The diet debate: fat vs protein vs carbs in type 2 diabetes Role of a Low carbohydrate, high protein, high unsaturated fat diet

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1 The diet debate: fat vs protein vs carbs in type 2 diabetes Role of a Low carbohydrate, high protein, high unsaturated fat diet ESA Seminar 2018 Diabetes, diet and exercise: Symposium in Honour of Dennis Wilson Professor Grant Brinkworth, PhD, MBA Principal Research Scientist 4th May 2018

2 Lifestyle Strategies for Type 2 Diabetes Management First Line Treatment: Lifestyle Modification (diet and exercise) to: - reduce body weight - improve blood glucose control Weight loss reduces hyperglycemia & metabolic risk factors in Type 2 Diabetes 1 1. How is this best achieved? 2. Which diet approach maximise the benefits of lifestyle modification? 2 Long-term Health Effects of Very Low- and High Carbohydrate Diets Grant Brinkworth 1. Lee et al. Am. J. Cardiol The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

3 Nutritional Management of Diabetes: The Dilemma Public guidelines (most countries) advise a High unrefined carbohydrate, low fat (HC) diet - Carbohydrate (45-75% of total E) emphasis on low glycemic index - Protein (10-20% of total E) - Fat (15-30% total E; <10% saturated fat) HC diets - modest weight loss and risk factor reduction 2 Carbohydrate restriction, higher intakes of protein and unsaturated fats, independent of weight loss: 3, 4,5 - improves blood glucose response/control - attenuates postprandial glucose rises and insulin response - reduces CVD risk Challenges: - clinical practice recommendations of HC diets should continue 3 - increased prevalence/use of very low carbohydrate diets (<50 g/day) 2. Toubro et al. BMJ 1997, 3. Parker et al. Diab. Care 2010, 4. Farnsworth et al. Am. J. Clin. Nutr. 2003, 5. Wolfe et al. Clin Invest Med The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

4 Nutritional Management of Diabetes - The Evidence Blood Glucose Control remains primary target - associated with reduced development and progression of microvascular complications 1 Assessments: - Glycated Hemoglobin (HbA1c) average blood glucose levels over 3 months standard clinical assessment of blood glucose control - Post-prandial glucose (PPG) peaks, hyperglycemic excursion & diurnal glycemic variability independent risk factor for micro- and macrovascular complications and CVD events 2,3 Targeting treatment options that both: 1. lowering HbA1c 2. minimizing PPG and daily glucose variability provides comprehensive approach to reduce diabetes related CVD risk & complications Tay et al. Ann Rev Nutr Colagiuri et al. National evidence based guidelines for blood glucose control in type 2 diabetes 2009, 2. Bonora et al. Int. J. Clin. Prac. 2002, 3. Cavalot et al. J. Clin. Endocrinol. Metab The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

5 Nutritional Management of Diabetes Carbs Carbohydrate (CHO) restriction for glucose control: Glycaemic load (GL) greatest influence on PPG and insulin response both type (GI%) and quantity (g) influence blood glucose levels/glycaemic control, but. Quantity impacts glycaemia the most 1 Gannon et al. 2-4 week energy balance study: CHO restriction reduced HbA1c by 1.25% (absolute units) 2016 Meta analysis 3 of randomised controlled feeding studies replacing CHO with MUFA or PUFA, but not SFA significantly lowered HbA1c reducing total CHO intake may offer strong option to reduce GL and improve glycaemic control 5 Low vs High Carbohydrate Diet for patients with type 2 diabetes Grant Brinkworth 1. Sheard et al. Diab. Care, 2004, 2. Gannon et al. Diabetes 2004, 3. Imamura et al The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

6 Nutritional Management of Diabetes Protein and Fat Protein and Fat for glucose control: - attenuate postprandial glucose rises by delaying gastric emptying of CHO 1,2 - via alternating gastrointestinal function caused by an incretin response 1,2 reducing glucose insulinotrphic polypeptide (GIP) increasing glucogon-like peptide-1 (GLP-1) increasing dietary protein and fat levels may reduce PPG response & improve glycaemic control Dietary pattern low in carbohydrate and high in fat and protein may be beneficial for improving glycaemic control for type 2 diabetes management 6 1. Gentilcore et al. J. Clin. Endocrinol. Metab. 2006, 2. Ma et al. Diab. Care The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

