include:

Review of lunch menus to: (i) ensure meals support optimal brain health; and (ii) substantially reduce high-glycaemic carbohydrate portions, given the strong likelihood that carbohydrates will dominate other meals and snacks throughout the day because they are the most affordable macronutrient.
Greater focus on waste reduction and management: implementation of recyclable or compostable packaging options and practices; utilizing more biodegradable packaging materials; improving communication around appropriate waste disposal methods; and enhancing provider’s recommendations for sustainable practices (Dey, 2025, p.244).

[II] EDUCATIONAL REFORM

9. Expand nutrition education across medical training: Encompassing functional nutrition (including the role of macro- and micronutrients in biological function, metabolic regulation, and the maintenance of cellular and neurobiological systems), including the role of nutrition not only in preventing deficiency, but in supporting health, and in reducing and reversing the biological and inflammatory drivers of chronic metabolic and brain-related illness.

Undergraduate level – with core, assessable nutrition competencies embedded within medical curricula.
Postgraduate level – including structured nutrition education within vocational training programmes and specialist colleges.
Professional organisations – increase the visibility and status of nutrition within professional bodies such as the Royal Colleges, including through formal competencies, accreditation standards, and continuing professional development (CPD) requirements.

10. Embed nutrition education throughout the school curricula. Improve the quality of nutrition education, incorporating recognition of the carbohydrate-insulin pathway, the specific role of micronutrients in human biological systems and in particular, brain health, and provide food addiction education and counselling alongside other forms of counselling services.

Preschool – food preparation and eating.
Primary – Embed stepwise nutrition education across health, science and wellbeing curricula so that students can gain an appreciation of nutrition’s role at the level of the mitochondria, the cell, an organ system, the gut microbiome and the brain. Educate children on the difference between craving refined sugars and starches and real (homeostatic) hunger, and the role of protein, fat and fibre in satiety.
Secondary – revise curriculums across biology, science and health so that the role of nutrition in sustaining and protecting animal/plant/human health is weighted at least as equivalently as genetic factors. Reintroduce compulsory nutrition and cooking education for years 7-9. Educate children on the difference between craving refined sugars and starches and real (homeostatic) hunger, and the role of protein, fat and fibre in satiety.
Tertiary – Increase content quality and pathways for research across health, medical and agricultural sciences. Course content to emphasise the role of nutrients in biological processes from the mitochondria, to cellular, to organ systems and the metabolism. For example, for psychology, nutrition may focus on brain health, for agriculture nutrition may focus on soil health, productivity and fertility, for health sciences and medicine nutrition can consider biochemical pathways to disease and health and the role of dietary nutrition in preventing mental and metabolic disease.

[III] INSTITUTIONAL & REGULATORY REFORM.

11. Alignment with some aspects of the Rebalancing our food system May 2024 report by the Public Health Advisory Committee (PHAC).[5] This supports increasing access to healthy foods. However, this report aligns with government dietary guidelines. Without a substantial policy shift it is likely that any policy shifts could prioritise access to healthy meat protein and healthy fats.

12. Expand access to laboratory testing services: New Zealand’s relatively small population size has resulted in a small group of laboratories who undertake the bulk of testing and privately funded testing must not be unduly restricted.

Expand publicly funded nutritional status testing for high-risk groups: vitamin D, vitamin B12, folate (B9), vitamin B6, copper and selenium. This includes the following categories of people diagnosed with a psychiatric and/or neurodegenerative condition: (i) under-25 year olds; and (ii) preconception and pregnant mothers; and (iii) Those with treatment resistant psychiatric illness; - diagnosed with depression, anxiety, schizophrenia, obsessive compulsive disorder, bipolar and/or ADHD; (iii) People diagnosed with dementia/neurodegenerative conditions.
Where a specific clinical pathway exists, expand testing for: (i) MTHFR polymorphism, (ii) CYP450 panel; (iii) Broader HLA safety screening; (iv) Monogenic diabetes (MODY) genetic testing.
Expand high-sensitivity C-reactive protein (hs-CRP) testing. Hs-CRP (>3 mg/L) can be used in routine clinical practice to identify primary prevention individuals at increased inflammatory risk as long as the patient is not acutely ill.
Remove barriers to enable the general public to independently request and self-fund laboratory serum testing directly through their medical practitioner. Access to such testing should not require specialist referral for approval of individual tests or test panels, nor require disclosure of personal information to laboratories beyond that included in the clinician’s test request.

13. Provide Pharmac funding for high dose multinutrient supplements for the under-25 age group and low-income, at-risk groups.

MoH/Medsafe can reverse their general sale medicine decision for the Hardy’s multinutrient product and that product can be generally available as a retail multinutrient supplement from health practitioners. Products with equivalent ingredients must not be classified as a general sale medicine.
Pharmac can fund the Hardys DEN products under the multivitamin preparation category for (i) the under-25 age group; and (ii) preconception and pregnant mothers; and (iii) Treatment resistant psychiatric illness; - diagnosed with depression, anxiety, schizophrenia, obsessive compulsive disorder, bipolar and/or ADHD; (iii) doctors can have discretion to expand use of the DEN product to other categories including for the prevention or slowing of neurodegenerative disorders for a period of two years.

14. Implement a pathway to regulatory reform that recognises that micronutrients have therapeutic potential and that they can be consumed at upper levels that are safe. The Medicines Act 1981 does not permit micronutrients to have therapeutic potential. This is not supported by science. The role of higher dose micronutrients has been ignored in government policy. After thirty years of the status quo, a pathway to reform must ensure open and collegial scientific and health-based engagement prior to the Ministry of Health taking action to draft legislation. This is to ensure that future legislation does not automatically adopt a toxicological perspective which could then rule important considerations out of scope during select committee consultation processes.

Regulations can be amended through Orders in Council (secondary legislation):

The terminology in the Dietary Supplements Regulations 1985 can be amended to replace ‘maximum daily dose’ with ‘recommended daily dose’.
The Medicines Regulations 1984 Schedule 1, Part 1 can be altered, removing lithium as an exclusively pharmaceutical medication.

15. Guiding principles for all health legislation:

Primum non nocere – First do no harm.
Evidence based. This includes (i) regular reviews and public reporting of the changing evidence base for safety and risk, (ii) Including evidence of safety and efficacy by age, gender and health status held by governments and industry and updates in the scientific literature; (iii) the obligation that all medical drug and device information is linked to the trials information and data that are claimed to support the safety and efficacy of the medical drug or device.
Require signed informed consent.
Match regulation to the biological risk.
Prevention through empowerment. People can read and review studies to establish whether dietary changes, dietary supplements and medical drugs and devices are beneficial or risky for them.

[IV] SCIENCE SYSTEM REFORM

16. Disestablish the Ministry of Business, Innovation and Employments’ (MBIE) control over science and technology funding. The decline of human and environmental health research, research to monitor and evaluate New Zealand resources and infrastructure, and the decline of basic research in agriculture, has mirrored the domestic pivot to prioritise innovation.

17. Establish a Ministry of Science, Research and Technology. Overarching principle for research funding revolves around the long-term stewardship, or kaitiakitanga, of New Zealand, her people and environment. Devote fully 50% of New Zealand’s science, research and technology budget to public good research. This involves shifting research that demands an innovation output to instead reposition innovation as one element or outcome that is embedded within the research, science and technology platform, rather than the current situation which positions innovation as the north star of New Zealand’s research architecture.

18. Establish a multidisciplinary environmental health institution in a New Zealand region which is tasked to drive chronic disease prevention and remission through the advancement of knowledge relating to the dietary, nutritional and toxic drivers of metabolic and mental illness. The institution board will include experts in nutrition, metabolism, nutritional psychiatry, nutrigenomics, endocrinology, inflammatory and biomarker assessment, epidemiology, toxicology and diet, who have a demonstrated research record in these sectors relating to chronic disease prevention.

