BMJ: Diabetic foot

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Summarised from BMJ Clinical Update Diabetic Foot by Mishra et al Mumbai and London 18 Nov 17

Foot disease troubles 6% of people who have diabetes and includes infection, ulceration or destruction of tissues of the foot. It can affect both social life and work. Up to 1.5% of diabetic people will end up with an amputation. Good foot care, screening and early treatment of ulceration is hoped to prevent a foot problem developing into a need for amputation. This article gives an update on the prevention and initial management of the diabetic foot that can be expected from primary care.

A combination of poor blood sugar control, foot neglect, lack of appropriate footwear, insufficient patient education and failure to find and treat pre-ulcerative lesions cause increasing foot damage and worsens the outlook.  Nerve and blood vessel damage make damage more likely to go unnoticed and more difficult to heal.

A careful examination of the feet by the patient or carer every day is a good idea. A careful examination by health professionals also detects problems early. Fungal infections, cracks and skin fissures, deformed nails, macerated web spaces, callouses, and deformities such as hammer toes, claw toes, and pes cavus increase the risk of ulceration.  Cold feet can suggest poor blood supply and warm feet can be an indicator of infection.

Monofilaments are often used to detect neuropathy at annual assessments. Pain after walking a certain distance and pain at rest suggest peripheral arterial disease.

Assessments every three to six months is needed for medium risk feet and every one or two months for high risk feet.

As neuropathy is difficult to reverse once established, prevention is key. Optimal glycaemic control is extremely important. Smoking cessation, maintaining a normal weight and continued exercise help the circulatory system.  Patients also know how to check their feet and who to get help from if they find problems. New shoes should be worn in gradually to prevent blisters.

Health care professionals need to send urgent cases to a specialised diabetic foot centre if at all possible. Such cases would include foot ulceration with fever or any signs of sepsis, ulceration with limb ischaemia, gangrene,  or suspected deep seated soft tissue or bone infection.

Ulcers are best washed in clean water or saline with a moist gauze dressing.  Anti-microbial agents can be cytotoxic  and can affect wound healing. Weight bearing on the area needs to be avoided. Tissue will be taken for bacterial culture and antibiotics prescribed due to local policies.

Referral within a day or two is needed for rest pain, an uncomplicated ulcer or an acute Charcot foot. (suspected fracture due to neuropathy).

Patients with rest pain and intermittent claudication need vascular referral.

Here are the top tips for patients:

Inspect your feet daily including between the toes and if you can’t do it yourself get someone else to do so

wash your feet in warm but not hot water daily and dry carefully especially between the toes

use oil or cream on dry feet but not between the toes

cut nails straight across and if necessary go to a podiatrist for this

Don’t do home treatments for corns and callouses

Check your shoes for objects or rough areas inside them and wear socks with them

avoid walking barefoot

get your feet examined regularly by a health care professional

notify the appropriate health care professional if you develop a blister, cut, scratch or sore on your feet

Public Health Collaboration Conference 2018: a great success for Lifestyle Medicine

I was delighted to attend and speak at the third PHC conference in London this year.  We met at the Royal College of General Practitioners in London on the sweltering weekend of the Royal Wedding. Apart from superb international speakers we were treated to low carb, high protein food, such as one would typically eat on a ketogenic diet. Instead of picking at our dinners as we often have to do with mass catering  we could eat the whole lot. Great!

Dr Peter Brukner from Australia started off the weekend with a review of what was happening in the low carb world. There are more and more reports coming out describing the advantages of ketogenic and low carb diets to different groups of people but the establishment are fighting back viciously as can be seen by the attack on Professor Tim Noakes in South Africa.  Indeed if his defence lawyers and expert witnesses had not worked for free he would be bankrupt.  This is a terrible way to wage war on doctors who are acting in the best interests of their patients.

