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Can shared decision making thrive in the current medical culture?

Nov 15, 2015Nov 15, 2015 kaitiscotlandLeave a comment

According to a Cochrane review patients are much more satisfied and have better health outcomes when their health care decisions are made in the context of full information and free choice. Patients said that “being in control” was what they most cherished.

At the present time the NHS doesn’t really support true shared decision making and options are likely to become even more limited with a shortage of doctors and strain on budgets. There also is considerable conflict when it comes to following guidelines which are designed for populations rather than individuals. Should a doctor really let the patient take the consequences of their individual choice or would they just be putting themselves at risk from a General Medical Council hearing?

Yet, not all patients want the most expensive treatments. When given full options a fifth of patients decided to avoid or defer surgery for instance.

What is meant to happen is that patients get given option grids with all the risks, benefits and uncertainties of possible investigations and treatments. They are then asked, “What is the most important thing to you?” and then the doctor is meant to guide the patient accordingly.

Take bowel cancer screening. Currently all 50 year olds get sent a pack for this along with their birthday cards. Nice that someone remembers eh? They then get given the usual barrage of one sided messages about how bowel screening is really easy and could save your life.

If you care to look at this in more depth bowel cancer screening gives a total mortality benefit of six days to the screened population. The main problem is bowel perforation which occurs in 1 in 800 procedures. This is more likely to happen when going round the bends of the bowel. Diagnosis of this can be delayed. Presumably with the shared decision making model all this is taken into account and the patient gets a truly informed choice.

Breast screening and statins are similarly pushed with considerable information asymmetry in the NHS. There is no total mortality benefit to women from breast screening or statins yet that does not stop them being promoted. Not much has changed regarding how health care information is put across to patients in decades. An authoritarian stance is taken by the health care promoter and the patient is treated like an idiot.

With shared decision making it is likely that less money would be spent on useless investigations and treatments. If someone particularly wanted to avoid breast cancer “at all costs” they may be happy to be able to have screening perhaps more frequently than occurs at present, or perhaps they may be offered bilateral mastectomy. Many women would however decline to have mammography and that would be a saving not only for the procedure but for the unnecessary surgery and treatments that follow.

Shared decision making certainly doesn’t occur in diabetic clinics. The high carb / low fat diet is a product of “politics based medicine” rather than “evidence based medicine”. Shared decision making is not for everyone. There will always be people and situations were doing what a doctor thinks is best is the most appropriate option.

But for a lot of non-acute health issues it is appropriate. I can only hope that shared decision making doesn’t wither on the vine but a large shift in medical culture will be needed before it becomes regular practice.

Based on BMJ Learning module by Alf Collins.

Eight Quick Dips

Nov 10, 2015Nov 10, 2015 kaitiscotlandLeave a comment

Tomato Base:

4 large, ripe tomatoes

1 heaped tsp of tom puree

½ tsp brown sugar

a few drops of sherry vinegar

olive oil

Method

Chop tomatoes until pulpy, add all ingredients escept oil, stir and then drizzle oil over.

Variations

Herby – add chopped oregano and basil to taste.

Spicy – add a large splash of tabasco, 1 tsp Worcestershire sauce and a good sprinkling of celery salt.

Sweet and chunky – stir in 2 heaped tbsp caramelised red onion relish, a chunk of diced cucumber and a few slices of green jalapeno.

Piquant pepper – chop 4 Peppadew peppers, a handful of black olives and add to the tomato base along with some chopped parsley.

Speedy salsa – add 1 chopped tomato, cut into chunks, along with 1 finely chopped red onion, the juice of 1 lime and a small bunch of chopped coriander.

Creamy base:

150g plain yoghurt

85g mayonnaise

salt and black pepper

Method

Mix all ingredients together thoroughly.

Sweet roasted garlic – roast the unpeeled cloves from ½ a garlic bulb with a drizzle of olive oil for 15 min at 190C/170c fan/gas 5. Peel, crush then stir into the base.