19. The environmental health institution board will establish the policy and work programme for the institution. Research, which can complement global research trajectories, will include anthropogenic exposure monitoring and assessment of risks from man-made chemicals, heavy metals and radiation. This includes occupational, household, industrial, urban and agricultural exposures, research to identify the additive and synergistic health risks from the food additives,[6] plastics, electromagnetic field radiation, pesticides, common drugs and low levels of chemicals in drinking water. The work programme will include the review and assessment of optimum micronutrient levels by age, gender and developmental stage. Aims will target increased recognition of health harms from poor diets,[7] [8] improved consumer knowledge through better labelling[9], improved school dietary choices[10] [11] and support the adoption of nutrient-dense diets across the population.[12] [13]

The quality of research will be ensured by rigorous reviews of the independent scientific literature where authorship, research methods and raw data is disclosed; and which take into account human difference (complexity and uncertainty) and biology. Evidence for research and policy can be drawn from structure and function studies to single cases, cohort studies and controlled trials.

20. The institution will be 50/50 funded by the health budget and the Ministry of Science. Ministers and political appointees, including chief science advisors will not direct funding trajectories. This institution will be based in Hamilton or Christchurch and affiliated with research across relevant academic institutions.

21. Environmental health institution to have independent powers to inform New Zealanders. The Institute will be tasked to independently support and inform communities, hospitals, the education sector and clinical practice to incorporate evidence-based nutritional and dietary education to reduce ultraprocessed food intake, increase wholefood intake, and optimise mental and metabolic health.

22. Innovation is recategorized as an element of research, not the key driver. For example, research funding can be allocated to co-design and development of healthy formulated foods with industry, development of screening and assays to identify harmful or toxic formulations. This could drive trust and promote consumer confidence in domestic and export markets. As a part of a recent project to reconfigure ultraprocessed foods to optimise human functioning, a group of researchers proposed a ‘Metabolic Matrix’ as a principle-based pathway which would revolve around protecting the liver, feeding the gut and supporting the brain.[14]

Conclusion: Reversing Surging Multimorbidity with 'Fantastically Cheerful Medicine.

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REFERENCES

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

[1] Schofield, G. (March 2025). Health Reform in New Zealand. https://prekure.com/petition/#proposal

[2] See also discussion Part III, above. [Chapter 9, Chapter 10, Chapter 11].

[3] E.g. Health Coaches Australia and New Zealand Association (HCANZA).

[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] Public Health Advisory Committee. 2024. Rebalancing our food system. Wellington: Ministry of Health.

[6] Payen de la Garanderie M, Hasenbohler A, Deschamp N, et al. (2025). Food additive mixtures and type 2 diabetes incidence: Results from the NutriNet-Santé prospective cohort. PLoS Med 22(4): e1004570. DOI:10.1371/journal.pmed.1004570

[7] Abar L, Steele EM, Lee SK, Kahle L, Moore SC, et al. (2025) Identification and validation of poly-metabolite scores for diets high in ultra-processed food: An observational study and post-hoc randomized controlled crossover-feeding trial. PLOS Medicine 22(5): e1004560. DOI: 10.1371/journal.pmed.1004560

[8] Good KE, Parnarouskis L, Cummings JR, Gearhardt AN (2025). Adapting anti-tobacco messages to ultraprocessed foods: message framing's impact on attitudes toward the food industry. Obesity. 33(5):903-914. DOI: 10.1002/oby.24272

[9] Mackay S, Eyles H, Gontijo de Castro T, Young L, Ni Mhurchu C, et al. (2021) Which companies dominate the packaged food supply of New Zealand and how healthy are their products?. PLOS ONE 16(1): e0245225. DOI:10.1371/journal.pone.0245225

[10] Myers I (April 9, 2025). California Assembly committee advances bill to protect schoolchildren from harmful UPF. EWG News. https://www.ewg.org/news-insights/news-release/2025/04/california-assembly-committee-advances-bill-protect

[11] Trask S, Thornley S, Sundborn G. (2024). School-based learning about sugary drinks: possibilities and potential for curriculum approaches supporting health promotion in New Zealand. Health Education Research, 39(5)475–485. DOI: 39/5/475/7696174

[12] Starck, C.S.; Blumfield, M.; Keighley, T.; et al. (2021).Nutrient Dense, Low-Cost Foods Can Improve the Affordability and Quality of the New Zealand Diet—A Substitution Modeling Study. Int. J. Environ. Res. Public Health18:7950. DOI: 10.3390/ijerph18157950

[13] Young, L., Kidd, B., Shen, S. et al. (2024) Trends in the healthiness and nutrient composition of packaged products sold by major food and beverage companies in New Zealand 2015 to 2019. BMC Med 22, DOI: 10.1186/s12916-024-03567-w

[14] Harlan TS, Gow RV, Kornstädt A, Alderson PW and Lustig RH (2023) The Metabolic Matrix: Re-engineering ultraprocessed foods to feed the gut, protect the liver, and support the brain. Front. Nutr. 10:1098453.

doi: 10.3389/fnut.2023.1098453

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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.

RETURN TO CONTENTS PAGE.

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

[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.

We welcome your use of this resource but please cite:

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(a) Respecting Individual Sensitivity to Dietary Interventions.

Current New Zealand guidelines recommend a cumulative intake of 5-8 servings of cereal a day, 2 servings of carbohydrate-based vegetables a day (e.g. potatoes), 2-4 servings of fruit, while acknowledging that people will normally have one sweet-dessert serving a day.

The Unwin team recognised that an emphasis on dietary carbohydrates initially created confusion, as both health professionals and patients found it difficult to judge the extent to which non-refined carbohydrate foods could raise blood glucose. In response, David Unwin and colleagues subsequently adapted existing glycaemic index values [1] [2] into ‘teaspoon-of-sugar equivalents’ to illustrate the likely post-prandial glucose impact of common foods.[3] This approach was piloted on patients and a cohort of twenty doctors.

The individual glycaemic response, and Individual insulin sensitivity (the gradual loss of insulin sensitivity in muscle, liver, and fat tissue) or stress on pancreatic insulin-producing cells (β-cell stress) is an important consideration to support patient health. The potential for food addiction that is associated with repetitive exposures to carbohydrates, and which is associated with many psychiatric conditions, is another factor which shapes how clinicians and health coaches address patient needs.

Explanatory charts have since been released to guide people to understand the sugar equivalent of one slice of brown bread or a serving of white rice.[4]

Figure 13. Unwin D, Haslam D, Livesey G (2016) It is the glycaemic response to, not the carbohydrate content of food that matters in diabetes and obesity: The glycaemic index revisited. Journal of Insulin Resistance.

Figure 14. Unwin D, Haslam D, Livesey G (2016) It is the glycaemic response to, not the carbohydrate content of food that matters in diabetes and obesity: The glycaemic index revisited. Journal of Insulin Resistance.

A follow-up 2023 paper by David Unwin and colleagues emphasised the importance of an individualised approach:[5]

Figure 15. Unwin D, Delon C, Unwin J, et al. What predicts drug-free type 2 diabetes remission? Insights from an 8- year general practice service evaluation of a lower carbohydrate diet with weight loss. BMJ Nutrition, Prevention & Health

‘Similar to many healthcare interventions, one size does not fit all, and individualisation needs to be considered. This may mean that a mixture of different levels of follow‐up intensity and mode of delivery (virtual compared to face to face) is likely to be necessary to maximise remission rates, with a more blended approach being taken.

…patients who would like to achieve T2DM remission should be offered a ‘menu’ of options with respect to educational and dietary approaches if they wish to attempt to achieve remission. This may be key to driving forward remission in a primary care setting.’

