Public Health Collaboration Glasgow November 2024

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This year’s Scottish PHC conference was as St Stephen’s Renfield Church Centre in Glasgow. The main theme of the conference was heart health. Many of the behaviours that improve heart health also improve health generally, and these will be familiar to readers of this blog. In this series of articles I will summarise some of the content of the day.

Dr David Unwin: Using continuous blood sugar monitors in Type Two Diabetes

David is a GP and he first started low -carbing ten years ago when he developed type two diabetes.

He got great results with low- carbing and persuaded his partners to join him in promoting the diet to type two diabetics in his practice. He has kept meticulous records of the transformations that have occurred in Southport, and also has tracked the savings he has made in medications that he would otherwise have had to use.

Lately, he been using the Dexcom continuous blood sugar monitor, which works very much like the Freestyle Libre. He has prescribed this in his practice for type two diabetics as well as type one diabetics, and has found that patients get faster and surer results when they can see immediate improvement when they stop eating sugar and starch and immediate high blood sugars when they do.

In the USA he has been advising United Healthcare Insurance on his findings and they are introducing the system for patients and will offer reduced premiums for users.

David was pleased to say that a recent innovation is a sensor that combines blood sugar testing and ketone testing in the same patch. This is going to be released by Abbott shortly. This is great news particularly for type one diabetics. I’m not sure if if will be useful or not for those on ketogenic diets, time will tell.

Jen Unwin PhD : Conquering Food Addiction with Low-Carb Eating

Jen is married to David. She is a Clinical Psychologist and is interested in people who struggle with low carb diets due to addiction to sugar and starch. Often processed food additives make the food irresistible to the person. Other food stuff addictions include nuts, dairy, breakfast cereals, and then of course there is alcohol.

She says that 10% of the general population are food addicted in some way.

20% of the population presenting to GPs are food addicted in some way.

55% of those with a binge eating disorder are addicted to food in some way.

She uses a modified Yale Addiction Scale for diagnosis.

There is a craving for the food and a compulsion to eat it. The person tends to increase the amount consumed over time to feel okay. “I can’t eat two biscuits, I have to have the whole packet”.

They neglect other activities in order to eat their food of choice. They feel a loss of control over their eating. They get withdrawal effects if they don’t eat it. Despite being aware that the food is causing them ill effects or harm, they continue to eat it in excess amounts.

Often depression and anxiety are the main symptoms.

In treating patients, Jen says that the person affected needs to clean up their diet, exercise to improve mental and physical health, and get back to healthy social habits. Gradually they can move to abstinence from the craved for food.

Those affected can’t have “cheat days”, like other people on diets perhaps can.

Jen has recently published a paper showing that control of Binge Eating Disorder is indeed possible with a low carb diet and reports that even a year after the intervention, the patients remained in remission from their compulsions.

She has released a book called Fork In The Road which explains how to gain mastery over food compulsion.

Dr Susan Pierce Thompson is a US psychologist who has also written, blogged and posted videos on this subject. She calls her programme Bright Line Eating.

Intensive insulin on diagnosis improves long term blood sugars compared to usual step up sequence in type twos.

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Adapted from BMJ 19 October 2024

My comments: Decades ago it was found that newly diagnosed type twos who were put on insulin clamps for two weeks, recovered beta cell function, and had better blood sugars over the next two years, than their compatriots who had usual treatment.

For as long as I can remember, type twos, on diagnosis, have been given a step up regime. In this dietary strategies are employed, then metformin, then other drugs and eventually insulin. This procedure can last years.

In China, L Liu et al, they embarked on a trial of immediate insulin via insulin pumps for two to three weeks, and then randomised the patients to one of three oral medication regimes or lifestyle advice, who acted as the control subjects.

The study was conducted across 15 centres in China. 412 patients took part. The mean BMI was 25.8 and the duration of diabetes at onset was a median of one month.

The insulin pumps were sent to deliver a fasting or pre-meal blood sugar of 6.1 mmol/l and two hour post meal blood sugars of less than 8 mmol/litre.