Blue Cheese – chop 50g Dolcelatte into small chunks, stir into base, making sure that cheese is well incorporated.

Thai – style – slice 2 spring onions into fine slivers, mix into base then swirl in 2 tbsp sweet chilli sauce.

What experts say about getting blood out of stones

Nov 3, 2015Oct 25, 2015 kaitiscotland1 Comment

Is getting blood out of you a trial for health care staff? If so, help is at hand, according to Associate professor Keith Dorrington and Clinical Pharmacologist Jeffrey Aronson from Oxford University.

They reckon, that perhaps taking blood in the opposite direction, could be the solution for someone for whom the regular tourniquets, hands and feet in hot water, hanging the arm or foot down and gently tapping and stroking veins has failed.

When you have a chronic condition like diabetes, but possibly more so with cancer treatments, someone is always after blood samples. Sometimes a lot. A good sized black pudding’s worth some days. Or at least that is how it seems. When the red stuff fails to flow, all sorts of tricks can be employed but sometimes all you get is tears on both sides. From my own experience I would say that sometimes the best thing to do is to leave it to someone else. Once you have tried two or three times, confidence is lost on both sides and it is best to jack it in.

William Harvey described the circulatory system in the 17^th century. The blood flows from the heart to the periphery, that is the hands and feet, and then back up arms and legs via the veins to the lungs and then back into the heart. The Oxford due have discovered that if you put in a small venflon into the smallest vein it will gradually fill up with blood that was intended to go back to the lungs if you put it in facing the fingers. Worth a try?

Based on BMJ Article 17 Jan 2015

When you are a food addict, what can you do to re-claim your body?

Oct 31, 2015Oct 31, 2015 kaitiscotlandLeave a comment

Susan Pierce Thompson PhD is a neuroscientist who used to be pretty hefty in her teens and twenties till she went on a 12 step programme along the lines of alcoholics anonymous but dealing with the issue of food addiction. She has stayed very slim for the last 12 years and reckons she knows what keeps us from losing weight and keeping it off long term. Indeed she teaches about this subject at university and has recently started online classes with team support to help the food addicts get “happy, thin and free”. She calls her programme Bright Line Eating.

The basics of this is that the “everything in moderation” mantra does not work with the seriously addicted food addict. Flour, sugar and anything that even tastes sweet gets the heave-ho permanently. Could you do this? Of course you could, if you want to get thin and stay thin. But Susan recognises that breaking your intentions happens and that the most important thing is to resume your plan immediately rather than beat yourself up about it, or use a minor deviation as an excuse to binge with a vow to start on Monday again.

Rats as well as humans seem to fall into three groups. The ones who seem able to resist temptation without a problem, the ones who can resist it for a while but then will give in, particularly if under some sort of stress, and the highly addicted who just can’t leave sugar, sweet stuff, refined flour products and white potatoes in all their forms alone. Susan says that modern foods and patterns of eating have hijacked the brain and sap willpower, induce cravings and set up feelings of hunger. Indeed she has found that rats rate sugar water as more pleasurable than cocaine even when they had been made into serious cocaine addicts by researchers.

The taste of anything sweet seems to be a problem. Saccharine, and all artificial sweeteners have the ability to induce cravings, even stevia. Although fat and salt make food more palatable, and humans eat more of it when laced with butter, cream, olive oil and salt for instance, they don’t set up the same addiction circuits. It is the flour/sugar items such as chocolate, ice cream and pizza that are the top addictive foods for most westernised humans, with potatoes and potato products coming in fourth.

When you get a craving for something, parts of your brain are being affected by chemicals that you have no control over. Cravings and hunger are controlled by the hypothalamus. This is your body’s thermostat that controls all sorts of complex processes through the release of hormones.

Your willpower centre is in the anterior cingulate cortex and behaviour is controlled here. The problem is that behaviour gets more difficult to control if you have to withstand temptation for just 15 minutes. It gets even harder to control behaviour when the blood sugar is low or you are already tired, have already had your temptation tested, are feeling emotional or have been focussing on tasks. Susan calls this the “willpower gap”. You know what you are meant to do but you just can’t seem to help yourself from doing something else. Like opening that packet of biscuits.

