BMJ: Children with type one diabetes do just as well with jags as pumps

 BMJ 13 April 19

Pumps versus Multiple Daily Injections

Across various centres in England and Wales, 294 new onset type one diabetes patients were randomised to receive either pumps or MDI from the very start after diagnosis. The age range was just 7 months to 15 years. There were 144 in the pump group and 147 in the MDI group.

At one year the average HbA1c was around 60 (7.6%) for both groups. There were 14 serious events such as diabetic ketoacidosis or severe hypoglycaemia in the pump group and 8 such events in the MDI group.

It cost £1,863 more to treat the pump group but they had no better outcomes or improvement in quality of life compared to the MDI group. Indeed adverse events were a bit more common in the pump group even though there were fewer of them.

My comment: Looks like they were not advised about low carb diets given the relatively high HbA1Cs at a time that the honeymoon phase can be protective.

BMJ 16 Feb 19

Type one children performed just as well as their schoolmates in exams

Although both high and low blood sugar can affect concentration and memory and cognitive function, Danish researchers found that in national exams, type one children performed just as well as other children.

Enterovirus may act as a trigger for Coeliac Disease

Norwegian researchers looked at infection with adenoviruses and enteroviruses in childhood and later diagnosis of coeliac disease.

They tested children who were already at risk due to a particular genotype. They were recruited between 2001 and 2007 and were followed up till 2016.

They found that infection with enteroviruses but not adenoviruses were associated with higher onset of coeliac later on.

My comment: Enterovirus infection has been associated with the onset of type one diabetes too. People with type one are also more likely to develop coeliac. There could be common genetic susceptibility and environmental triggers.

 

 

Sam Everington: I moved the diabetes consultant into the community and greatly improved results

Adapted from BMJ 26 January 19, Five minutes with Sam Everington,  by Susan Major

Sam Everington worked as a lawyer before re-training as a GP. He is now the chair of Tower Hamlets Clinical Commissioning Group, has served on the Kings Fund, and gained a knighthood.

Tower Hamlets is a very deprived area in east London, despite this they have achieved the best rates of blood pressure control and cholesterol in patients with type two diabetes.

Sam puts this down to a much closer involvement by the hospital diabetes consultant with patients directly in the community instead of the hospital ivory towers which is traditional in the UK.

By mainly giving telephone advice to local GPs and pharmacists, he was able to give quick decisions on optimal treatment.

Sam says, “Diabetes is a complex disease, so you have to have a comprehensive approach, using everything you can to improve lifestyle and motivate patients by focussing on what is important to them. It is key to have a care plan that is individualised to each patient, systematically going through with a nurse and creating the plan in partnership with them.

“If you accept that social factors are responsible for 70% of a person’s health and wellbeing, then there is a big gap in primary care. If we don’t tackle social factors, we are really only having access to 30% of the therapies that we really need. Therefore we have introduced social prescribing in every practice in Tower Hamlets.

“We use a referral form, ticking boxes on lifestyle, environment, social and mental health. Patients then see the social prescribing advisor and talk through what will motivate them. They are then connected to one or more of 1,500 voluntary sector organisations in Tower Hamlets.

“We also encourage patients to access their own notes so they can see their results and take control. All the evidence shows that when patients manage their own illness the outcomes are better. All our patients are offered a half or whole day diabetes education workshop.”

My comment: Well done Sam. A great example of joined up thinking being adequately resourced to achieve great results.

 

 

60 today

Today I reach 60 years of age.  This is a milestone birthday mainly because I’m retiring from general practice. I’ve worked in Ballochmyle Medical Group since I was 27. Since then I’ve seen huge changes.

Lloyd George envelopes for records, which had been used since 1948,  were diligently assembled into A4 files in the late 80s, and then computerisation started in the mid 90s.  In the 80s days doctors had to guess the diagnosis or open someone up,  but today MRI and CAT scans and many more keyhole, radiological and diagnostic procedures make diagnosis faster and easier, at least for the doctor.

The single handed and small group  GP practice doing all their own surgeries, visits and on call, have thankfully been replaced by large practices with GPs and nurses specialising in different areas. They are supported by in house Pharmacists, Physios, Mental Health nurses and Podiatrists.  GPs work very long, intense days now, but they have appointment slots of 10-15 minutes instead of 7.5 which was standard. Many also have largely given up working out of hours and large health board run groups of doctors, nurses, paramedics and drivers do this now.