Further studies assessing the safety of a higher protein and low-carbohydrate ketogenic approaches have added to the findings of the Unwin model and demonstrated the safety of increasing dietary fats and proteins relative to carbohydrates.[6] [7]

As people have vastly different temperaments, digestive tracts and genetic and epigenetic factors, dietary tolerances, clinicians and health coaches increasingly recommend a graduated approach to removing refined products from the diet.

Considerations for patients, doctors and health practitioners when reducing dietary carbohydrates relate to concurrent inflammatory risks, including gastrointestinal conditions and food allergies. Individuals may have difficulty digesting particular proteins such as lectins or cereal gluten, and these can aggravate existing digestive symptoms.

For some patients, rapid shifts in macronutrient balance may also unmask underlying gut-microbiome disturbances, exacerbate irritable-bowel–type symptoms, or interact with pre-existing intolerances (e.g., lactose, FODMAPs, or histamine sensitivity). Clinicians therefore need to assess digestive tolerance, inflammatory history, and individual variability when recommending lower-carbohydrate approaches. [8] [9] [10] [11] [12]

Harvard-trained psychiatrist Dr Georgia Ede has found this to be the case for many years, by adopting a graduated dietary nutrition approach with the dual goal of optimising brain health and reducing inflammatory responses, in her U.S. based clinical psychiatric practice. [13] Ede refers to her graduated approach as a ‘quiet’ approach, which involves reducing dietary ingredients understood to be inflammatory, watching for improvements, and continuing to withdraw ingredients while maintaining a nutrient dense diet, to increase the potential for remission of psychiatric conditions. [14] Ede has reported that healthy fats and grass-fed (rather than feed-lot fed) meat may form an underestimated dietary component of healthy wholefood diets, having found that fewer patients tend to experience adverse inflammatory reactions on these macronutrients.[15]

Doctors and health care professionals emphasise that dietary changes to manage gut-based inflammation are not necessarily permanent, but may be part of a flexible, stepped process to identify inflammatory drivers and support healing in the digestive tract.

(b) Food Addiction Counselling to address Ultraprocessed Food Addiction.

A major, largely unaddressed factor in understanding why many individuals struggle to adopt healthier diets is the role of high-carbohydrate, ultra-processed food addiction. Over the past decade, researchers have characterised ‘food addiction’ as a measurable construct, developed validated methodologies to assess it, and advanced coherent physiological and behavioural models explaining its drivers. This body of work highlights how highly processed, rapidly absorbed carbohydrate-rich foods can dysregulate appetite, reward pathways and metabolic control, making sustained dietary change considerably more difficult for affected individuals. The scientific basis supporting food addiction as a facet of was discussed in chapter 4.

The financial and health gains from integrating addiction-informed counselling into food and nutrition coaching, whether delivered in medical clinics, community settings or educational environments, may be substantial. Such an approach has the potential to improve long-term adherence, reduce preventable healthcare costs, and better support individuals whose eating patterns are shaped by addictive drivers. A September 2025 Unicef report[16] stated that:

The cost of inaction for children, adolescents, families, societies and economies is immense. Unhealthy diets increase the risk of overweight, obesity and other cardiometabolic conditions in children and adolescents, including high blood pressure, elevated blood glucose and abnormal blood lipid levels. These health problems can persist into adult life, increasing the risk of non-communicable diseases, including type 2 diabetes, cardiovascular disease and some cancers. Overweight and obesity are also associated with low self-esteem, anxiety and depression among children and adolescents. Parents bear the emotional toll of their children’s mental health challenges and the financial strain of higher medical expenses and lost income to care for them. Economies throughout the world are already struggling with escalating health care costs and reduced workforce productivity because of rising overweight and obesity.

The relevance for coaching programmes that address high-carbohydrate ultraprocessed food addiction was recently highlighted in a small trial which followed the outcomes of clinics in North America, Sweden and the U.K. The programs consisted of 10–14 weeks of 90–120-min sessions in groups of 11–40 participants.

Figure 16. Unwin J, Delon C, Giæver H, Kennedy C, et al. (2022) Low-carbohydrate and psychoeducational programs show promise for the treatment of ultra-processed food addiction. Front. Psychiatry

The pre- and post- program outcomes assessed food addiction symptoms measured by the modified Yale Food Addiction Scale 2.0, the ICD-10 symptoms of food related substance use disorder (CRAVED), while mental wellbeing as measured by the short version of the Warwick Edinburgh Mental Wellbeing Scale, [17] and body weight. The ICD-10 symptoms were adapted as the CRAVED screening tool. [18] The researchers identified a significant reduction in food addiction symptoms, significant improvement in mental wellbeing and a significant reduction in body weight. [19]

Follow-up data was assessed for the North America/Sweden/U.K. trial at 6 and 12 months. The researchers reported:

The 12-month follow-up data show significant, sustained improvement in ultra-processed food addiction symptoms and mental well-being. These data are the first long-term follow-up results to be published for a food addiction program.[20]

Figure 17. Unwin J, Delon C, Giæver H, Kennedy C,Painschab M, Sandin F, Poulsen CS and Wiss DA (2025) Low-carbohydrate and psychoeducational programs show promise for the treatment of ultra-processed food addiction: 12-month follow-up. Front. Psychiatry.

Models to support the integration of programmes that can support patients with ultraprocessed food addiction into general practice have been established. In a 2025 conference presentation[21], Dr Jen Unwin outlined suggestions for treatment of ultraprocessed food addiction:

Screen using CRAVED then education.
Working towards abstinence from sugar, flour and processed foods.
Real food focus. Adequate protein and fat.
No cheat days and caution with fasting (don’t alternate access and restriction).
No sweeteners (only use in transition if necessary).
Focus isn’t weight loss but stable nutritious eating and neurotransmitter regulation.
Educate re the addicted brain (+stress management, other activities to replace food rewards).
Beware alcohol, nicotine, caffeine, (one disease, many outlets).
Nuts, cheese/dairy with caution and eliminate if cravings persist.
Ongoing peer support via online groups.

(c) Technologies to support patient knowledge: Continuous glucose monitoring (CGM) devices.

Continuous glucose monitoring (CGM) devices, or sensors are worn on the abdomen or the back of the arm and continuously measure glucose levels, usually in interstitial fluid (the clear fluid that surrounds cells). Glucose diffuses from blood, into the interstitial space where the sensor sits. Real-time glucose monitoring using CGM sensors enable the user to immediately see the response in blood glucose following food consumption, acting as a feed-back mechanism to support patient change. CGM’s may be a powerful, low-cost tool for use in patient support and health coaching (contact and non-contact) to assist people with glycaemic control and shift dietary habits over the longer term.[22] [23] [24]

Pharmac provides CGMs to people with T1DM, permanent neonatal diabetes, some types of ‘monogenic diabetes with insulin deficiency, type 3c diabetes and some atypical inherited forms of diabetes. Pharmac provides funding for the Dexcom One and FreeStyle Libre 2 or 2 Plus standalone CGMs.[25] People with T2DM do not have access to a Pharmac funded CGM. Diabetes organisations in Australia, the UK and Canada have campaigned for expanded access to subsidised CGM sensors.[26] The U.K. based National Institute of Clinical Excellence (NICE) has recommended CGM technology for children and young people living with T2DM.[27]

Some people who would benefit from a CGM device choose not to use one because of the associated clinical oversight. As a long-term T1DM individual observed to PSGRNZ, patients are acutely aware that a range of health professionals, including their general practitioner, clinical nurse specialists (CNS) and/or endocrinologist, can view their glucose data. This creates the possibility of being asked, ‘What did you eat that day?’ and of feeling subject to continual surveillance of dietary habits. The implication of misdemeanour or non-compliance is neither welcome nor benign; many experience it as intrusive.