Dr Aseem Malhotra also described bullying tactics that had been used against him when he was a junior doctor and first becoming publicly engaged in the low carb debate. I have been subjected to this as well.  Professor Iain Broom showed that the proof that low carb diets are superior to low fat diets goes back 40 years.

Dr Zoe Harcombe gave us an explanation of how the calories in- calories out idea just doesn’t add up. The well known formulas about how many calories you need to avoid to lose weight don’t work in practice because of the complex compensatory mechanisms we have to avoid death from starvation.  How you put this over to patients and give them useful strategies for weight loss and blood sugar control was explored by Dr Trudi Deakin.

Food addiction is a real issue, at least it is for the majority of the audience in attendance, who answered the sort of questions usually posed by psychiatrists when they are evaluating drug addiction.  Unlike drugs, food can’t entirely be avoided but ketogenic diets are one tool that can be used to break  unhealthy food dependence. This worked for presenter Dr Jen Unwin who at one point had a really big thing for Caramac bars.  I haven’t seen these in years but they did have a unique taste.

Dr David Unwin showed clearly that fatty liver is easily treatable with a low carb diet.

Dr Joanne McCormick describes how her fortnightly patient group meetings are making change accessible for her patients and how many GPs in the audience could broach the subject in a ten minute consultation.

The website Diabetes.co.uk will shortly be starting up a type one educational programme online that all are welcome to join. I discussed the issue of what blood sugar targets are suitable for different people and how they can achieve this with dietary and insulin adjustment.

Dr David Cavan spoke about reversing diabetes in patients in Bermuda. Although Bermuda looks idyllic the reality is that good quality food is about five times as expensive in the UK as it is all shipped in. Many inhabitants work their socks off but barely cover their costs and cheap sugared drinks and buns are their staple diet. Despite these setbacks he managed to persuade a lot of diabetic patients to ditch the carbs and this had favourable results even after the educational programme had stopped.

A cardiologist Dr Scott Murray described the effects of metabolic syndrome on the heart and really why sticking stents in diseased arteries is too little, too late. He is convinced dietary change is needed to reverse and prevent heart disease. This is the first time I have been told that certain types of heart failure and atrial fibrillation are direct effects of metabolic syndrome on the heart.

The importance of exercise for physical and mental well being was not neglected and we had Dr Zoe Williams describing the great benefits that even the minimum recommended exercise can produce.

Dr Simon Tobin and Tom Williams spoke enthusiastically about Parkrun. This is a free event that runs every Saturday morning in parks all over the world. You can choose to walk, jog or run the course.

Claire McDonnell-Liu is the mother of two children who have greatly benefited from a ketogenic diet. The conditions are urticaria and epilepsy.  Although NHS dieticians do help families with childhood epilepsy who want to use a ketogenic diet, they can’t do it unless drugs have failed, as this is NICE guidance. I wonder how many children would benefit in fit reduction without side effects of drugs if this guidance was changed?

This was a fabulous conference with a positive enthusiastic vibrancy. Thanks to Sam Feltham for organising this event especially since he has become a new dad as well.

The Public Health Collaboration are putting all the talks on You Tube.

I was interviewed about diabetes and women’s health issues for Diabetes.co.uk and Diet Doctor and these interviews and many others will be available for you all to see to improve your lives with diabetes.

 

 

 

Jovina cooks: Easy fish and vegetable foil parcels

Fish and Veggie Grilled Packets

Until I started cooking fish on the grill with this method, I never realized how delicious and moist the fish would taste.
4 servings
Ingredients
16 oz Mahi Mahi fish fillets, about 1/2 inch thick and cut into 4 equal pieces
8 extra-large shrimp, cleaned and peeled
4 large sea scallops
4 fresh thyme sprigs
4 garlic cloves, finely minced
1 small red onion, cut into eighths
2 bell peppers, each cut into 12 thin slices
12 grape tomatoes, cut in half
Paprika, salt and pepper
2 tablespoons chopped chives
Extra-virgin olive oil

