NICE 20015 Diabetes guidelines reveal magical thinking for our diabetic youngsters (again)

NICE have done a major diabetes review over all areas and the new guidelines went out to consultation recently.   I was lucky enough to be sent them by the Royal College of General Practitioners but only given 2 weeks to respond to them. So far I have only managed to study the children and young people’s guideline but my critique of the others will follow.

The new guideline gets some things correct in my view. The target hbaic for one. It is now 6.5%  or 48 mmol, because the group have finally realised that tight blood sugar control is the actual key to preventing complications from diabetes. (7.2)  Okay, it took a long while, but at least they got there in the end. Previously target hbaic levels have been set too high at 7.5%.

Even NICE however are concerned that children and young people will find this terribly hard to attain. They certainly will, especially, if they attempt to follow the unchanged and still illogical, non-evidence based, consensus plans which are to eat lots of carbohydrate and make sure you avoid saturated fat. Yet they have a sense of humour about themselves and state that children and parents “should develop a good working knowledge of nutrition and how it affects diabetes”. (3.4)

Obviously Emma and I think you should too, and this is why you should read our book and not pay too much attention to what an NHS dietician or diabetologist tells you about what to eat.

There was only 0.3% improvement in hbaic after learning about carbohydrate counting. Not a single low GI study showed a 0.5% improvement in hbaic. Unless you specifically understand  to greatly limit carbohydrate intake, no significant improvements in blood sugar control will be made.

The entire report is littered with study after study which show that our diabetic youngsters have very high hbaic levels indeed. Mean levels of 8.5 to 11.5% are common in diabetic children and adolescents no matter what parameters are under scrutiny.  Meanwhile, although structured education is increasingly popular, and costs £683 per person, it too fails to make any changes to hbaic over 6 months or 12 months. (20) None of the structured education programmes could produce even a 0.5 % reduction in hbaic though one study did show a reduction in severe hypoglycaemia.  Could it be the lousy rubbish they teach about what constitutes a healthy diet perhaps?

There is no longer a consensus view that diabetics should “eat the same healthy diet as everyone else”.  The American Association of Clinical Endocrinologists has been the first major group to tell diabetics to limit carbohydrate to 90-120g per day and to adjust this if they are not reaching target blood sugars.  Consensus opinion in this context is just another word for a bunch of bullies and failure to remove these appalling dietary recommendations is in my opinion reprehensible, immoral and disgusting. They don’t have to keep consensus opinions. SIGN got rid of them. So can NICE.

Meanwhile, NICE, seem to let diabetologists off the hook and explain that the avoidance of undue hypoglycaemia, is a barrier to attaining decent hbaic levels. (5.7) They have again refused to see that a low carb diet can be a straightforward way of minimising blood sugar variability and that it has been proven by Dr Bernstein and Dr Neilsen. Why? Because they did not look at this sort of evidence. Indeed no new dietary evidence was looked for at all, before they embarked in a hugely expensive operation into researching the current guidelines.

They notice that even kids realise that their blood sugars are not under control and that young though they may be, this affects them poorly psychologically.( 7.7)  It must be very disheartening to be doing everything you are told yet not achieving single figures on your meter.  You feel tired and out of sorts when your blood sugars are high, but at least it doesn’t “show”. Low blood sugars single you out as different from your friends, and continually remind you that you are a patient. Indeed NICE have the proof that depression can result from poor glycaemic control. (10.3)

Albuminuria is correctly recognised by NICE as the first sign that the kidneys are being damaged by high blood sugars. Yet the recommend a low protein diet to “prevent” it. (11.43)  Why? High blood sugars from high carbohydrate diets are the major cause of the kidney damage in the first place. Again, the recommendation is neither evidence based or thought out at all. They again have ignored research by eg Facchini and Saylor who showed that high protein, high polyphenol, low carb diets improved kidney disease in diabetics.

One of the useful things this review stated was that there was no harm found in injecting insulin through clothes. I know this can sometimes facilitate insulin injections in public places.

Another is the unusual but serious issue of Diabetic Ketoacidosis. It can occur even when diabetic kids on insulin have normal blood sugars. (18 recommendation 177). DKA should be suspected if there is nausea or vomiting, abdominal pain, fast breathing, dehydration and a reduced level of consciousness. Blood ketone testing is preferable to urine testing.

After an episode of DKA, NICE recommends that the factors that could have led to the episode are explored with the diabetes team. (18) Non adherence to therapy needs to be considered especially if DKA is recurrent. Diabetics should get advice on how to reduce future episodes and the management of intercurrent illness is particularly important. We cover some of these aspect in our book but for the best possible advice on this I recommend Dr Bernstein’s Diabetes Solution. I also recommend that you become familiar with this well before you get ill.

When it comes to the increasing numbers of children and adolescents with type two diabetes, the blood sugar targets have been similarly set for a hbaic of 6.6% or 48 mmol/mol. (14).

The dietary advice is the same rubbish as for type ones. NICE states that “healthy eating” ie high carb, low protein, low fat diets, “can reduce hyperglycaemia, reduce cardiovascular risk, and promote weight loss”.  They don’t produce any evidence to back this up of course, it’s neatly packaged as “consensus”. (13.17)

Albuminuria was present in 29% of this young population independent of the duration of the diabetes. First morning samples are preferred for testing. (17).

The age of transfer to adult clinics is discussed in the new document. As an example of typical blood sugar levels, in Finland the mean age of transfer to adult clinics was 17.5 years. Average hbaics one year before transfer ie at age 16.5 was 11.2% + or – 2.2% and at age 17.5 the average hbaic was 9.9% + or – 1.71%.  These kinds of averages litter the report and indicate that diabetic complications are inevitable for our young diabetics unless they radically change what they are doing regarding diet and blood sugar management.

Health economists have been busy bees regarding diabetes expenditure and costs. For your typical person on multiple daily injections the cost is £2,155 per year. (20) This includes initial instruction and seeing consultant diabetologists and nurses at typical hospital clinics in the NHS. For those who inject 2 or 3 times a day the cost is £1,500.  The MDI was shown however to be cost effective compared to the less frequent injections, which use mixed insulins, due to the long term reduction in complications. The typical baseline hbaic was 11.4% in 10-14 year olds in England and Wales.  Scary, isn’t it! (Adhikari 2009). All sorts of cost for complications are listed  and these make interesting  if somewhat gruesome reading. An amputation with the provision of a prosthesis for example costs £15,000.

Reduction in complications occurs with every reduction in hbaic.  Similarly lifetime complication costs are reduced with adequate monitoring. Five times a day seems to be the optimal, minimal  testing frequency.

NICE have been very good at telling us what is going on in the UK with diabetes management of children and young people. They have a lot  of new,  sensible and research based recommendations. Unfortunately they chose NOT to review dietary recommendations and until they do this, hbaics of 6.5% will remain pie in the sky. Unless you just ignore them and eat low carb of course!