However, glucose spikes can occur independently of carbohydrate intake, yet a remote clinician monitoring the data cannot easily distinguish between physiological and dietary causes.[28] [29] Clinical inferences may be inaccurate, and it is plausible that a patient could be viewed as non-compliant when they have done nothing wrong.

Low-cost, over-the-counter CGM sensors are becoming more widely available, but privacy concerns remain. At present, there is no inexpensive CGM that guarantees data is never transmitted to a company or healthcare system. Users who wish to keep their information entirely private may be able to do so only if the device supports a standalone reader and they avoid connecting it to the internet or disable all wireless functions.

The increasing body of case studies using CGM sensors in the scientific literature, provides an evidence base to incentivise adoption by groups and individuals.[30] [31] [32] Large language models (artificial intelligence) are then able to use this data to improve diabetes care[33] however issues relating to surveillance, ethics and oversight, and public use of data will remain.

Current evidence suggests that the use of CGM sensors results in superior outcomes, as compared to standard care, in improving glucose control in patients.[34] [35] Health coaching in combination with the use of CGM devices for patients with sub-optimally controlled T2DM has been demonstrated to improve glycaemic control.[36] Studies show that for people who opt out of standard care, non-insulin treated groups have superior gains in glycaemic control with the use of CGM sensors.[37]

People have the opportunity to become more discerning in their dietary intake when they can directly associate their current carbohydrate intake with their corresponding blood glucose levels. CGM sensors can be used across all diabetes populations, including for people with type 1 diabetes, type 2 diabetes (T2D), and gestational diabetes and to assess neonatal risk.[38] Recommendations for the clinical use of CGM devices have been published. Education is required to ensure that CGM is undertaken correctly and that data interpretation is accurate, and devices must be checked to ensure that they are correctly calibrated. [39]

(d) Technologies to support patient knowledge: Breath Ketone Sensors.

Ketogenic diets are a subset of low-carbohydrate diets. By markedly reducing carbohydrate intake, these diets induce a metabolic state of nutritional ketosis, in which the body shifts its primary energy source from glucose to fatty acids. The liver then produces ketone bodies. Typically, this is achieved by restricting carbohydrate intake to below approximately 50 g per day, consuming protein in moderate amounts to avoid inhibiting ketosis, and allowing fat intake ad libitum to satiety.[40] [41] [42]

The primary ketone bodies produced by the liver comprise acetoacetate, β-hydroxybutyrate (BHB) and acetone. Acetone is slightly volatile, it can turn into a gas and leave the body through the lungs and be recorded on the breath. Breath acetone roughly correlates with circulating ketone bodies (predominantly BHB). Breath acetone is being used to monitor trends (when used consistently) but may struggle to deal with acute changes. These devices are not a substitute for blood tests, which remain required for clinical ketogenic use (such as for treatment of epilepsy).[43] [44]

Breath-ketone monitors can non-invasively detect and quantify ketone levels via exhaled breath. Commercial development of breath-based ketone-sensing technologies is ongoing, with several prototype and early-market devices already available. As sensor sensitivity and calibration improve, these tools may eventually become accurate enough to support clinical applications, including the diagnosis or monitoring of diabetes mellitus.[45]

(e) Technologies to support patient knowledge: Digital Apps.

Digital health applications that adhere to current dietary guideline recommendations may support improvements in glycaemic control, cardiovascular risk factors, and diabetes remission, with secondary benefits including weight loss, increased physical activity, and improved mental wellbeing. The GroAus/Gro Health app has demonstrated clinically relevant reductions in body weight and blood glucose, including reductions in, or discontinuation of, diabetes medications and instances of diabetes remission. [46] However, the app does not present itself as a carbohydrate-reduction programme in its outward-facing materials and is framed as general lifestyle coaching aligned with national dietary guidance. In the absence of explicit attention to cumulative carbohydrate intake and the relative balance of fat and protein macronutrient groups, such digital interventions may offer utility for some individuals but remain relatively underpowered to address broader population-level metabolic needs.

(f) The Question of Protein Choice.

Ministry of Health health-promotion materials tend to under-emphasise the role of dietary protein. Public messaging typically centres on vegetables and fruit, with comparatively little attention to the macronutrients protein and fat. Current health-promotion literature makes no substantive link between protein quality and mental health, despite protein quality referring to a food’s capacity to meet human requirements for essential amino acids (EAAs) and nitrogen. Adequacy is determined by whether intake supports key metabolic endpoints, including nitrogen balance, amino-acid balance and isotope-oxidation measures.[47]

In both New Zealand and Australia, NHMRC macronutrient reference values for protein are derived largely from data identifying levels that prevent frank deficiency, rather than levels that optimise function across age, developmental stage or sex. Much of the evidence informing these reference values for adults, pregnant women, adolescents and children predates 2002, and upper intake limits primarily reflect population-distribution data rather than physiological benchmarks for optimal metabolic performance.

Protein requirements for pregnant women, children and adolescents are framed around growth, weight gain and skeletal maintenance, rather than the broader metabolic and stress-related demands characteristic of these life stages. This leaves important questions regarding optimal protein intake, particularly the role of EAAs in neurocognitive development and mental health, largely unaddressed in current policy guidance. [48]

The optimum macronutrient balance for health and prevention of obesity, T2DM and mental illness is not discussed by the NHMRC and the threshold for ‘sufficiency’ may be set far below what may be optimal for neurotransmitter homeostasis and mental health resilience. Estimated average requirements reflect approximations based on the NHMRC data:

Diets as low as 10% of energy from protein will provide the protein required for maintenance and replacement of body tissues and for the necessary functional and structural proteins required by the body, intakes at or above 15% protein appear to be required for ensuring that the EARs for micronutrients are met, particularly for people with energy requirements below about 15,000 kJ/day.

The HRMRC discussion does not highlight the critical role of dietary protein in neurological health. The brain is heavily dependent on substances that are disproportionately high in meat proteins, including iron, B vitamins, and amino acids.[49] Iron and B vitamins are indispensable to neurotransmitter synthesis[50], and knowledge concerning the role of amino acids in the immune system, in gut-brain axis signalling, and neurotransmitter synthesis has accelerated. Amino acids are not simply required to build neurotransmitters but are required by the enzymes needed to build the neurotransmitters and the receptors that receive their messages.[51] [52]

Essential amino acids: histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan and valine.
Conditionally essential: arginine, cysteine, glutamine, glycine, proline, selenocysteine, tyrosine, taurine.
Nonessential: Alanine, aspartic acid, asparagine, glutamate and serine.

Nearly all animal proteins contain all amino acids, whereas plant proteins tend to be lower in amino acids.

Animal-derived proteins generally contain sufficient amounts of each EAA (relative to daily EAA requirements), making them complete protein sources. In contrast, plant-derived proteins often lack sufficient amounts of 1 or more EAAs, making them incomplete protein sources. Cereals, grains, and seeds tend to be proportionally low in lysine, whereas legumes and vegetables are proportionally low in the sulfuric amino acid, methionine. Most plant-derived proteins also contain limited amounts of valine and isoleucine. [53]

Data used to recommend macronutrient ratios is derived from studies showing population averages where intake tails off in the upper range. The U.S. and Canada established an acceptable macronutrient range in 2002, recommending an:

upper limit of 35% energy from protein. However, there is very limited information about the longer-term effects of diets in which protein provides >25% energy. Average usual intakes within the range 25-35% energy from protein are not reported in western populations, even in athletes.[54]

The NHMRC has not established a formal upper limit for protein intake due to insufficient evidence. Instead, it notes a recommended upper boundary of approximately 25% of total energy intake from protein, with the justification located in the ‘Chronic Disease’ section of the guidelines.[55] That section frames its reasoning around an increasingly sedentary population engaged in less physically demanding work. However, it does not address the protein requirements needed to prevent fatigue, support exercise capacity, or meet the differing metabolic demands associated with age, developmental stage or sex. These considerations remain largely absent from the current guidance.