7 Low carbohydrate, high fat (LC) diets and glycaemic control in T2DM Study Team n Duration Results : HbA1c Westman et al. (2008) weeks LC - 1.5% vs. HC -0.5% Stern et al. (2004) weeks LC- 0.7% vs. HC 0.1% Mayer et al. (2013) weeks LC- 0.7% vs. HC 0.2% Absolute Difference 1 % 0.6 % 0.8 % 2017 meta-analysis of 10 RCTs showed greater HbA1c lowering with LC vs HC in T2D 8 Dose response effect: greater carbohydrate restriction the greater glucose-lowering effect 8 Limitations of previous studies: No formalised exercise program or control of physical activity Glycaemic control assessment limited to HbA1c and FBG - GV and PPG - emerging independent risk factors for diabetes complications including CVD 4-7 Comprehensive approach to reduce diabetes related CVD risk & complications target both: - lowering HbA1c (chronic) - minimising daily fluctuations (acute) 7 1. Westman et al. Nutr & Metb. 2008; 2. Stern et al. Ann Intern Med. 2004; 3. Mayer et al. Diabs Obes Metab. 2013; 4. Nalysnyk et al. Diabs Obes Metab. 2010; 5. Di Flaviani et al. Diabetes Care. 2011; 6. Monnier et al. JAMA. 2006; 7. Buscemi et al. Diabet Med Snorgaard et al. BMJ Open Diabetes Research & Care The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

8 Low carbohydrate, high fat diets & CVD risk - Evidence in obese, non-diabetes populations Several RCT s show up to 1 year, cf. HC diet, an LC diet achieve: comparable or greater weight loss 1 3 greater ä in triglyceride greater ã in HDL-C similar reductions in blood pressure, insulin resistance, glucose homeostasis, and inflammatory marker status 1-3 Detrimental effects of LC diets on blood lipids and CVD risk concern remains Studies often show LC diet promote higher LDL-C 1-4 Flow Mediated Dilatation (FMD - vascular function) impaired 5 7 Long-term Health Effects of Very Low- and High Carbohydrate Diets Grant Brinkworth 1. Stern et al. Ann. Intern. Med. 2004, 2. Foster et al. NEJM 2003, 3. Gardner et al. JAMA 2004, 4. Nordmann et al. Arch. Intern. Med. 2006, 5. Wycherley et al. J. Inter. Med The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

9 Low carbohydrate, high fat diets & CVD risk - Evidence in non-diabetes populations but LC diet studies, concomitantly increase total fat and promote high saturated fat intakes Fat quality/type rather than quantity per se is more important: Saturated Fat: - promotes insulin resistance 1 - elevates LDL-C 2 - adversely affects FMD 3 Mono- and Polyunsaturated fat: - promotes insulin sensitivity - improves lipids profile (reduce total, LDL-C and triglycerides, increases HDL-C) 4 - improve FMD 5,6 \ high saturated fat content of LC diets maybe promote detrimental effects on LDL-C and FMD higher dietary fat intakes, provided saturated fat content remains low maybe advantageous for reducing CVD risk 8 Long-term Health Effects of Very Low- and High Carbohydrate Diets Grant Brinkworth 1. Riccardi et al. Clin. Nutr. 2004, 2. Clarke, BMJ 1997, 3. Keogh et al. Arterioscler. Thromb. Vas. Biol. 2005, 4. Mensink etal. Am. J. Clin. Nutr. 2003, 5. Fuebtes eral. Ann. Inter. Med. 2001, 6. Rallidis et al. Am. J. Clinic, Nutr The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

10 Australian 2-year study Devised novel eating pattern: - markedly limits carbohydrates - increases protein and unsaturated fat - and is nutritionally replete - Adequate vitamins, minerals, trace elements and fibre Hypothesis: A low carbohydrate diet, high in protein and unsaturated fat and low in saturated fat offer: - greatest improvements in glucose control - without detrimental effects on CVD risk 9 Long-term Health Effects of Very Low- and High Carbohydrate Diets Grant Brinkworth 10 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