 

Directions
Preheat grill to medium.
To make the packets: lay two 18-inch sheets of heavy-duty foil on top of each other (the double layers will help protect the contents from burning); generously coat the top piece with olive oil cooking spray. Repeat with six more pieces of foil.
Divide the onions and bell pepper equally on bottom of the 4 pieces of heavy-duty foil.
Place a piece of fish on top. Sprinkle with salt and pepper, Add 2 shrimp and 1 scallop to each packet.
Sprinkle with salt and pepper.
Add tomatoes, garlic and chives to each packet.
Drizzle with olive oil.
Bring the short ends of the foil together, leaving enough room in the packet for steam to gather and cook the food.
Fold the foil over and pinch to seal. Pinch seams together along the sides. Make sure all the seams are tightly sealed to keep steam from escaping.
Grill the packets until the fish is cooked through and the vegetables are just tender, about 15 minutes.
To serve, carefully open both ends of the packets and allow the steam to escape. Use a spatula to slide the contents onto plates. Serve with the lemon sauce.

Lemon Sauce
1 stick unsalted butter, at room temperature
2 cloves garlic, minced
2 tablespoons chopped fresh flat-leaf parsley
2 tablespoons lemon juice
Dash or two of hot sauce
Kosher salt and freshly ground black pepper to taste
Directions
Place all the ingredients in a small saucepan. Heat on the grill or on the stove. Serve with the fish packet.

Celebrate the NHS 70th birthday with tea and cakes?

On the 5th of July the NHS celebrates its 70th Birthday.  There is a concerted effort to celebrate this with tea parties and people are meant to contribute the proceeds to an NHS charity of their choice. Diabetes UK perhaps?

The trouble could be the cakes, sandwiches, scones and stuff that is likely to be scoffed along with the tea and coffee.

My practice has been gifted a hamper to celebrate the event.

This is what it contains:

plain and fruit scones

Clotted cream

strawberry jam

tea

Fudge oat crunch cookies

strawberries and cream shortbread biscuits

If you are having one of these events at your workplace, there are many low carb alternatives you can bring instead.

It is a pity the event didn’t feature something that emphasised good health promotion instead of bad health promotion. Going for a 30 minute walk for instance.

https://nhsbig7tea.co.uk/

Jovina cooks: A traditional French feast

Madame Saucourt’s Ratatouille
Hotel Mas des Serres in Saint Paul de Vence.
Source: Mediterranean Grains and Greens by Paula Wolfert