The mean HbA1c was around 11% on diagnosis and on the pumps fell to around 9.4% after two weeks. At the twelve week mark all groups has HbA1cs of around 6 to 6.5%.

After 48 weeks the proportions of patients who still had HbA1cs under 7% were calculated.

The most successful intervention was Linagliptan 5mg + Metformin 1000mg a day. 80% of these patients had HbA1cs under 7%.

Next was Metformin 1000mg only at 73% closely followed by Linagliptan 5mg only at 72%.

Lastly came “lifestyle” only at 60%.

Other outcomes measured were beta cell function and insulin sensitivity.

Authors have shown that the intensive insulin treatment and step down approach gives excellent long term glycaemic control in patients with severe hyperglycaemia in newly diagnosed type two patients.

In patients who are willing to undergo training on pump using on diagnosis, surely this would be a better way to manage diabetes than our “usual” treatment.

Amitriptyline improves irritable bowel syndrome in RCT

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Adapted from BMJ 2-9 Nov 2024

I have prescribed Amitriptyline for years for irritable bowel syndrome so I was pleased to see this article that showed a recent RCT gave good results, with the hope that General Practitioners will use it more often.

First line treatments for irritable bowel syndrome include removal of the offending foodstuffs from the diet and the prescription of medication for such symptoms as constipation, diarrhea, and abdominal spasms. Should these not work, low dose anti-depressants including SSRIs and Amitriptyline may be used. This study named ATLANTIS compared Amitriptyline with placebo in patients who had not responded to dietary and simple prescriptions for symptoms.

The study took place in England over 55 practices. Patients described their symptoms as moderate to severe. The average age was 49 and 68% were female. 232 patients were randomised to take the active drug and the other 231 took and identical placebo for six months. The dose was 10mg in the evening increasing to two or three a day depending on symptom control and side effects. Dietary advice from the GPs continued. 338 patients completed the whole six months trial, 75% of the active drug group and 71% of the placebo group. A questionnaire was given to assess symptoms towards the completion of the study.

The Amitriptyline group score for symptoms improved by 99 points compared to 69 points in the placebo group. 61% of the active group reported relief from their symptoms compared to 45% in the placebo group. 58% of the active group thought the treatment was acceptable, compared to 47% in the placebo group. The anxiety, depression, work and social adjustment scores were similar in each group. 20% of the active drug group dropped out of the study compared to 26% in the placebo group.

The active drug users had more of a dry mouth and drowsiness but less insomnia than the active group. There were two “serious” adverse effects in the active group, compared to three in the placebo group. At six months 74% of the active group were still on the medication compared to 68% of the placebo group.

The researchers have said that this is the largest ever trial of Amitriptyline in irritable bowel syndrome. The drug is cheap, reduces symptom severity, is safe and is well tolerated. They hope that this drug will be considered more often for this debilitating condition.

My comment: a low carb diet with removal of wheat from the diet can also improve irritable bowel syndrome and acid reflux.

Worldwide child mortality at the lowest level ever.

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Adapted from BMJ 8 June 2024

The United Nations has stated that there has been a fall in global mortality for children under the age of 5 between 2000 and 2022 from 76 deaths in every thousand live births to 37 in every thousand live births. This is a drop of 51%, a result that they consider remarkable.

Still, 4.9 million in total under the age of 5 died in 2022. The UN aim to get these deaths below 25 for every thousand children born alive. 134/200 countries are already at this target but sub-Saharan Africa and Southern Asia are still struggling. The causes of death are mainly pneumonia, gut and other infections, malaria, prematurity, birth asphyxia and trauma.

Cambodia, Malawi, Mongolia, Rwanda, Sao Tome and Principe and Uzbekistan have managed to achieve a 75% reduction in mortality since 2000. They instituted widespread interventions to improve sanitation, clean water and hygiene and improved primary healthcare systems.

Chad, Niger, Nigeria, Sierra Leone and Somalia have child mortality risks over 100 per thousand live births. They don’t have the widespread healthcare, food supply and political stability necessary.