11 2012 Study - Safety Effects of low carb, high fat Diet effects not systematically examined Evaluate chronic effects of an LC diet vs HC diet on: Cognitive Function Mood & Psychological Wellbeing Renal Function & Bone Health T2D increased risk of cognitive decline T2D increased risk of depression and lower quality of life T2D increased risk of renal impairment / failure 10 Long-term Health Effects of Very Low- and High Carbohydrate Diets Grant Brinkworth 11 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

12 2012 Study: Multi Aims with diverse health outcomes Compare the long-term effects (24 months): 1. energy-reduced, low carbohydrate, high fat, low saturated fat (LCLSF) diet 2. energy-matched, conventional high carbohydrate (low-gi), low fat (HC) diet in overweight/obese individuals with T2DM on multiple health outcomes: * * Blood glucose control HbA1c, FBG, Glycemic Variability (PPG), changes in diabetes meds The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

13 Study Design 2 Year RCT Lifestyle Intervention 115 overweight and obese men and women with type 2 diabetes Diets: isocalorically matched, with moderate energy restriction Low Carbohydrate, low saturated fat (LCLSF) 14% carbohydrate (< 50g CHO/day) 28% protein 58% fat 0wk - <10% saturated fat - 35% monounsaturated fat - 12% polyunsaturated fat 12 wk High Unrefined Carbohydrate, low fat (HC) 53% carbohydrate (low-gi: 46) 17% protein 30% fat - <10% saturated fat - 15% monounsaturated fat - 9% polyunsaturated fat 104 wk 2-weekly dietary counselling Food samples provided Monthly dietary counselling $50 food voucher or Food samples alternate months Supervised Exercise Training (combined aerobic/resistance, mod intensity): 60 minutes, 3 x / wk 13 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