Your brainstem is where leptin is active. Your brainstem is the most primitive part of the brain and the most basic functions that keep you alive such as breathing reside here. The trouble is that insulin resistance leads to leptin resistance, and although your brain stem may be flooded with leptin, telling you that you are full, the leptin resistance means that the message doesn’t get through, and your brain stem thinks you are starving. Mindless eating ensues just as mindless breathing continues.

A major step in resolving this impasse is that insulin levels need to be lowered. And what raises insulin the most? Yes, sugar and starch. This is why a low carb diet, as we describe in our book, can help you lose weight and get your appetite under control. It is all down to physiology.

Susan goes a bit further than we do, however, in that all sweet stuff, with the exception of sweet fruit, is banned. Also all flour products are completely banned. This is because those people who have very serious food issues are more susceptible to dopamine, the reward hormone.

Dopamine is active in the nucleus accumbens. It goes up in response not only to food stimuli but also to sex stimuli for example. Indeed Susan describes sugar as the pornography equivalent of sex. I have to agree with her here.

In large magazine shops you often see rows of women’s magazines on one side and men’s magazines on the other. The men’s magazines seem to be mainly all about becoming more competent in something eg music, muscle building, computer know-how, with some soft pornography thrown in. Women’s magazines have “how to be more nurturing” magazines with pets, home decorating and crafts taking about a quarter of the space. The rest seems evenly split between “how to make lovely food” often featuring beautifully iced sponge cakes with lashings of cream on the one hand, and “how to get thin from not eating beautifully ices sponge cakes with lashings of cream on them”. I’ve often thought of food articles and particularly photographs as being porn for women.

So, back to dopamine. What a great hormone. You have lots of it and you feel like you rule the world. The downside is that your reward feeling gets worn down by the never ending waves of dopamine and you tend to need a bigger fix for the same wonderful feelings over time. Also if dopamine becomes depleted you can feel pretty unhappy and also can need another fix to bring it up. This is a reason why Zyban, the anti-smoking drug can induce suicidal depression.

Zyban, also known as varenicicline, makes the craving for cigarettes stop by blocking dopamine. When you smoke, you don’t get the hit. Instead you think, “This fag is lousy, why the hell am I smoking it?” This makes it somewhat easier to break the smoking habit. The downside is that you can feel lousy about everything. And sometimes the effect is unpredictably tragic.

Despite the common belief that we are in control of our behaviour rather than our brain chemicals, Susan is so convinced of the chemical superiority over willpower, that she builds methods of how to resist the hijack into her diet plan.

Dr Thompson knows that a chemically affected brain really has the belief that the body is starving and that flour and sugar are even more powerfully addictive than heroin or cocaine for about a third of the population. She knows you can’t reason with your brain stem. Instead it reasons with you.

That little voice says, “I deserve that”. “It’s only one time”. “It’s only a little bit.” As more and more exceptions to our dietary plan creep in, we watch ourselves breaking rules, and the belief that we are incapable and lacking in some way, especially compared to thin people, reduces our feelings of competency. Our self-esteem goes down the plug hole. As I have said before, a prominent bariatric surgeon told me that the drop out rate with bariatric patients was particularly high because of the very low self- esteem that this group of people have.

Susan says that very clear boundaries are necessary to get back on track. A lot of planning, daily preparation, long term habit change and support is necessary to overcome addictive eating. Emergency action plans and support are needed for the inevitable breaks in willpower. But, she says that dopamine receptors recover in time and that as insulin resistance disappears, the insatiable hunger goes with it. She says that reliance on willpower is the single biggest mistake dieters make. Instead you need a whole system to deal with false hunger, addiction and social pressures to eat flour and sugar.