Vegetables provide relatively low EEAs per portion size. Complementary proteins, such as chickpea and lentil dishes can increase the metabolic availability of individual amino acids, while natto, tempeh, mycoprotein, and soy-based meat alternative (SBMA) products provide ∼6–7 g EAAs per 100 g. This is similar to equivalent portions of whole eggs. [56] [57]

People who favour vegetarian or vegan diets must be competent cooks in order to ensure that their levels of protein, B vitamins, iron and essential amino acids do not become depleted, either rapidly during times of high physiological stress or over the longer term. High quality protein is not only reliant on the EAA profile but on the range, digestibility and bioavailability potential of that food. The role of selection of plant protein, processing (including soaking and fermenting) and cooking. [58]

Health coaching may play an important role in supporting vegetarians and vegans to acquire the knowledge and practical skills needed for adequate meal planning, food preparation and cooking, particularly among younger people and women of childbearing age, whose nutritional requirements are more demanding. Achieving optimal intakes of protein, B-group vitamins, iron and essential amino acids is generally more straightforward on an omnivorous diet, whereas plant-based diets require more deliberate planning to ensure nutritional adequacy.

From a practical standpoint, animal-source proteins often require minimal preparation to deliver complete essential amino acid profiles. In contrast, many convenient plant-based protein options are either industrially formulated (with preservatives or flavourings) or derived from crops that may routinely be treated with agricultural chemicals under current farming conventions. These factors do not preclude healthy vegetarian or vegan eating, but they do reinforce the value of tailored health coaching to help individuals meet nutrient needs safely and consistently.

People may also face challenges if amino-acid availability is compromised. Deficits in essential amino acids can impair synaptic signalling, and these effects may be amplified by inflammation, metabolic stress or genetic variations that reduce enzyme efficiency. Trauma, chronic stress and psychiatric illness can shift certain amino acids from being ‘non-essential’ to functionally essential, while high carbohydrate burdens may further reduce circulating amino-acid diversity.

Figure 18. Matthews JJ, Arentson-Lantz EJ, Moughan PJ et al. (2025). Understanding Dietary Protein Quality: Digestible Indispensable Amino Acid Score and Beyond. J Nutrition.

Digestive tract dysfunction can additionally impair protein breakdown and absorption. Whole-food proteins are generally more efficiently digested and utilised in younger adults than in older adults. [59] Bioavailability is influenced by multiple factors, including prior dietary exposure to specific proteins (and therefore gut adaptation), the extent of food processing, and the composition and integrity of the gut microbiota and gastrointestinal lining.[60]

Chapter 12. Whole of System Reform: In Brief

RETURN TO CONTENTS PAGE.

REFERENCES

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

[1] Atkinson FS, Foster-Powell K, Brand-Miller JC. (2008) International tables of glycemic index and glycemic load values. Diabetes Care. 2008;31(12):2281–2283. DOI:10.2337/dc08-1239

[2] Jenkins DJ, Wolever TM, Taylor RH, et al. 1981. Glycemic index of foods: A physiological basis for carbohydrate exchange. Am J Clin Nutr. 34(3):362–366.

[3] Unwin D, Haslam D, Livesey G (2016) It is the glycaemic response to, not the carbohydrate content of food that matters in diabetes and obesity: The glycaemic index revisited. Journal of Metabolic Health | Journal of Insulin Resistance: 1 (1)a8, DOI: 10.4102/jir.v1i1.8

[4] Public Health Collaboration UK. Dr David Unwin’s Sugar Infographics. https://phcuk.org/sugar/

[5] Brown A, McArdle P, Taplin J, Unwin D, Unwin, J, et al. (2022). Dietary strategies for remission of type 2 diabetes.

[6] Lin, S.-P.; Chen, C.-M.; Chiu, S.-H. et al (2025) Associations of Dietary Protein Intake and Amino Acid Patterns with the Risk of Diabetic Kidney Disease in Adults with Type 2 Diabetes: A Cross-Sectional Study. Nutrients 17:2168. DOI: 10.3390/nu17132168

[7] Harvey CJDC, Schofield GM, Zinn C, Thornley S. (2019). Effects of differing levels of carbohydrate restriction on mood achievement of nutritional ketosis, and symptoms of carbohydrate withdrawal in healthy adults: A randomized clinical trial. Nutrition. 2019;67-68S:100005. DOI: 10.1016/j.nutx.2019.100005.

[8] Cosme-Blanco W, Arroyo-Flores E, Hanadays A. (2020). Food Allergies. Pediatr Rev 41(8):403–415.

https://doi.org/10.1542/pir.2019-0037https://renaissance.stonybrookmedicine.edu/system/files/Food_Allergies.pdf

[9] Vojdani A, Afar D, and Vojdani E. (2020). Reaction of Lectin-Specific Antibody with Human Tissue: Possible Contributions to Autoimmunity. J Immun Res., DOI: 10.1155/2020/1438957

[10] Bellini M, Tonarelli S, Nagy AG, Pancetti A, Costa F, Ricchiuti A, de Bortoli N, Mosca M, Marchi S, Rossi A. (2020) Low FODMAP Diet: Evidence, Doubts, and Hopes. Nutrients, 12(1):148. DOI:10.3390/nu12010148

[11] Roster K, Xie L, Nguyen T et al. (2024). Impact of Ketogenic and Low-Glycemic Diets on Inflammatory Skin Conditions. 113:2

[12] Albers J, Kraja G, Eller D, Eck K, McBrian D Main JM. (2022). Assessing the feasibility of using the ketogenic diet in autism spectrum disorder. JHND, 36(4):1303-1315. DOI: 10.1111/jhn.13115

[13] Ede G (2024). Change Your Diet, Change Your Mind: A Powerful Plan to Improve Mood, Overcome Anxiety, and Protect Memory for a Lifetime of Optimal Mental Health. Dimensions.

[14] Ede G (2024). Change Your Diet, Change Your Mind

[15] Dhakal S, Hossain M, Parajuli S. (2025). The Inclusion of Red Meat in Higher-Quality Diets Supports Nutritional Adequacy, Microbial Diversity, and Mental Health With No Observed Adverse Effects. Current Developments in Nutrition. 9(2)106040. DOI: 10.1016/j.cdnut.2025.106040

[16] United Nations Children’s Fund (UNICEF), Feeding Profit. How food environments are failing children. Child Nutrition Report 2025, UNICEF, New York, September 2025

[17] Warwick-Edinburgh Mental Well-being Scale (WEMWBS). User Guide Version 1 (2008). http://www.mentalhealthpromotion.net/resources/user-guide.pdf

[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. Supplementary materials.

[19] Unwin J, et al. (2022). Low-carbohydrate and psychoeducational programs show promise.

[20] Unwin J, Delon C, Giæver H, et al. (2025). Low carbohydrate and psychoeducational programs show promise

for the treatment of ultra-processed food addiction: 12-month follow-up. Front. Psychiatry 16:1556988.

DOI: 10.3389/fpsyt.2025.1556988.

[21] Unwin J. The Growing Epidemic of Ultra Processed Food Addiction. Primary Healthcare Lifestyle Conference September 2025. Birmingham UK.

[22] Ahn YC, Kim YS, Kim B, et al. (2023). Effectiveness of Non-Contact Dietary Coaching in Adults with Diabetes or Prediabetes Using a Continuous Glucose Monitoring Device: A Randomized Controlled Trial. Healthcare (Basel). 11(2):252. DOI: 10.3390/healthcare11020252.