14 Received: 13 August 2017 Revised: 24 October 2017 Accepted: 14 November 2017 DOI: /dom Commonwealth Scientific and Industrial Research Organisation (CSIRO) Health and Biosecurity, Adelaide, Australia 2 Discipline of Medicine, University of Adelaide, Adelaide, Australia 3 Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, Australia 4 Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina 5 Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina 6 Agency for Science, Technology and Research (A-STAR), Singapore Correspondence Grant Brinkworth, PhD, Commonwealth Scientific and Industrial Research Organisation- Health and Biosecurity, Riverside Corporate Park, 11 Julius Avenue, North Ryde, NSW, Australia, grant.brinkworth@csiro.au Funding information This study was supported by a National Health and Medical Research Council of Australia Project Grant (103415). J. T. was supported by a postgraduate research scholarship from the Agency for Science, Technology and Research (A-STAR), Singapore. Funding sponsors had no role in the design, conduct or reporting of the study or the decision to submit the manuscript for publication.agency for Science, Technology and Research; National Health and Medical Research Council, Grant/Award number: KEYWORDS John Wiley & Sons Ltd wileyonlinelibrary.com/journal/dom Diabetes Obes Metab. 2018;20: Results 12 month outcome results - Blood glucose control - metabolic health & CVD risk - renal function - mood and quality of life - cognitive function 24 month outcome results - weight and metabolic health ORIGINAL ARTICLE Effects of an energy-restricted low-carbohydrate, high unsaturated fat/low saturated fat diet versus a highcarbohydrate, low-fat diet in type 2 diabetes: A 2-year randomized clinical trial Jeannie Tay PhD 1,2,6 Campbell H. Thompson MD 2 Natalie D. Luscombe-Marsh PhD 1 Thomas P. Wycherley PhD 3 Manny Noakes PhD 1 Jonathan D. Buckley PhD 3 Gary A. Wittert MD 2 William S. Yancy Jr MD 4,5 Grant D. Brinkworth PhD 1 Aim: To examine whether a low-carbohydrate, high-unsaturated/low-saturated fat diet (LC) improves glycaemic control and cardiovascular disease (CVD) risk factors in overweight and obese patients with type 2 diabetes (T2D). Methods: A total of 115 adults with T2D (mean [SD]; BMI, 34.6 [4.3] kg/m 2 ; age, 58 [7] years; HbA1c, 7.3 [1.1]%) were randomized to 1 of 2 planned energy-matched, hypocaloric diets combined with aerobic/resistance exercise (1 hour, 3 days/week) for 2 years: LC: 14% energy as carbohydrate, 28% as protein, 58% as fat (<10% saturated fat); or low-fat, high-carbohydrate, low-glycaemic index diet (HC): 53% as CHO, 17% as protein, 30% as fat (<10% saturated fat). HbA1c, glycaemic variability (GV), anti-glycaemic medication effect score (MES, calculated based on the potency and dosage of diabetes medication), weight, body composition, CVD and renal risk markers were assessed before and after intervention. Results: A total of 61 (LC = 33, HC = 28) participants completed the study (trial registration: ANZCTR No. ACTRN ). Reductions in weight (estimated marginal mean [95% CI]; LC, 6.8 [ 8.8, 4.7], HC, 6.6 [ 8.8, 4.5] kg), body fat (LC, 4.3 [ 6.2, 2.4], HC, 4.6 [ 6.6, 2.7] kg), blood pressure (LC, 2.0 [ 5.9, 1.8]/ 1.2 [ 3.6, 1.2], HC, 3.2 [ 7.3, 0.9]/ 2.0 [ 4.5, 0.5] mmhg), HbA1c (LC, 0.6 [ 0.9, 0.3], HC, 0.9 [ 1.2, 0.5] %) and fasting glucose (LC, 0.3 [ 0.4, 1.0], HC, 0.4 [ 1.1, 0.4] mmol/l) were similar between groups (P 0.09). Compared to HC, the LC achieved greater reductions in diabetes medication use (MES; LC, 0.5 [ 0.6, 0.3], HC, 0.2 [ 0.4, 0.02] units; P = 0.03), GV (Continuous Overall Net Glycemic Action calculated every 1 hour (LC, 0.4 [ 0.6, 0.3], HC, 0.1 [ 0.1, 0.2] mmol/l; P = 0.001), and 4 hours (LC, 0.9 [ 1.3, 0.6], HC, 0.2 [ 0.6, 0.1] mmol/l; P = 0.02)); triglycerides (LC, 0.1 [ 0.3, 0.2], HC, 0.1 [ 0.2, 0.3] mmol/l; P = 0.001), and maintained HDL-C levels (LC, 0.02 [ 0.05, 0.1], HC, 0.1 [ 0.1, 0.01] mmol/l; P = 0.004), but had similar changes in LDL- C (LC, 0.2 [ 0.1, 0.5], HC, 0.1 [ 0.2, 0.4] mmol/l; P = 0.85), brachial artery flow mediated dilatation (LC, 0.5 [ 1.5, 0.5], HC, 0.4 [ 1.4, 0.7] %; P = 0.73), egfr and albuminuria. Conclusions: Both diets achieved comparable weight loss and HbA1c reductions. The LC sustained greater reductions in diabetes medication requirements, and in improvements in diurnal blood glucose stability and blood lipid profile, with no adverse renal effects, suggesting greater optimization of T2D management. dietary intervention, type 2 diabetes, weight control 14 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

15 Weight loss LCLSF: kg vs. HC: kg No difference in weight loss between diets (P=0.18) Weight (kg) % % 105 LSLSF Diet 103 HC Diet Body Composition No difference between diets for change in FFM:FM ratio with weight loss (P=0.15) Long-term Health Effects of Very Low- and High Carbohydrate Diets Grant Brinkworth Weeks Values are estimated marginal means SEM FM: Fat mass FFM: Fat free mass Tay et al. ACJN, The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

16 Glycemic Control: HbA1c NS: time x diet interaction (p=0.65) - 1 % - 1 % Long-term Health Effects of Very Low- and High Carbohydrate Diets Grant Brinkworth Tay et al. ACJN, 2015 Values are estimated marginal means SEM 16 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

17 Diabetes Medication Use Antiglycemic Medication Effect Score (MES) * Significant time x diet interaction (p=0.007) * Long-term Health Effects of Very Low- and High Carbohydrate Diets Grant Brinkworth Tay et al. ACJN, 2015 Values are estimated marginal means SEM 17 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