Restorative behaviours such as meditation are important. So is getting out in nature. Anything other than food that boosts your willpower battery is good. Exercise is not part of the plan for most people because it can be a step too far when good eating habits are in the process of being embedded. She thinks exercise can be too much a sap on a person’s willpower unless it is already an entrenched habit.

The path to being slim and healthy is not easy so a different way of looking at the problem is welcome. In particular simple calorie measuring is no good for some people if sugar and flour are part of the calories. Also low carbing may not be extreme enough for some people and cutting out all sweeteners and sugar rather than keeping to small amounts of sugar and starch may be necessary.

Based on an online webinar by Susan Pierce Thompson PhD. October 14 2015.

What’s new for type one diabetics?

Oct 28, 2015Oct 28, 2015 kaitiscotlandLeave a comment

NICE have released their new guidelines for type one adults. This paper was given some prominence in September’s BMJ as well as other papers that could be of interest to diabetics, their carers and health professionals.

In many respects the adult guidelines are similar to the children’s guidelines. Structured education gets support as does advice to aim for a hba1c of 6.5% (48) or lower provided hypos can be minimised. Of course this is virtually impossible if a high carb diet is followed but is much easier if the low carb dietary advice and precision meal to insulin matching as we describe in our book is done.

Levemir twice a day is the recommended basal insulin for all new patients and Lantus is advised only for those who refuse to use a twice daily bolus or perhaps need assistance from others for injection. We know that Lantus has some gaps in coverage as a 24 hour insulin and that it is less stable in heat and light than Levemir. It also stings on injection. Levemir also gives fewer hypos. Of course if someone is happy with Lantus, they can stay on it.

Life expectancy for type ones is currently 13 years less than for people without the condition. Fewer than 30% of adults achieve a hba1c of 7.5% or less.

Although the Cochrane collaboration noted a small degree of success with a low glycaemic diet strategy for type twos, this was not seen in the research that NICE looked at for type ones and therefore they don’t recommend low glycaemic as a dietary strategy.

Blood sugar targets are suggested to be ideally 5-7 first thing in the morning, 4-7 before meals and 5-9 at least 90 minutes after meals. Adults are advised that 4-10 blood sugar tests may be required each day. Before each meal and before bedtime are minimum testing times.

NICE want type ones to stick to their finger tips for blood sugar testing. This is the most accurate as hypos can be missed if other parts of the upper limb are used.

It is recommended that hypos are evaluated at least annually by a scoring system. The idea is to seek out those people for whom these are a problem and then fix it. NICE say this should not involve simply raising blood sugar targets. The obvious thing is to match insulin to meals, activity and basal needs more closely. If structured education around this appears to fail then the person should be considered for pump therapy and real time glucose monitoring.

Meal insulin boluses are recommended before meals. After meals is a strategy that works for toddlers but adults are expected to be able to adjust their insulin to meals and that means that they must be able to carb count.

So what can we expect from the implementation of these guidelines? There is still no clarity over diet and exactly how patients will get near normal blood sugars just by carb counting without actually restricting the amount they consume isn’t explained. There certainly will be a lot more adults who could be considered for pumps. But these are relatively expensive and require a lot of training. Setting strict blood sugar targets and hoping that technology will solve the problem has been going on for decades now. Why should it work now? NICE admits it hasn’t worked so far with more than 70% of type one adults having wildly high blood sugars. I would have been very interested to know what percentage of adults with diabetes achieved the target blood sugars of 6.5% or 48.

NICE do admit that to implement their proposals the medical workforce will need to be sufficiently trained to deliver the structured education and to help individual diabetics with their problems.

What if that amputation wasn’t necessary?

Oct 24, 2015Oct 28, 2015 kaitiscotlandLeave a comment

Expert advisers thought that 7.3% of the cases they reviewed had had unnecessary amputations. Revascularisation or conservative management was thought to have been more appropriate.

The National Confidential Enquiry in to Patient Outcome and Death looked at 479 cases in England and Wales in 2014. They considered that only 44% of patients who had amputations for vascular or diabetes had received care in accordance with recommended standards published in the Vascular Society’s Quality Improvement Framework for Major Amputation Surgery.