High quality antenatal care, nutrition, skilled health care, immunisation, management of childhood illnesses and efficient referral systems for severe illness are necessary.

Glasgow University Medical School Reunion

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In October we had our class reunion from Glasgow University Medical School some 42 years after we qualified. We met for dinner at the iconic Central Hotel Glasgow for dinner.

It was an evening full of nostalgia and it was great to see old classmates, several who had come from as far away as New Zealand and Malaysia to meet up again. Our very hard, and long working hours as junior doctors, forged deep friendships and common bonds of respect. 120 to 145 hours a week was usual, and pay was one third of the basic rate after the first 40 hours of work.

We have had several reunions over the years and I’m fortunate to have attended all of them. I graduated when I was 22, on the younger side, since I went to university from 5th year rather than the more common 6th year at secondary school. At university, some students, perhaps looking for more academic or science based careers, also added science degrees and graduated later than 1982.

We had reunions at various life stages: early parent-hood around our mid thirties, settled in our careers, around our mid forties, around the age of early retirement in our mid 50s, and now with almost everyone retired in our mid 60s.

This was for me, the happiest reunion, because I was finally completely retired from medical practice. At the last reunion, around half of the doctors who had become GPs had retired. Although I was extremely envious of their new found freedom, I was determined to avoid the unfair financial penalty on our pensions and vowed to continue till the age of 60. Due to having a portfolio career, I did a step-wise reduction, stopping forensic/custody work when I was 61 and legal work when I was 63.

It took just over a year after that, before I was finally free of court appearances, follow up reports, and case decisions. It took many months to finally declutter my house and to dispose of my case reports and paperwork. Retirement is an event or series of events, but it is also a process.

The doctors who are still working were mainly in laboratory based roles, where patient contact is very limited, or in medical politics, education or academia, where there has been a long and competitive climb to the top. Some surgeons and consultants who have well established private practices are also continuing. There were very few NHS doctors still at “the coalface”. And to those few that are, I warmly salute you! There are real staffing problems and access to experienced doctors is so necessary.

It was uplifting to hear of the achievements of so many doctors. One Mauritian doctor had set up the first renal service with dialysis and transplants there. Not only had he spent years away from home as a student in Scotland: he had to return to London for years to gain the expertise to develop services and train people in Mauritius. My experience of Mauritius has sadly only been from watching romantic comedies on Netflix, but I do know where I would rather have been!

One woman had become the first female head of the medical school and head of the university Senate. This was smashing a few glass ceilings. This was all while working as a GP and bringing up a family.

Several doctors had great achievements in sports medicine. A daughter of one, gained a medal in the recent Paris games. Another has taken young women players on football matches abroad and attended Wimbledon as an events doctor. Some have been well known football and rugby club doctors.

When it comes to sports, there were several accomplished sailors and one woman who seemed quite normal in her 20s but who has transformed into Wonder Woman. She can swim, cycle, sail and do almost anything better than any man.

It doesn’t always work out for the sporty ones. One man had a terrible accident and sustained punctured lungs and seven fractures. He lived to tell the tail and is even back skiing. (He must be mad).

One woman had six children while working as a GP for over 30 years. One man had married three times. That’s optimism for you!

There had been huge successes in transplant and other surgery techniques from within our year group. One man had become the head of the NHS in England and you will have seen him on the television. Several doctors had fallen in love with people of different nationalities and moved to the other side of the world. Others were in Europe and Scandinavia, but not only changed countries but languages too.

Several people who started in one field or another changed medical careers completely. GP to Palliative care, GP to Psychiatrist, Surgeon to Radiologist, Surgeon to Politician, Psychiatrist to Research Fellow. It is difficult to change to careers in medicine because essentially you have to start right at the bottom of the heap again in another field of study, apprenticeship and exams.

It was with considerable sadness that we also remembered the doctors who have died. One died of cancer in his mid thirties, several have died of cancer and heart attacks around their early 50s.

