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

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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(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

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