Amputations can become necessary for a variety of reasons: severe trauma, sudden artery blockage, or sudden overwhelming infection for instance. But for many diabetic and vascular patients the damage is insidious, and treatment to reverse damage can be effective if done early enough. At the end of months or years of unsuccessful interventions sometimes amputation gives relief from unrelenting pain or infection, mobility can be restored, and a better quality of life can begin again.

The UK mortality rates for people undergoing the operations was 12.4% compared to the USA’s 9.6% for a similar group of patients.

A major problem was that the co-ordinated multi-disciplinary care that is needed to divert patients away from amputation and for successful rehabilitation after amputation is not always in place. A Leeds vascular consultant, Michael Gough said, “patients need treatment of diabetes and heart problems, physiotherapy, rehabilitation and a properly planned discharge”.

In my own area, the multi-disciplinary teams are not in place to reliably prevent amputations nor to give smooth discharge home and rehabilitation afterwards. It is bad enough to struggle at home after an amputation but truly devastating to think that something far less final could have been attempted.

Based on BMJ article by Susan Mayor 15 Nov 2014.

Can your job cause type two diabetes?

Oct 20, 2015Oct 14, 2015 kaitiscotlandLeave a comment

A study of English civil servants has shown that those who earn the least are almost twice as likely to get type two diabetes than those who earn the most.

The ones who earn the least are also over one and a half times more likely to be obese and also one and a half times more likely to pursue an unhealthy lifestyle. This lifestyle includes a group of factors including smoking, drinking excessively, having a poor diet and being physically inactive.

The group comprised of over 7000 adults and equal numbers of men and women and measurements were repeated over an average of 14 years. The authors of the Whitehall II study, do not discuss what the reasons may be for the associations but I can think of a few possibilities.

Healthy food such as meat, fish, eggs, cheese, butter, olive oil, fruit and vegetables cost a lot more than unhealthy food such as sausages, sausage rolls, bread, pasta, pizza, chips, burgers, vegetable oil and margarine. As you will know from our book, the cornerstone to preventing weight gain and controlling diabetes is a low carbohydrate diet that is plentiful in protein, vegetables, some fruit and naturally saturated and mono-unsaturated fats.

I’m not sure if the studied civil servants all worked in central London or not. If they did, it would be logical for those who earned more to be able to afford housing nearer their place of work, thereby having to spend less time commuting.

Spending more time travelling to work each day certainly can eat into time that could otherwise be spend on planning meals, shopping and undertaking planned exercise. Being able to have flexible working hours can also help people spend less time commuting and undergo less stress while they do so.

As employees rise higher in the civil service the annual leave time allowed tends to rise as well as the pay. This could also affect the time that could be spent on exercise as well as enjoyable pursuits. As we know, many exercise options are free, but some are not, and with poor weather outside, exercise plans can slide. Being able to go to a gym, tennis club or golf course can provide a social outlet as well as an opportunity to exercise. Exercise helps improve mood and relief stress as well as being an opportunity to gain muscle and being able to eat more calories a day and get away with it.

What about smoking and drinking then? Why are these behaviours more common in those who are paid less?

It has been known for a long while that those with less money tend to smoke more. As for drink, the more affluent can certainly put away plenty of drink too, particularly the more affluent, executive middle class woman, compared to her shop assistant or factory working sister. Greater workplace stress and difficulty with the elusive work/life balance are thought to be factors for the higher earning woman.

What about mental health factors? It has been found that the lower choice someone has about their job role the higher their stress and the greater their chances are of becoming depressed. Perhaps the lower the job status the less autonomy civil servants have at work? From my work in the police force and the NHS I have seen the opposite scenario as well. I have seen very able people refuse promotion because of the necessity to do a lot of unscheduled extra work and take on responsibility that seems relatively poorly rewarded financially as people rise up the hierarchy.

Television watching also tends to increase the amount of sugary food and drink consumed across all age groups according to a study. Do the more affluent watch less telly? Perhaps having a dining table and using it for family meals can be a factor in reducing our waistlines?