[23] Richardson KM, Jospe MR, Bohlen LC, et al. (2024). The efficacy of using continuous glucose monitoring as a behaviour change tool in populations with and without diabetes: a systematic review and meta-analysis of randomised controlled trials. Int J Behav Nutr Phys Act. 21(1):145. DOI: 10.1186/s12966-024-01692-6.

[24] Kumbara AB, Iyer AK, Green CR. (2023). Impact of a Combined Continuous Glucose Monitoring–Digital Health Solution on Glucose Metrics and Self-Management Behavior for Adults With Type 2 Diabetes: Real-World, Observational Study. JMIR Diabetes 8:e47638, DOI: 10.2196/47638.

[25] Pharmac. Continuous glucose monitors (CGMs). https://www.pharmac.govt.nz/news-and-resources/cgms-and-insulin-pumps/continuous-glucose-monitors-cgms

[26] Diabetes Australia (2024). Position Statement. Equitable Access to Diabetes Technology.

[27] NICE (May 2023) Diabetes (type 1 and type 2) in children and young people: diagnosis and management. NICE guideline. Reference number:NG18 Published: 01 August 2015 Last updated: 11 May 2023.

[28] Avner S, Robbins T. (2025). A Scoping Review of Glucose Spikes in People Without Diabetes: Comparing Insights from Grey Literature and Medical Research. Clinical Medicine Insights: Endocrinology and Diabetes. 2025;18. DOI:10.1177/11795514251381409.

[29] Hantzidiamantis PJ, Awosika AO, Lappin SL. (2025) Physiology, Glucose. [Updated 2024 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

[30] Unger J and Franco DR. (2023). Practical Application of Continuous Glucose Monitoring in Clinical Practice: Case Studies. Diabetes Technology & Therapeutics. 25:S3. DOI: 10.1089/dia.2023.0080.

[31] Charleer S, Mathieu C, Nobels F, et al. (2018). RESCUE Trial Investigators, Effect of Continuous Glucose Monitoring on Glycemic Control, Acute Admissions, and Quality of Life: A Real-World Study, The Journal of Clinical Endocrinology & Metabolism, 103(3):1224–1232, DOI: 10.1210/jc.2017-02498.

[32] Rodbard D (2017). Continuous Glucose Monitoring: A Review of Recent Studies Demonstrating Improved Glycemic Outcomes. Diabetes Technology & Therapeutics. 19:S3. DOI: 10.1089/dia.2017.003

[33] Healey, E., Tan, A.L.M., Flint, K.L. et al. (2025). A case study on using a large language model to analyze continuous glucose monitoring data. Sci Rep 15, 1143 DOI: 10.1038/s41598-024-84003-0.

[34] Di Molfetta S, Caruso I, Cignarelli A. et al.(2023). Professional continuous glucose monitoring in patients with diabetes mellitus: A systematic review and meta-analysis. Diabetes obesity and Metbolism.25(5):1301-1310.

[35] Jancev, M., Vissers, T.A.C.M., Visseren, F.L.J. et al. (2024). Continuous glucose monitoring in adults with type 2 diabetes: a systematic review and meta-analysis. Diabetologia 67:798–810. DOI: 10.1007/s00125-024-06107-6.

[36] Griauzde DH, Ling G, Wray D, et al. (2022). Continuous Glucose Monitoring With Low-Carbohydrate Nutritional Coaching to Improve Type 2 Diabetes Control: Randomized Quality Improvement Program. J Med Internet Res. 24(2):e31184. DOI: 10.2196/31184.

[37] Ferreira ROM, Trevisan T, Pasqualotto E, et al. (2024). Continuous Glucose Monitoring Systems in Noninsulin-Treated People with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Diabetes Technology & Therapeutics. 26:4. DOI: 10.1089/dia.2023.0390.

[38] Chisnoiu, T., Balasa, A. L., Mihai, L., et al. (2023). Continuous Glucose Monitoring in Transient Neonatal Diabetes Mellitus—2 Case Reports and Literature Review. Diagnostics, 13(13), 2271. DOI: 10.3390/diagnostics13132271.

[39] Grunberger G, Sherr J, Allende M, et al. (2021). American Association of Clinical Endocrinology Clinical Practice Guideline: The use of advanced technology in the management of persons with diabetes mellitus. Endocr Pract 27(6):505–537. DOI: 10.1016/j.eprac.2021.04.008.

[40] Phillips MC. (2022). Metabolic strategies in healthcare: a new era. Aging Dis.13:655–72. DOI: 10.14336/AD.2021.1018.

[41] Athinarayanan SJ, Hallberg SJ, McKenzie AL, et al. (2020). Impact of a 2-year trial of nutritional ketosis on indices of cardiovascular disease risk in patients with type 2 diabetes. Cardiovasc Diabetol. 19:208. DOI: 10.1186/s12933-020-01178-2

[42] Volek JS, LaFountain RA, Dituro P. (2019). Extended ketogenic diet and physical training intervention in military personnel. Mil Med. 184:199–200. DOI: 10.1093/milmed/usz184.

[43] Marfatia K, Ni J Preda V, & Nasiri N. (2025). Is Breath Best? A Systematic Review on the Accuracy and Utility of Nanotechnology Based Breath Analysis of Ketones in Type 1 Diabetes. Biosensors, 15(1):62. DOI:10.3390/bios15010062

[44] Bastide GMGBH, Remund AL, Oosthuizen DN, et al. (2023). Handheld device quantifies breath acetone for real-life metabolic health monitoring. Sens Diagn. 2(4):918-928. DOI: 10.1039/d3sd00079f.

[45] Wang W, Zhou W, Wang S, et al. (2021). Accuracy of breath test for diabetes mellitus diagnosis: a systematic review and meta-analysis. BMJ Open Diabetes Research & Care.;9:e002174. DOI: 10.1136/bmjdrc-2021-002174

[46] Shahidi M, deCourten B, Glennan J, et al. (2025) Implementing a Scalable, personalised, behaviour Change digitAL hEalth programme in primary care for type 2 diabetes treatment: the SCALE cluster- randomised study protocol. BMJ Open 15:e101531. DOI:10.1136/bmjopen-2025-101531.

[47] Matthews JJ, Arentson-Lantz EJ, Moughan PJ et al. (2025). Understanding Dietary Protein Quality: Digestible Indispensable Amino Acid Score and Beyond. J Nutrition, DOI: 10.1016/j.tjnut.2025.07.005

[48] NHMRC (2017). Nutrient Reference Values for Australia and New Zealand. Pages 26-30

[49] NHMRC (2017). Nutrient Reference Values for Australia and New Zealand. Pages 26

[50] Kumar, Sumit, et al. (2022) Nutrition, Neurotransmitters, and Behavior. Nutrition and Psychiatric Disorders. Singapore. Springer Nature Singapore, 2022. 89-108.

[51] Ede G (2024). Change Your Diet, Change Your Mind. See discussion Chapter 4.