18 Glycaemic Variability: MAGE, CONGA, SD P= 0.09 P= mmol/l mmol/l - 1.7mmol/L mmol/l P= P= mmol/l mmol/l * mmol/l mmol/l * Tay et al. ACJN, 2015 MAGE: Mean amplitude of glucose excursions; CONGA: Continuous overall net glycemic action; SD: Standard Deviation 18 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

19 CVD risk markers: Blood pressure, Insulin, HOMA2-IR, CRP Significant reduction on both diets No diet effect (P 0.38) CVD Markers Risk Systolic Blood Pressure (mmhg) Diastolic Blood Pressure (mmhg) Insulin (mmol/ L) HOMA2- IR CRP (mg/ L) LCLSF Diet Change HC Diet week 0 Week 52 week 0 week Change Tay et al. ACJN, 2015 Data are estimated marginal means 19 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

20 Triglycerides * Significant time x diet interaction (p=0.001) mmol/ L * mmol/ L Tay et al. ACJN, 2015 Values are estimated marginal means SEM 20 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

21 HDL cholesterol * Significant time x diet interaction (p=0.002) 0.1 mmol/ L * 0.06 mmol/ L Tay et al. ACJN, 2015 Values are estimated marginal means SEM 21 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

22 LDL cholesterol No time x diet interaction (p=0.81) Tay et al. ACJN, 2015 Values are estimated marginal means SEM 22 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA 22

23 Flow Mediated Dilatation (Endothelial Function) LCLSF Diet No time x diet interaction (p=0.41) Wycherley et al. Atherosclerosis 2016 Values are estimated marginal means SEM 23 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

24 Mood Significant improvements (reduction in scores) over time for BDI and POMS (TMDS and subscales Anger, Confusion, Depression, Fatigue, Tension) - Magnitude of change across domains: 14-43% No difference in time-course response between diets (NS, P 0.22 time x diet) 10 Beck Depression Inventory Score LC HC POMS - Total Mood Disturbance Score 20 LC HC Week Week Brinkworth et al. J Intern Med, 2015 Values are estimated marginal means SEM 24 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

25 Cognitive Function 9 domains No differences in response between diet groups for any cognitive function outcome (P 0.24 time x diet). DSST (perceptual speed), OMO (Reasoning Speed), Mscan (Speed of Memory Scanning) improved overtime (P<0.01 time) Tay et al. British J Nutr 2016 Values are estimated marginal means SEM 25 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

26 Renal Function Markers: AER, Scr, egfr and CrCl no differential response between groups, P³0.25 (time x diet effect) egfr (CKD-EPI) CrCL (Cockroft-Gault) LC Diet HC Diet LC Diet HC Diet egfr-ckd-epi (ml/min/1.73m 2 ) CrCl- Cockroft-Gault (ml/min) Albuminuria: week 0 week 52 0 week 0 week 52 Baseline: 7 participants (LC=4, HC=3) with pathological albuminuria Week 52: 4 participants (LC=2, HC=2) became normoalbuminuric Participants with norm albuminuria at baseline remained constant after 52 weeks Tay et al. Medicine, The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

27 2-year metabolic outcomes Outcome LCLSF HC P Value Completed Study 33/58 28/57 Weight (kg) Body fat (kg) Blood Pressure (mmhg) HbA1c (%) Fasting Blood Glucose Anti-glycemic Medication Effect Score Glycemic Variability Indices - CONGA MAGE Triglycerides (mmol/l) HDL-C (mmol/l) LDL-C (mmol/l) FMD response Renal Function CONGA Continuous Overall Net Glycaemic Action 1; MAGE Mean Amplitude of Glucose Excursion No Difference between groups No negative effect The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA Tay et al. DOM 2018

28 Results Summary & Conclusion Low carbohydrate, high protein, high unsaturated, low saturated fat diet Anthropometric - Weight loss - Body composition CVD risk - Total and LDL-Cholesterol - HDL-Cholesterol (2x) - Triglycerides (40x) - Flow meditated dilatation Glycemic Control - HbA1c - Diabetes Medication reduction (2x) - Diurnal glycemic variability (3x) Psychological Wellbeing - Mood - Quality of Life, Diabetes self-management - Cognitive Function Renal Function - egfr, albuminuria Current Standard Practice High unrefined carbohydrate (low GI), low protein, low fat Anthropometric - Weight loss - Body composition Glycemic Control - HbA1c - Diabetes Medication reduction - Diurnal glycemic variability CVD risk - Total and LDL-Cholesterol - HDL-Cholesterol - Triglycerides - Flow meditated dilatation Psychological Wellbeing - Mood - Quality of Life, Diabetes self-management - Cognitive Function Renal Function - egfr, albuminuria 28 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