The reasons for the socio-economic differences in the causation of type two diabetes are up for discussion. But also up for discussion is what can we do to lessen the chances of being affected?

Being aware that your job could be putting you are more risk of type two diabetes is a first step. How can you get more control over how you do your job? Can you get flexi-time so as to make home arrangements and commuting less stressful? Can you eat in a more healthful way? Can you make more time for exercise or incorporate physical activity into your working day? Are those self- soothing habits such as smoking, drinking and watching the telly stealing years from your life?

Sadly it looks like the workplace subsidised canteen and gym perks are becoming less likely rather than more likely. I would not be surprised to see these socio-economic differences between civil servants greatly amplified between people who are unemployed and those workers who are just scraping a living wage compared to more affluent workers. And where type two diabetes goes so does the increased rates of complications, cardiovascular disease and cancer.

Based on Contribution of modifiable risk factors to social inequalities in type 2 diabetes: prospective Whitehall II cohort study. Silvia Stringhini et all. BMJ Sept 12 and BMJ learning module: The effect of television watching on dietary intake.

Hba1c: when the diagnosis of diabetes can be wrong

Oct 17, 2015Oct 14, 2015 kaitiscotlandLeave a comment

Many doctors are now using the hba1c on its own to diagnose type two diabetes. It means that there is no need to fast overnight, and that you don’t have to spend hours in the GP surgery. But the test relies on having an average turnover time of your red blood cells and this can lead to an incorrect diagnosis if certain conditions are not taken into account.

For some people they DO have diabetes but the blood sugar changes have been so rapid that the red cells have not had time to accumulate enough sugar on them. Therefore children and young people, women who are pregnant, or who has been pregnant in the last two months, and anyone in whom type one diabetes is suspected, who tend to have a short duration of symptoms, should still get glucose measurements to determine the diagnosis. Testing for blood or urinary ketones would also be good practice in this group of people.

In people who are anaemic or whose haemoglobin is fragile and gets destroyed earlier than the usual 120 days, blood sugars will be higher than they look for any given hba1c value. Therefore if the hba1c is relied on a diagnosis of diabetes could be missed. Those with haemoglobinopathies, renal failure or HIV infection will be in this group.

If someone is acutely ill, their blood cortisol rises, and effectively blocks the action of a person’s own insulin. Thus the blood sugar rises. This can make it look like someone has developed diabetes but blood sugars will settle back to normal once the person is over the illness.

Certain drugs such as corticosteroids and anti-psychotics also rapidly raise the blood sugar. If a person is acutely ill it is best to rely on blood glucose measurements but after two months of continued drug use the hba1c can be used as long as the person is not acutely unwell.

People with pancreatic damage or who have just had pancreatic surgery also may have a deficient insulin response. This may or may not recover sufficiently over time. Blood glucose measurements are again more reliable in this group.

One of the major reasons that hba1c testing was introduced was to facilitate the diagnosis of type two diabetes. Currently about one in 4 type two diabetics in the UK is thought to be undiagnosed. It is certainly easier to do a hba1c than a glucose tolerance test, but the oral glucose tolerance test still has its place.

Although I’m a doctor I wasn’t fully aware of all the types of people and situations in which the hba1c could be misleading.

Based on an article by Professor Andrew Farmer of Oxford BMJ 10^th November 2012.

Bariatric surgery better than diets for sustained weight loss

Oct 13, 2015Oct 13, 2015 kaitiscotlandLeave a comment

Bariatric surgery has been shown to be the most effective treatment for substantial and sustained weight loss with a significant reduction in obesity related conditions and long term mortality according to the National Confidential Enquiry into Patient Outcome and Death 2014. Bariatric surgery operations are likely to become more popular as a result.