[52] Dalangin R, Kim A, Campbell RE. (2020). The Role of Amino Acids in Neurotransmission and Fluorescent Tools for Their Detection. International Journal of Molecular Sciences. 21(17):6197. DOI:10.3390/ijms21176197

[53] Matthews JJ, Arentson-Lantz EJ, Moughan PJ et al. (2025). Understanding Dietary Protein Quality: Digestible Indispensable Amino Acid Score and Beyond. J Nutrition, DOI: 10.1016/j.tjnut.2025.07.005

[54] NHMRC (2017). Nutrient Reference Values for Australia and New Zealand. Pages 240

[55] NHMRC (2017). Nutrient Reference Values for Australia and New Zealand. Pages 29

[56] Matthews JJ, Arentson-Lantz EJ, Moughan PJ et al. (2025). Understanding Dietary Protein Quality: Digestible Indispensable Amino Acid Score and Beyond. J Nutrition, DOI: 10.1016/j.tjnut.2025.07.005

[57] Hertzler SR, Lieblein-Boff JC, Weiler M, Allgeier C. (2020) Plant Proteins: Assessing Their Nutritional Quality and Effects on Health and Physical Function. Nutrients. 12(12):3704. DOI: 10.3390/nu12123704

[58] Matthews JJ, Arentson-Lantz EJ, Moughan PJ et al. (2025). Understanding Dietary Protein Quality: Digestible Indispensable Amino Acid Score and Beyond. J Nutrition, DOI: 10.1016/j.tjnut.2025.07.005

[59] Matthews JJ, Arentson-Lantz EJ, Moughan PJ et al. (2025). Understanding Dietary Protein Quality: Digestible Indispensable Amino Acid Score and Beyond. J Nutrition, DOI: 10.1016/j.tjnut.2025.07.005

[60] Wu S, Bhat ZF, Gounder RS, et al. (2022). Effect of Dietary Protein and Processing on Gut Microbiota—A Systematic Review. Nutrients. 14(3):453. DOI: 10.3390/nu14030453

PART III. REFORM. FOCUS ON HUMAN BIOLOGY

We welcome your use of this resource but please cite:

Chapter 9. Type 2 Diabetes: Remission is Real.

Type two diabetes mellitus (T2DM) has traditionally been characterised as a chronic, progressive condition not amenable to reversal. It was believed that pancreatic beta cell function was permanently lost by all people who were diagnosed with T2DM. However, clinicians working with patients now understand that the permanent loss of beta cell function is rare. Clinicians report that the sooner the patient adopts a low-carbohydrate diet, after a diagnosis of prediabetes or T2DM, the more likely natural insulin metabolism can resume. [1] Reversal and/or remission of T2DM is well documented in 2025.

T2DM remission, defined as normal blood glucose levels for 3 months or more in the absence of pharmacological therapy is dependent on factors including the length of time with T2DM, personal capacity and support networks.[2]

Physicians adopting a low-carbohydrate approach with patients have demonstrated that long-term improvements in blood glucose control (lower HbA1c levels),[3] can lead to remission of prediabetes and T2DM[4] [5] and reduce or eliminate dependence on diabetes medication use. [6] [7] [8] [9]

A battery of papers has been published in recent years which demonstrate broad improvement across metabolic disease parameters beyond T2DM. Trials consistently demonstrate that ketogenic diets reduce seizure risk and improve neurologic and cardiometabolic outcomes.[10] [11] [12] [13] Studies report:

Improvements in kidney function, [14]
Improvements in neurodegenerative conditions. E.g. Parkinson’s and Alzheimer’s disease.[15] [16] [17]
Reduced risk for cancer.[18] [19] [20]
Lower blood pressure.[21]
Improved mitochondrial function.[22]
Improvements in biomarkers for cardiovascular disease.[23] [24] [25] [26]

Type 1 diabetes mellitus: Carb Control Sees Improvements in Health Biomarkers & Quality of Life.

Type 1 diabetics (T1DM) who adopt a long-term low carb or ketogenic diet can experience improvements in quality of life and reduce risk for chronic conditions that are commonly associated with T1DM.[27] People with T1DM have a ten-fold higher risk for cardiovascular disease risk compared to the general population. Case studies assessing the metabolic parameters of T1DM individuals on ketogenic diets to manage glycemia and lower insulin requirements, have demonstrated improvements in biomarkers which suggest that such individuals, if this diet is maintained over time, can reduce risk for cardiovascular disease and other complications, compared to individuals that follow a conventional T1DM approach.[28] [29] [30] [31]

A protocol was developed in 2021 to support parents to adopt and monitor a low-carbohydrate/ketogenic approach in children and adolescents.[32] Diabetic ketoacidosis (where the body lacks sufficient insulin) may not be a major risk for T1DM individuals who pursue ketogenic diet.[33] Research is still in its infancy and this approach ‘may be cautiously considered in highly motivated, well-supported adult patients with structured education and access to continuous glucose and ketone monitoring’.[34]

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

RETURN TO CONTENTS PAGE.

REFERENCES

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

[1] Taylor R, Al-Mrabeh A, Zhyzhneuskaya S, et al. (2018). Remission of human type 2 diabetes requires decrease in liver and pancreas fat content but is dependent upon capacity for β cell recovery. Cell Metabolism, 28(4), 547–556.e3. DOI: 10.1016/j.cmet.2018.07.003.

[2] Hallberg SJ, McKenzie AL, Williams PT, et al. (2018). Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. Diabetes Ther. 9(2):583-612. doi: 10.1007/s13300-018-0373-9. Epub 2018 Feb 7. Erratum in: Diabetes Ther. 2018 Apr;9(2):613-621. doi: 10.1007/s13300-018-0386-4.

[3] Yuan, X., Wang, J., Yang, S. et al. (2020). Effect of the ketogenic diet on glycemic control, insulin resistance, and lipid metabolism in patients with T2DM: a systematic review and meta-analysis. Nutr. Diabetes 10, 38 (2020). DOI: 10.1038/s41387-020-00142-z

[4] Unwin D, Delon C, Unwin J, et al. (2023) What predicts drug-free type 2 diabetes remission? Insights from an 8- year general practice service evaluation of a lower carbohydrate diet with weight loss. BMJ Nutrition, Prevention & Health.

[5] 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. DOI: 10.1111/jhn.12938.

[6] 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 Nutr Prev Health.2020;3:285–94 bmjnph‐2020-000072.

[7] MacKay D, Chan C, Dasgupta K et al. (2022). Remission of Type 2 Diabetes. Diabetes Canada Clinical Practice Guidelines Expert Working Group. Can J Diabetes, 46:753-761. DOI: DOI: 10.1016/j.jcjd.2022.10.004.

[8] Lingvay I, Sumithran P, Cohen RV, le Roux CW. (2022) Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation. Lancet;399:394–405

[9] 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. DOI: 10.1007/s00125-020-05224-2.

[10] Dyńka D, Kowalcze K, Paziewska A. (2022). The Role of Ketogenic Diet in the Treatment of Neurological Diseases. Nutrients. 14(23):5003. DOI: 10.3390/nu14235003.

[11] Patikorn C, Saidoung P, Pham T. et al. (2023). Effects of ketogenic diet on health outcomes: an umbrella review of meta-analyses of randomized clinical trials. BMC Med 21:196. DOI:10.1186/s12916-023-02874-y

[12] Nojek P, Zawół M, Zimonczyk M, et al. (2024) Ketogenic diet and metabolic health.

[13] Baylie T, Ayelgn T, Tiruneh M, Tefsa KH (2024). Effect of Ketogenic Diet on Obesity and Other Metabolic Disorders.

[14] Athinarayanan SJ, Roberts CGP, Phinney SD, et al. (2025). Effects of a continuous remote care intervention including nutritional ketosis on kidney function and inflammation in adults with type 2 diabetes: a post-hoc latent class trajectory analysis. Front Nutr. Jun 6(12):1609737. doi: 10.3389/fnut.2025.1609737. PMID: 40547366

[15] Phillips, M.C.L., Deprez, L.M., Mortimer, G.M.N. et al. Randomized crossover trial of a modified ketogenic diet in Alzheimer’s disease. Alz Res Therapy 13, 51 (2021). https://doi.org/10.1186/s13195-021-00783-x

[16] Phillips, M.C.L., Picard, M. Neurodegenerative disorders, metabolic icebergs, and mitohormesis. Transl Neurodegener 13, 46 (2024). https://doi.org/10.1186/s40035-024-00435-8

[17] Rong L, Peng Y, Shen Q. et al. (2024). Effects of ketogenic diet on cognitive function of patients with Alzheimer's disease: a systematic review and meta-analysis. J nutrition, health and aging. 28(8):100306. DOI: 10.1016/j.jnha.2024.100306

[18] Duraj, T., Kalamian, M., Zuccoli, G. et al. Clinical research framework proposal for ketogenic metabolic therapy in glioblastoma. BMC Med 22, 578 (2024). https://doi.org/10.1186/s12916-024-03775-4

[19] Phillips MC, Thotathil Z, Hari Dass P, Ziad F and Moon BG: Ketogenic metabolic therapy in conjunction with standard treatment for glioblastoma: A case report. Oncol Lett 27: 230, 2024.