Ingredients
5 pounds eggplant
5 pounds zucchini
5 pounds sweet onion, peeled, halved, and thinly sliced
1 quart extra-virgin olive oil
2 tablespoons crushed garlic
2 tablespoons chopped fresh mixed herbs: rosemary, savory, peppermint, thyme, and celery
1 bay leaf
1/2 tablespoon sugar
1 teaspoon salt
1 teaspoon freshly ground black pepper
2 cups dry yet fruity white wine
2 pounds ripe red tomatoes, cored and seeded
5 pounds red bell peppers
A few drops of red wine vinegar
3 tablespoons chopped mixed herbs for garnish: basil, parsley, thyme
Directions
Stem and peel the eggplant. Cut the flesh into 1″ cubes and place them in a deep kettle filled with very salty water. Keep submerged with a non-corrodible plate for at least 1 hour
Stem and peel the zucchini. Cut the flesh into 1″ cubes and place in a deep colander. Toss the zucchini with salt and let stand 1/2 hour.
In a very large heavy skillet or heavy-bottomed roasting pan cook the chopped onions in 1/2 cup water and 1 cup olive oil until the onions are soft and golden, about 30 minutes. Add the garlic, chopped herbs, bay leaf, sugar, salt, pepper, and 1 cup of the wine. Cook over medium heat, stirring often, for 10 minutes.
Coarsely chop the tomatoes with their skins in the work bowl of a food processor. Add to the skillet and continue cooking at a simmer for 11/2 hours. Whenever the onion-tomato mixture starts to stick or burn, “deglaze” with a few tablespoons of water and scrape with a wooden spoon.
Grill the peppers; when cool, peel, stem, seed and cut into small pieces. Set aside.
Rinse and drain the eggplant and zucchini and lightly press dry with toweling.
Slowly heat the remaining 3 cups of olive oil in a wide pan or fryer until medium-hot. Add the zucchini in batches, and fry until golden on all sides. Transfer the zucchini with a slotted spoon to a colander set over a bowl to catch any excess oil. When all the zucchini has been fried, fry the eggplant in the same manner. From time to time return the drained oil in the bowl to the pan.
Spread the zucchini, eggplant, and peppers over the simmering onion-tomato mixture and pour in the remaining wine. Cover and cook at a simmer for 11/2 hours. From time to time remove the cover to help evaporate some of the liquid.
Place a colander over a large bowl and pour the contents of the skillet into it to drain. Stir carefully to avoid crushing the vegetables while trying to encourage any trapped oil and juices to drain. Quickly cool down the captured juices in order to remove as much oil as possible. If there is a lot of juice, boil it down until thick. Reserve all the frying oil and oil from the vegetables for another use. Pour the juices over the vegetables, taste for seasoning, add vinegar, and carefully stir to combine. Serve hot or cold. Sprinkle with fresh herbs.

Coquilles St-Jacques

Serves 6
Ingredients
8 oz. button mushrooms, minced
6 tablespoons unsalted butter
3 small shallots, minced
2 tablespoons minced parsley
1 tablespoons minced tarragon, plus 6 whole leaves, to garnish
Kosher salt and freshly ground black pepper, to taste
3/4 cup dry vermouth
1 bay leaf
6 large sea scallops
2 tablespoons flour
1/2 cup heavy cream
2/3 cup grated Gruyère
1/2 teaspoon fresh lemon juice
Directions
Heat mushrooms, 4 tablespoons butter, and 2⁄3 of the shallots in a 4-qt. saucepan over medium heat; cook until the mixture forms a loose paste, about 25 minutes. Stir the parsley and minced tarragon into the mushroom mixture; season with salt and pepper.
Divide mixture among 6 cleaned scallop shells or shallow gratin dishes. Bring remaining shallots, vermouth, bay leaf, salt, and 3⁄4 cup water to a boil in a 4-qt. saucepan over medium heat. Add scallops; cook until barely tender, about 2 minutes.
Remove scallops; place each over mushrooms in shells. Continue boiling cooking liquid until reduced to 1⁄2 cup, about 10 minutes; strain.
Heat broiler to high. Heat remaining butter in a 2-qt. saucepan over medium heat. Add flour; cook until smooth, about 2 minutes. Add reduced cooking liquid and cream; cook until thickened, about 8 minutes. Add cheese, juice, salt, and pepper; divide the sauce over scallops.
Broil until browned on top, about 3 minutes; garnish each with a tarragon leaf.