Bariatric surgery is particularly helpful for diabetics because it can greatly improve blood sugar control and even induce complete remission of type two diabetes. NICE recommends that those with a body mass index over 30 who have had diabetes for under ten years are considered for the operation. Asians may be considered at even lower BMIs. Simple observation will demonstrate that there are many more people eligible for these operations than can currently be dealt with on the NHS. Indeed currently just under a third of patients pay for the operations themselves.

There are various types of surgery. Some reduce the area of the stomach like the laparoscopic adjustable band, and some reduce absorption of nutrients like the sleeve gastrectomy. Some are a mixture of the two like the Roux-en-Y gastric band which is the commonest procedure that also produces the greatest weight loss.

Excess weight loss can be as high as 58% with patients’ weight levelling off after two years. Weight gain can recur and this can be due to not following the diet or a surgical failure than needs adjustment.

Once referred to a bariatric clinic the advantages and disadvantages of the various types of surgery is discussed. Psychological support and dietetic support is given. I recall that a bariatric surgeon told me that people referred to his clinic had very marked self- esteem issues and often defaulted from the clinic.

The short term problems after surgery include wound infections, vomiting, intolerance to pureed meals, problems swallowing and leaks at the staple lines for some operations.

Long term patients will need to continue to restrict calories and take multivitamins. Acid suppression therapy is often required and patients should avoid non- steroidal anti-inflammatories. Gall stones may occur and may require surgical removal. Hair loss may occur but is temporary.

After a Roux-en-Y operation calories are restricted to less than a thousand a day. Patients have to take a protein rich diet so they do not become deficient. Iron supplement are particularly needed by women. Most people require vitamin B12 injections every 3 to 6 months. B vitamins, calcium and vitamin D, and the fat soluble vitamins A, D, E and K may be needed. Annual checks of full blood count, electrolytes, liver function, glucose, iron, ferritin, vitamin D, B 12, calcium, parathyroid hormone, thiamine, folate and selenium are required.

The good news for diabetic is that blood sugars often improve a great deal and for many return to normal. Thus insulin and drug requirements will lessen or even stop. Blood pressure, lipid problems and obstructive sleep- apnea also improve or resolve.

Women may find that they are able to conceive after bariatric surgery but this is discouraged for about 18 months after surgery because of the rapid weight loss and nutritional deficiencies that are common at this time. There is more risk of pre-term and small for age births in women post- surgery.

It can be seen that should the number of surgeries be increased to anything like what is required to deal with the obesity/diabetes epidemic, that resources for long term follow up of these patients will also need to be improved. Support for General Practitioners will be needed, particularly as there is not sufficient structured follow up, particularly for those who have had operations out with the NHS and even abroad.

Based on article by Vamshi P Jagadesham and Marion Sloan from Sheffield in British Journal of General Practice August 2014.

Nina’s challenge to the USA food guideline team

Oct 11, 2015Oct 11, 2015 kaitiscotland3 Comments

Nina Teicholz’s article How dietary guidelines are out of step with science has provoked online furore since it made front page headlines on the BMJ 26 September 2015.

Nina, a journalist who took ten years to research and write her bestselling and highly acclaimed book Big Fat Surprise, has been attacked for having the temerity to explain how bias on the part of the expert panel who decide what should be published in this year’s Dietary Guidelines for Americans, is making people fatter and sicker, instead of improving their health.

Her opponents claim that as a mere journalist she has no business criticising scientists and doctors who know what is good for patients. They claim that their guidelines are scientifically sound and just because they have missed out studies on low carbohydrate diets that show improvements in weight, diabetes control and cardiovascular risk factors, and also failed to evaluate studies that show that saturated fat does not cause any health related problem, does not mean that their recommendations are unsound.

Nina is concerned that anything that goes against the low fat/high carbohydrate “healthy eating” advice of the last 35 years is being systematically suppressed. The committee comprises of only 11-15 “experts” yet the recommendations have ramifications for millions of people, not only in the USA, but worldwide. A congressional hearing will be set in October to discuss the guidelines, hence the importance of signing Professor Jeff Volek’s petition for clarity over the scientific basis for the guidelines.

