Marcus Hawkins

Background/Objectives: The global epidemic of type 2 diabetes (T2D) is a critical public health issue, particularly in New Zealand, where prevalence rates are high, especially among Māori and Pacific people. Recent research indicates that dietary interventions, particularly carbohydrate reduction, can lead to the remission or reversal of T2D. However, little is known about how such approaches perform when implemented in routine New Zealand primary care, particularly within high-risk and underserved populations. This study aimed to evaluate changes in HbA1c, diabetes status, and cardiometabolic outcomes among adults with prediabetes and T2D engaged in such a model of care. Methods: This study reports findings from a retrospective, observational, real-world, multi-site clinical audit (service evaluation) of a holistic model of care implemented in three primary care practices in New Zealand. The model of care is characterised by a three-pronged approach: whole food, carbohydrate reduction; a health-coach, behaviour-change-based delivery approach; and community- or peer-based initiatives. Audit data from 106 patients with prediabetes (PD) and T2D were analysed (median follow-up 19 months; IQR 6–32) to assess changes in glycosylated haemoglobin (HbA1c) levels, diabetes status, and cardiometabolic outcomes. Results: We observed an overall reduction in HbA1c (median change −3 mmol/mol (IQR: −7 to 3), p = 0.004), with 32% of patients with T2D at baseline achieving reversal and 44% of those with PD attaining normoglycaemia at final follow-up. Weight loss was associated with greater HbA1c reduction (0.56 mmol/mol decrease per kg lost) and additional improvements seen in lowered alanine aminotransferase (ALT). HDL cholesterol showed a small decline (r = 0.31), and triglycerides and blood pressure showed no significant change, indicating that these measures remained broadly stable over the evaluation period. Conclusions: Given the retrospective and uncontrolled audit design, findings should be interpreted with appropriate caution. However, the consistent improvements observed across multiple practices suggest that carbohydrate-reduction strategies within holistic models of care can meaningfully improve diabetes outcomes in real-world primary care settings. Future research should evaluate longer-term sustainability, implementation fidelity, and the applicability of this model at scale, particularly for Māori and Pacific communities.

Type 2 diabetes (T2DM) is a condition that involves insulin resistance and a reduced ability to control blood glucose. Science and logic indicate that reducing the very nutrient that raises blood sugar, ie carbohydrate, would be worth consideration, yet it's been overlooked for many years. Global dietary guidelines have been updated to align with scientific evidence. The American Diabetes Association (ADA), The British Diabetes and Dietetic Associations, Diabetes Canada and Diabetes Australia have included carbohydrate reduction (CR) in their official T2DM dietary guidelines. 1,2 An ADA 2019 consensus report concluded: 'reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences'. This report was included in the 2020 ADA Standards of Medical Care in Diabetes update. 3 Diabetes Australia states: 'For people with type 2 diabetes, there is reliable evidence that lower carb eating can be safe and useful in lowering average blood glucose levels in the short term (up to 6 months). It can also help reduce body weight and help manage heart disease risk factors such as raised cholesterol and raised blood pressure.' 4 New Zealand (NZ) does not endorse CR as a viable option for individuals, but rather cautions against it. The NZ Society for the Study of Diabetes states in their guidelines 'meta-analyses show that the benefits of ketogenic diets are unlikely to be sustained'. 5,6 and the Ministry of Health states 'Very low carbohydrate diets: Not recommended'. 5 This is surprising, as clinical trials and primary care practice data report beneficial and sustained results from CR. 7,8 Virta Health, a US-based research entity has shown CR to be safe in prediabetes/T2DM. Their 5-year data concluded their model of care showed excellent retention, sustained clinically significant weight loss, stable glycaemic control and less dependency on diabetes medication. 9 British general practitioner, Dr David Unwin used CR to reverse/remit T2DM; of 199 patients with T2DM, 46% achieved drug-free remission, with enormous cost savings from reduced diabetes medication. 10 In view of the rapid growth of evidence around CR and T2DM, and the global guideline adoption, we simply ask why NZ is not at least including a CR approach in its guidelines, alongside other dietary approaches, to manage T2DM. We now call upon NZ to catch up and follow suit.