I used to have Ordinance Survey and Street Maps covering all Ayrshire in the car, and still have, but locating a house or farm is now so much easier with in car GPS systems. We relied on land line phones and answering machines and pages. Now we have mobile phones that are so smart we can watch TV on them and see as well as speak to patients via skype just like Captain Kirk and Dr Bones McCoy did in the 60s on Star Trek.

When I entered medical school in 1977, it was the first year that half of the students were women. Now there are about 3 or 4 women for every man.  It was normal to be a full time GP but now most GPs prefer to work part time. Maternity leave used to be 3 months and now it is a year.

Diabetes monitoring was very primitive, with glucose sticks as the main way of monitoring  with venous blood samples when a patient was acutely ill when I was in medical school. In the 80s BM blood testing stix were a major advance acutely and the HbA1C test used for long term information. Personal blood glucose monitors were a major advance. These can give visual information on your computer or meter. In the last few years these have been trumped by the Freestyle Libre Flash system.

The outlook for diabetic patients is also much better. There is more accurate information about dietary choices, a lot of varied insulin regimes to choose from and better patient education and partnership.

I will be leaving my GP practice and my complementary therapy and private practice but will be continuing my police and prison work, legal work and diabetes education work via this blog.

Emma and I will continue to update you on all matters diabetic and I hope you all continue to enjoy visiting.

 

 

 

Heartburn can be treated with Imipramine

From Cheong K et al. Low dose imipramine for refractory functional dyspepsia: a randomised double blind placebo controlled trial. Lancet Gastroenterology Hepatol. Oct 22 2018.

Heartburn is a miserable and very common symptom. It can be treated with antacids such as Peptac and Gaviscon and drugs such as Ranitidine and Omeprazole or Lansoprazole.  Domperidone, which increases gut motility can be used short term. But sometimes these don’t work.

Imipramine is an old anti depressant drug which was used in this recent drug trial for heartburn that had not responded to Esomeprazole and Domperidone.

107 patients entered the trial. The treatment arms were placebo or imipramine 25mg at night for two weeks, then 50mg a night for a total of 12 weeks.

In the Imipramine arm 63% of patients got a good reduction in symptom score compared to placebo’s 36.5%.

There was a higher rate of stopping the Imipramine, 18% versus 8% for the placebo. The side effects were dry mouth, constipation, drowsiness, insomnia, palpitations and blurred vision.

My comment: The re use of this old drug will be very helpful for patients who have run out of options for their heartburn. Many patients get an excellent effect when they go on a low carb diet too. The side effects of this are: slim down, lose belly fat, feel more energetic, clearer skin and for diabetics a great improvement in blood sugar control.

 

Type Ones get near normal blood sugars on very low carb diets

Adapted from Management of Type One Diabetes with a very low carbohydrate diet by Belinda S Lennerz et al. Pediatrics Volume 1 number 6, June 2018.

Exceptional glycaemic control of type one diabetes mellitus with low rates of adverse events was reported by a community of children and adults who consumed a very low carb diet. This study was done by recruiting patients via an online survey. Their medical records were then used to confirm their results.

Of the 316 respondents, just over a third were parents of diabetic children. The mean age of diagnosis was 16 years and the duration of diabetes was a mean of 11 years. The mean time of following a VLCD was just over 2 years. The mean daily carb intake was 36g. The mean HbA1c was 5.67%. Only 2% of the respondents reported diabetic hospitalisations. 4 admissions were for DKA and 2 for hypoglycaemia.

In the USA the average HbA1C for type one diabetics is 8.2%.  The ADA target to reduce complications is set at under 7.5% for children and under 7% for adults. Only 20% of children and 30% of adults reach these targets.

A major difficulty is achieving post meal blood sugar targets. The carbohydrate load has the greatest influence on this. A VLCD is regarded as between 20 and 50g of carb at each meal or between 5-10% of total meal calories from carbohydrate. Some practitioners worry about advising diabetics about VLCD because of concerns about DKA, hypos, lipid problems, nutrient deficiency, growth failure and sustainability.

The study was approved by the Boston Children’s Hospital.  The recruitment group were people who were following Dr Bernstein’s Diabetes Solution. They came from the USA, Canada, Europe and Australia. They were all confirmed as having type one diabetes from their medical records.

Symptomatic hypoglycaemia was reported by 69% of the participants but severe hypos were rare. Most people had 1-5 episodes of mild hypos a month.