The USA government set up the Nutrition Evidence Library in 2010 in order that systematic reviews on nutrition could be comprehensive and standardised. Yet, the current expert team did not use this resource for over 70% of the topics on their review, instead choosing to rely in the opinions of the American Heart Association and American College of Cardiology, both of whom have significant funding by food and drug companies.

Among other inconsistencies Nina points out that the Women’s Health Initiative, in which 49,000 women took part, that the lower saturated fat intervention group had no benefit in heart attacks or strokes. Three meta-analyses concluded that saturated fat did not increase cardiovascular mortality, and yet the recommendation of the group has been to limit saturated fat to less than 10% of calories, saying that the evidence basis for this is “strong”…..Stretching the truth a bit?

Low carbohydrate diet research was also not systematically reviewed. A meta-analysis and critical review concluded that a low carb diet was the best type of diet to control type two diabetes. Two other meta-analyses showed that low carbing was the best diet for weight loss, and improving cardiovascular risk factors. Despite the evidence that would have been revealed, had it been actually looked for, the guidelines went ahead without it. About the only positive message to come out of the guidelines are that a cap on dietary sugar is being proposed.

The three diets that are endorsed by the new guidelines are the “healthy vegetarian diet”, the “healthy US diet” and the “healthy Mediteranean diet”. Systematic NEL reviews were done on these diets and the evidence base was given as “limited” which means that the evidence quality was low. Despite this the committee decided to boost the evidence rank to “moderate”. Despite at least three National Institutes of Health funded trials on 50,000 people that show that a low fat and low saturated fat diet is ineffective in combating heart disease, obesity, diabetes or cancer, this is the main thrust of the 2015 guidelines, just like all the other guidelines published in the last 35 years.

Nina thinks that many experts, institutions and industries have an interest in keeping the status quo and that these interests create bias. The potential conflicts of interest in some of the committee members is discussed. This subject has also been discussed regarding our UK guidelines by Hannah Sutter in her book Big Fat Lie.

Nina concludes: Given the ever increasing toll of obesity, diabetes and heart disease, and the failure of existing strategies to make inroads in fighting these diseases, there is an urgent need to provide nutritional advice based on sound science. It may be time to convene an unbiased and balanced panel of scientists to undertake a comprehensive review. There needs to be transparency, disclosure of conflicts of interest, and rigorous scientific evidence that is reliably analysed to produce the best possible nutrition policy.

Well…..Nina, you are quite right, and since Jeff Volek’s petition was launched 4 days ago, at least 4,000 people agree with you. So just how important is having a good food guideline for diabetics?

Take the NICE 2015 type two guideline. A main trust is the promotion of structured education for all types of diabetics. “This should be evidence based ….nutritional advice should be given by a health care professional with specific expertise and competencies in nutrition…emphasise “healthy eating” (also known as the high carb / low fat diet)…limit saturated and trans fats to 5-10% of calories…..reducing hypoglycaemia should be a particular aim for those on insulin or a sulphonylurea…Type two diabetes consists of insulin resistance and insulin deficiency…. Insulin resistance is characterised by increased body weight and is worsened by overeating and lack of exercise…commonly associated with high blood pressure, lipid disturbance and a tendency to thrombosis, fatty liver and abdominal adiposity.”

Surely NICE are kidding? Despite also having a distinct lack in worthwhile evidence for their dietary guidelines, they are pushing all diabetics into nutrition classes led by NHS dieticians. They want them to continue teaching a diet that is well known to increase insulin resistance, burn out the pancreatic beta cells that produce insulin and make hypoglycaemia more likely if you are an injected insulin user who aims for good blood sugar control.

NICE conclude their impossible wish list, ”Aims of education are to improve outcomes by addressing health beliefs, optimising metabolic control, addressing cardiovascular risk factors, facilitating behaviour change, reducing complications, improving quality of life and reducing depression. The relationship between the person with diabetes and healthcare professionals should be enhanced thereby providing the basis of true partnership in diabetes management.”

Hypocritical or what?