29 Conclusions Both LCLSF and HC diets produced similar weight loss, body composition changes, improvements in CVD risk markers, mood, quality of life and cognitive function LCLSF diet had more favorable effects on: lipid profile glycaemic control attenuating glucose fluctuations Incorporation of a low carb, healthy fat eating plan (50-70g CHO/day) within a comprehensive lifestyle modification program magnifies therapeutic benefits for: - improving both acute and chronic glycaemic control - reducing glycemic variability - enhancing CVD health 29 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

30 Conclusion All Low carb diets may not be equal All energy reduced diets (including Low Carb and High Carb diets) produce weight loss and improve glycemic control and CVD risk markers A low carb diet (high unsaturated / low saturated fat) may: - magnify metabolic benefits of weight loss - more effective for people with Type 2 Diabetes and Metabolic Syndrome One size (diet) may not fit all individuals Variety of diet approaches for weight and diabetes control is required to individualise management based on personal preferences: - tradition, culture, religion, economics, and metabolic and health beliefs and goals 30 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

31 The CSIRO Low-Carb Diet Step-by-step guide to translate low carb diet plan into easy practice Daily food allowance units tailored for individual energy requirements 12 weekly meal plans and shopping lists 80 recipes, including breakfasts, lunch, dinner (including vegetarian), snacks & desserts A comprehensive exercise plan 31 1 Bread, cereals, legumes and starchy vegetables Limited Carb 2 Low-moderate carb vegetables Unlimited Low Carb Veg 3 Healthy Fats High healthy fats / low saturated fat Nuts, seeds, oils, avocados, olives, fish 4 Dairy Adequate dairy Low-fat milk / yoghurt, cheese 5 Lean meat, fish, poultry, eggs, tofu High lean protein

32 Study and Funding Collaborators External Funding NH&MRC Project Grant (App , ) Collaborators University of South Australia University of Adelaide Flinders University Duke University Community Service Providers Fit for Success SA Aquatic Centre & Leisure Centre Boot Camp Plus 32 Long-term Health Effects of Very Low- and High Carbohydrate Diets Grant Brinkworth 32 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

33 Acknowledgements Team Members Chief Investigators - Grant Brinkworth, PhD; Manny Noakes, PhD; Jonathan Buckley, PhD; Campbell Thompson, PhD; Natalie Luscombe- Marsh, PhD; Carlene Wilson, PhD; Gary Wittert, MD Co-Investigators and Research Associates - Tom Wycherley, PhD; Will Yancy,PhD, Jeannie Tay (PhD); Vanessa Danthiir, PhD; Ian Zajac, PhD Clinical Research Team and Data Management - Anne McGuffin; Lindy Lawson; Julie Syrette; Julia Weaver; Vanessa Courage; Peter Royle Dietetics Research Team - Pennie Taylor; Janna Lutze; Fiona Barr; Paul Foster; Hannah Gilbert; Gemma Williams Laboratory Research Team - Vanessa Russell; Cathryn Pape; Candita Dang; Sylvia Usher; Andre Nikelic Research Exercise Leaders - Fit for Success: Luke Johnston, Annie Hastwell - SA Aquatic Centre & Leisure Centre: Kelly French, Jason Delfos, Kristi Lacey-Powell, Marilyn Woods, John Perrin, Simon Pane, Annette Beckette - Boot Camp Plus: Angie Mondello, Josh Gniadek 33 The Diet Debate fats vs protein vs carbs for type 2 diabetes Grant Brinkworth, PhD, MBA

34 The diet debate: fat vs protein vs carbs in type 2 diabetes Role of a Low carbohydrate, high protein, high unsaturated fat diet ESA Seminar 2018 Diabetes, diet and exercise: Symposium in Honour of Dennis Wilson Professor Grant Brinkworth, PhD, MBA Principal Research Scientist 4th May 2018