Most people had the characteristic low triglycerides, high HDL, high total cholesterol and high LDL pattern.  The average trig/hdl ratio was 1:1 indicating excellent cardiometabolic health. BMI was also lower than population averages for age. The DCCT covered 1441 adolescents and young adults and the factors that showed the greatest effect on cardiovascular risk were: HbA1c, then trigs, then LDLc.

The commonly reported growth deceleration noted with type one diabetes is generally thought to be due to poor blood sugar control.  In this study group however the children’s height were modestly above averages for age and gender.

A few participants deliberately did not disclose their low carb diets to their health care providers due to concerns about being criticised, pressured to change behaviour or accused of child abuse. Although 49% of participants thought that their health care provider approved of VLCDs, a robust 82% of the health care providers said they did.

We don’t know how generalisable the findings in this study could be. This group may be particularly well motivated and may be pursuing other health related behaviours such as physical activity. None the less,  the level of glycaemic control and low rates of DKA and severe hypos revealed by this study break new ground in research into diabetes management for type one diabetes.

 

 

 

Merry Christmas Everybody

Emma and Katharine wish you a lovely Christmas today.

I will be doing my usual Christmas routine, which is to go off round the police stations in Ayrshire visiting prisoners, while my husband Norman, makes the Christmas dinner which we eat at 7pm, when I get home.

Steven and David, now in their mid twenties, revert to their teenage selves, and play with their new “toys” of whatever nature.  Their main job is to keep out of their dad’s way while he is doing his Master Chef routine.

We usually have the same thing each Christmas:

Lobster bisque or tempura prawns

Gordon Ramsay’s treacle and chilli covered ham with the usual trimmings

My low carb, wheat free,  and very boozy Tiramisu.

I make the sponges a couple of days before, and assemble the dessert the day before.  The prawns and bisque are pre-bought, and the ham pre-boiled the day before so that it cuts down the hard labour of the chef on the day.

Whatever you are eating, many of you will be having some festive drinks too. Here is a list of some of the drinks that you could be having, just so you can keep the carb and perhaps calories in mind.

From Diabetes Forecast March 2019 ( one ounce is 30 mls)

Rum and diet cola, 6 oz (1.5 oz rum) 100 calories, less than 1g carb

Scotch and club soda, 6 oz (1.5 oz Scotch) 100 calories, less than 1g carb

Martini, 2.5 oz (2.25 oz vodka or gin and 0.25 oz vermouth) 156 calories, less than 1g carb

Champagne, 4 oz, 100 calories, 4g carb

Red or White Wine, 5oz, 120-125 calories, 4g carb

Bloody Mary, 5oz (1.5 oz vodka) 120 calories, 5g carb

Light Beer, 12 oz, 100 calories, 6g carb

and what are a bit high in the carbs?

Sweet White Wine, 3.5 oz, 14g carb

Regular Beer, 12 oz, 13g

Margaritas and certain other sugary cocktails, 30g carb.

 

 

 

BMJ: Asking better questions in the diabetic clinic

Adapted from BMJ 24 Nov 18

Are you well controlled?

Judith Hendley writes:

I am a mum who has type one diabetes. It troubles me to be referred to as a “diabetic”. Although this doesn’t bother everyone, I feel that this reduces me to someone with diabetes and nothing more.

Once diagnosed you are referred to as a patient for evermore. No matter how healthy and active I am, I seem to have crossed an invisible line from the “healthy” to the “unhealthy”.  I don’t want assumptions made about me and I don’t want the first question I am asked to be about my most recent HbA1c result.

The language used by healthcare professionals, the media and others makes a big difference to how I feel about living with a long term condition.

Living with type one diabetes requires mental agility, resilience, stamina, perspective and a healthy sense of humour, so state of mind is everything and language plays a big part in that.

There are questions that particularly get on my nerves.

Instead of saying, “Do you suffer from diabetes?” it would be much better to simply ask, “Do you have diabetes?”

I am sometimes asked if I am “well controlled”. It makes me want to reply, “No. In fact you just can’t take me anywhere.”

I often think that health care professionals don’t realise how difficult keeping a consistent equilibrium with diabetes really is. I would like to be asked questions such as,

” How are things going with your diabetes.”

“Are you having any difficulties with your blood sugar at the moment?”

“Are you finding anything particularly challenging?”

Open, non judgemental questioning is best. “How are you feeling about your diabetes at the moment?” “What is most important to you right now?” “What ideas have you thought about for how you could handle that?”

I realise some people may think I’m being overly precious about language, but health care professionals would be seen as much more “on side” and they could still get all the relevant information they need, if they just minded how they phrase things to patients.