This study explores a novel healthcare model employed in the primary care setting integrating a carbohydrate‐reduction dietary approach and health coaching for managing prediabetes (PD) and Type 2 diabetes (T2D) in New Zealand. Using qualitative methods, we conducted focus groups with 46 patients and individual interviews with health coaches and general practitioners across two regions. Five major themes emerged from inductive thematic analysis: reduced carbohydrate lifestyles, health coaching, implementation, empowerment, and sustainability. Patients reported significant health improvements, including weight loss, reduced medication burden, and increased energy. Challenges included resistance from some medical professionals and negative public perceptions. Health coaching played a crucial role in patient care, providing individualised support and enhancing health literacy. The study found that this model both improved patient outcomes and also alleviated the burden on healthcare professionals by managing time‐intensive aspects of patient care. Barriers to the adoption of this model include scepticism about low‐carbohydrate diets and the need for more education and awareness among healthcare professionals. The findings suggest that this healthcare model has the potential to transform the management of PD and T2D in primary care, shifting patients from lifelong medication dependence to significant health improvements and potential disease remission or reversal.

The New Zealand Medical Journal (NZMJ) is the principal scientific journal for the medical profession in New Zealand. The Journal has become a fundamental resource for providing research and written pieces from the health and medical industry.

Background: Carbohydrate-reduction has been used successfully in the management of conditions arising from insulin resistance.Aim: In this audit, the authors report on metabolic outcomes from 72 patients in primary care who have undergone counselling using a low-carbohydrate dietary approach.Setting: This audit took place in a family medical practice located in a relatively affluent suburb in East Auckland, New Zealand.Methods: Patients adopted a carbohydrate reduction diet with regular follow-up and monitoring of health parameters.Results: The mean duration of observation was 21.5 (± 10.4) months. On average, patients lost 11 (± 8.4) kg, with 17% attaining a healthy body mass index (BMI). Four out of five patients reversed prediabetes over 20.8 (± 13.4) months. Twenty-five per cent (28/113) of the practice population with type 2 diabetes (T2DM) participated, of which 64% reversed and 11% remitted T2DM over 20.7 (± 11.8) months. Two patients stopped insulin and 10 reduced or stopped other diabetes medications. Nearly 35% (25/72) of participants were initially hypertensive. Thirty-six per cent (9/25) normalised systolic blood pressure (SBP), 28% (7/25) normalised diastolic blood pressure (DBP), and 16% (4/25) normalised both SBP DBP. Sixty-four per cent reduced or stopped some or all antihypertensive medication. There was a mean reduction in SBP of 10.3 (± 17.7) mmHg and DBP of 4.8 (± 12.3) mmHg over 23.8 (± 9.0) months. Lipid changes were generally favourable, with 52% normalising triglycerides, 61% increasing high density lipoprotein cholesterol (HDL-C) to greater than 1.0 mmol/L, and 39% reducing low density lipoprotein cholesterol (LDL-C).Discussion: This real-world audit aligns with published data on the benefits of carbohydrate reduction.Conclusion: Effective management of prediabetes using CR might represent the biggest ‘bang for buck’ with a potential reduction in weight and prevention of diseases related to IR.Contribution: A low-carbohydrate dietary approach in primary care may serve as a realistic option for improving multiple health outcomes.

Obesity is a scourge on modern society and an epidemic has exploded in the developed world over the last half century, resulting in sicker populations and economically unsustainable health expenditure. The Pacific region became colonised by Europeans from the early nineteenth century onwards and, as a consequence, ‘European’ foodstuffs were introduced to New Zealand Māori. This has intensified over the last 150 years; so much so, that obesity is now common among New Zealand Māori, who suffer disproportionately from the chronic diseases arising from obesity. This commentary seeks to explore and compare the ‘then’ and ‘now’ in terms of New Zealand Māori nutrition and anthropometrics. It also asks the specific questions: were New Zealand Māori originally eating a low carbohydrate healthy fat diet? and should we all now reflect on a previous dietary pattern of eating in an effort to reverse the obesity epidemic?