[20] Klement, R. J. (2025). Is the ketogenic diet still controversial in cancer treatment? Expert Review of Anticancer Therapy, 1–5. DOI:10.1080/14737140.2025.2522936

[21] Unwin DJ, Tobin SD, Murray SW, et al. (2019) Substantial and Sustained Improvements in Blood Pressure, Weight and Lipid Profiles from a Carbohydrate Restricted Diet: An Observational Study of Insulin Resistant Patients in Primary Care. Int J Environ Res Public Health, 16(15):2680. doi: 10.3390/ijerph16152680.

[22] Miller VJ, LaFountain RA, Barnhart E. et al. (2020) A ketogenic diet combined with exercise alters mitochondrial function in human skeletal muscle while improving metabolic health. Am J Physiol Endocrinol Metab. 1;319(6):E995-E1007. DOI: 10.1152/ajpendo.00305.2020.

[23] Bhanpuri NH, Hallberg SJ, Williams PT, et al. (2018). Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study. Cardiovasc Diabetol.;17:56. DOI: 10.1186/s12933-018-0698-8

[24] Hu T, Mills KT, YaoL ,et al (2012) Effects of Low-Carbohydrate Diets Versus Low-Fat Diets on Metabolic Risk Factors: A Meta-Analysis of Randomized Controlled Clinical Trials, American Journal of Epidemiology, 176(7): S44–S54, DOI:10.1093/aje/kws264

[25] Unwin DJ, Tobin SD, Murray SW, Delon C, Brady AJ.(2019) Substantial and Sustained Improvements in Blood Pressure, Weight and Lipid Profiles from a Carbohydrate Restricted Diet: An Observational Study of Insulin Resistant Patients in Primary Care. Int J Environ Res Public Health. 16(15):2680. DOI: 10.3390/ijerph16152680

[26] Saslow, L.R., Daubenmier, J.J., Moskowitz, J.T. et al. (2017) Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr & Diabetes 7, 304 (2017). DOI:10.1038/s41387-017-0006-9

[27] Turton JL, Brinkworth GD, Parker HM, et al. (2023) Effects of a low-carbohydrate diet in adults with type 1 diabetes: A single arm non-randomised clinical trial. PLoS ONE 18(7): e0288440. DOI:10.1371/journal.pone.0288440

[28] Watso JC, Robinson AT, Singar SAB et al. (2024). Advanced cardiovascular physiology in an individual with type 1 diabetes after10-year ketogenic diet. Am J Physiol Cell Physiol 327: C446–C461. DOI:10.1152/ajpcell.00694.2023

[29] Gardemann C, Knowles S, Marquardt T (2023). Managing type 1 diabetes mellitus with a ketogenic diet. Endocrinology, Diabetes & Metabolism, 23:008 DOI:10.1530/EDM-23-0008

[30] Koutnik AP, Klein K, Robinson AT, Watso JC. (2024). Efficacy and Safety of Long-term Ketogenic Diet Therapy in a Patient With Type 1 Diabetes, JCEM Case Reports, 2(7):luae102, DOI: 10.1210/jcemcr/luae102

[31] Tóth C, Clemens Z. (2014). Type 1 diabetes mellitus successfully managed with the paleolithic ketogenic diet. Int J Case Rep Images 2014;5(10):699–703. DOI: 10.5348/ijcri-2014124-CR-10435

[32] Rydin AA, Spiegel G, Frohnert BI, et al. (2021). Medical management of children with type 1 diabetes on low-carbohydrate or ketogenic diets. Pediatric Diabetes, DOI: 10.1111/pedi.13179.

[33] Ozoran H, Matheou M, Dyson P et al. (2023). Type 1 diabetes and low-carbohydrate diets—Defining the degree of nutritional ketosis. Diabetic Medicine, 40(10);15178. DOI: 10.1111/dme.15178

[34] Korakas E, Kountouri A, Petrovski G, Lambadiari, V. (2025). Low-Carb and Ketogenic Diets in Type 1 Diabetes: Efficacy and Safety Concerns. Nutrients, 17:2001. DOI:10.3390/nu17122001

Subcategories

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For over 20 years the Physicians and Scientists for Global Responsibility New Zealand Charitable Trust (PSGR) has produced reports and submitted to government Bills and Inquiries.

We’ve been extraordinarily busy over the past 2 years with our work.

This Update aims to inform members and colleagues – and act as a go-to summary of our recent work.

2022 UPDATE - PDF

As well as our recent work All PSGR’s submissions are available to the public on our Submissions pages. In addition, we are now on LinkedIn, Twitter, Odysee & Instagram.

MEMBERSHIP

Please – without your support and membership PSGR cannot do this work. We’ve kept our fees deliberately low because your membership is important to us.

MOVING FORWARD 2022+

The PSGR recognise that the perspectives that have been expressed by the PSGR from 2020 onwards will not necessarily reflect the perspectives of all trustees and all members.

However, we sincerely hope that PSGR’s perspectives are more likely to reflect the perspectives of the majority of our membership and of collegial organisations – which represents a diverse quorum of inquiring minds.

We hope that we have demonstrated a consistency to our work, that reflects and upholds the principles reflected in 20 years of research, information communications and submissions to policy

[I] DIET FIRST APPROACHES IN LOCAL COMMUNITIES.

[II] EDUCATIONAL REFORM

[III] INSTITUTIONAL & REGULATORY REFORM.

[IV] SCIENCE SYSTEM REFORM

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.

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

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

(a) Respecting Individual Sensitivity to Dietary Interventions.

Figure 14. Unwin D, Haslam D, Livesey G (2016) It is the glycaemic response to, not the carbohydrate content of food that matters in diabetes and obesity: The glycaemic index revisited. Journal of Insulin Resistance.

Figure 15. Unwin D, Delon C, Unwin J, et al. What predicts drug-free type 2 diabetes remission? Insights from an 8- year general practice service evaluation of a lower carbohydrate diet with weight loss. BMJ Nutrition, Prevention & Health

(b) Food Addiction Counselling to address Ultraprocessed Food Addiction.

Figure 16. Unwin J, Delon C, Giæver H, Kennedy C, et al. (2022) Low-carbohydrate and psychoeducational programs show promise for the treatment of ultra-processed food addiction. Front. Psychiatry

Figure 17. Unwin J, Delon C, Giæver H, Kennedy C,Painschab M, Sandin F, Poulsen CS and Wiss DA (2025) Low-carbohydrate and psychoeducational programs show promise for the treatment of ultra-processed food addiction: 12-month follow-up. Front. Psychiatry.

(c) Technologies to support patient knowledge: Continuous glucose monitoring (CGM) devices.

(d) Technologies to support patient knowledge: Breath Ketone Sensors.

(e) Technologies to support patient knowledge: Digital Apps.

(f) The Question of Protein Choice.

Figure 18. Matthews JJ, Arentson-Lantz EJ, Moughan PJ et al. (2025). Understanding Dietary Protein Quality: Digestible Indispensable Amino Acid Score and Beyond. J Nutrition.

PART III. REFORM. FOCUS ON HUMAN BIOLOGY

Chapter 9. Type 2 Diabetes: Remission is Real.

Type 1 diabetes mellitus: Carb Control Sees Improvements in Health Biomarkers & Quality of Life.

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