French Cassoulet
This hearty dish from southwestern France, known as a cassoulet, is a one-pot meal. A slow-simmered mix of beans, pork sausages, pork shoulder, pancetta and duck topped with a bread crumb crust , takes its name from the earthenware casserole in which it was traditionally made. My comment:You don’t need to use the breadcrumb crust.
Serves 6-8
Ingredients
1 lb. dried great northern beans
10 tablespoons duck fat or olive oil
16 cloves garlic, smashed
2 onions, chopped
2 carrots, chopped
2 large ham hocks
1 lb. pork shoulder, cut into 1″cubes
1⁄2 lb. pancetta, cubed
4 sprigs oregano
4 sprigs thyme
3 bay leaves
1 cup whole peeled canned tomatoes
1 cup white wine
2 cups chicken broth
4 duck legs
1 lb. pork sausages
2 cups bread crumbs (preferably not on a low carb diet!)
Directions
Soak the beans in a 4-qt. bowl in 7 1⁄2 cups water overnight.
Heat 2 tablespoons of duck fat in a 6-qt. pot over medium-high heat. Add half the garlic, onions, and carrots and cook until lightly browned, about 10 minutes. Add ham hocks along with beans and their water and boil. Reduce heat and simmer beans until tender, about 1 1⁄2 hours.
Transfer ham hocks to a plate; let cool. Pull off meat; discard skin, bone, and gristle. Chop meat; add to beans. Set aside.
Heat 2 tablespoons duck fat in a 5-qt. dutch oven over medium-high heat. Add pork and brown for 8 minutes. Add pancetta; cook for 5 minutes. Add remaining garlic, onions, and carrots; cook until lightly browned, about 10 minutes.
Tie together oregano, thyme, and bay leaves with twine; add to pan with tomatoes; cook until liquid thickens, 8–10 minutes. Add wine; reduce by half. Add broth; boil. Reduce heat to medium-low; cook, uncovered, until liquid has thickened, about 1 hour. Discard herbs; set dutch oven aside.
Sear the duck legs in 2 tablespoons duck fat in a 12″ skillet over medium-high heat for 8 minutes; transfer to a plate. Brown the sausages in the fat, about 8 minutes. Cut sausages into 1⁄2″ slices. Pull duck meat off bones. Discard fat and bones. Stir duck and sausages into pork stew.
Heat the oven to 300˚F. Mix beans and pork stew in a 4-qt. earthenware casserole. Cover with bread crumbs; drizzle with remaining duck fat.
Bake, uncovered, for 3 hours. Raise oven temperature to 500˚; cook the cassoulet until the crust is golden, about 5 minutes.

 

BMJ: Varicoceles can be a marker for metabolic syndrome and type two diabetes

Nancy Wang from Stanford University is a urologist and says, “Varicoceles which are varicose veins of the spermatic cords, are associated with low testosterone. This in turn makes men more likely to develop metabolic risks and heart disease. No one has connected the dots before now”.

These men have higher risks of heart disease, diabetes, and hyperlipidaemia.

My comment: Varicoceles feel just  like a bag of worms in the scrotum. Up to one in 5 men will develop these over their lifetime. 

Homemadewithmess: Prawn courgetti with a red pepper sauce

courgettes spiralised
For the Red Pepper Sauce
1 red pepper – deseeded and roughly chopped
Splash olive oil
½ yellow pepper – deseeded and roughly chopped
165g cherry tomatoes – halved
2 cloves garlic – left whole
75ml red wine
Pinch sugar
1 tbsp tomato puree
150ml vegetable stock
For the courgetti
2 courgettes – spiralised
1 tbsp lemon juice
1 pinch sugar
To serve
1 red onion – finely sliced
Splash olive oil
200g raw king prawns
1 handful fresh basil
Parmesan shavings – to serve

Pre-heat the oven to 180’C
Toss the pepper in the olive oil and roast for 20 minutes
Add the tomatoes and garlic and cook for a further 20 minutes
Squeeze out the garlic from their skins and return to the dish. Stir in the red wine, sugar and tomato puree and cook for a final 10 minutes
Once cooked, blend the mixture together with the stock until smooth, and then push through a fine sieve to make even smoother.
Set-aside until ready to serve.
Spiralise your courgettes and then toss through the lemon juice and sugar and set aside.
Heat a large pan with a splash of oil and fry the onion until soft.
Add the sauce and once bubbling stir in the prawns
Cook through until the prawns have turned lovely and pink and then turn off the heat.
Fold in the courgetti and then plate up, sprinkling over your basil leaves and parmesan and enjoying with salad.

Nutritional Info:
Calories – 316
Fat – 9g
Carbs – 26g
Sugars – 15g
Protein – 28g