As the years continue, I expect we will see a diminishing number of people coming back. Some will be happy to just be living their lives, some will find the journey and expense too daunting, some have family and health burdens of their own.

I remember the fresh, young, hard working, fun and idealistic people we once were, and I’m grateful to see that we got through our careers, had the families we wanted to have, and can have some time to ourselves at last.

Most people took three weeks to recover from Covid infection

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Adapted from BMJ 13 July 2024

Columbia University asked 5,000 participants about their personal factors and recovery time after Covid infection.

Median recovery time was 20 days, but more than one in 5 were still having symptoms at 90 days.

People who took a long time to recover tended to be women or to have pre-existing cardiovascular disease.

Those who had been vaccinated against covid-19 or who had been affected by the omicron variant were more likely to recover faster.

Speed of recovery was not linked to age, educational attainment, smoking history, obesity, diabetes, chronic kidney disease, asthma, chronic obstructive pulmonary disease or depressive symptoms.

Reported in JAMA 2024.

Type one diabetics are living longer and in better health in developed countries than 30 years ago

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Adapted from BMJ 15 June2024 Global burden of type 1 diabetes in adults aged 65 years and older. 1990-2019.

The number of people from 21 regions and 204 countries was collated in this study. The number of older adults with type one diabetes increased from 1.3 million in 1990 to 3.7 million in 2019.

This was due to a decrease in deaths from type one diabetes in young people, who therefore had the fortune to be able to grow old. There is also an increasing amount of type one diabetes occurring in the population both young and old. The older population of people with type one diabetes are also living longer and in better health. This is mainly a tribute to better diagnosis and treatment.

The prevalence (the total number of people counted who have the condition) increased from 400 to 514 per 100,000 people.

Mortality decreased from 4.74 to 3.54 per 100,000 people.

Disability life adjusted years (DALYs) decreased from 113 to 103 per 100,000 people.

Mortality rates fell 13 times faster in countries with a high sociodemographic index compared to low to middle index countries. The measures included education level, per capita income and lowest fertility rates.

The countries with the most older people with type one diabetes were in high income countries such as North America, Australasia, and Western Europe.

The highest disability rates were found in southern sub-Saharan Africa, Oceania and the Caribbean. A high fasting glucose level remained the highest risk factor for disability among older adults.

Chicken Fricassee

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Adapted from recipe in New York Times by Craig Claiborne and Pierre Franey July 2 2024

This dish is traditionally served with rice. Feel free to use any low starch vegetable combination. I have de-carbed the original recipe so that the flour has been omitted.

Total time about and hour and 30 minutes.

For 4-6 people.

Ingredients

I medium chicken cut into serving pieces or chicken breasts or thighs as you have available.

Salt to taste.

Ground black or white pepper

one ounce of butter

one banana shallot chopped finely

one clove of garlic chopped finely (Morrison’s have whole peeled cloves in jars)

one glass dry white vermouth

one chicken stock cube dissolved in a quarter cup of hot water (Starr, an Italian make are excellent)

I bay leaf

2 sprigs fresh Thyme or half a teaspoon of dried

about a cup of finely cut carrots in julienne strips

1 and a half cups of loosely packed leeks in julienne strips about 3 inches long

1/2 cup of double/heavy cream.

Method

Season the chicken with salt and pepper

Heat the butter in a frying pan and add the chicken skin side down. Fry only for about a minute without browning.

Add the onion and cook for another minute or two. Add the garlic. Cook for another four or five minutes turning the chicken to ensure even colour.

Add the vermouth, chicken stock, bay leaf and thyme. Cover and cook for 20 minutes.

Once the chicken is simmering, you can boil the carrots and leeks in two separate pans. These are finely chopped so only need one minute for the carrots and four for the leeks. (Or you can use a microwave vegetable steamer).

Now cook your rice or green vegetable accompaniment.

I cook rice in a plastic microwave steamer for 16 minutes or green vegetables in the same microwave container for 7 minutes. (Broccoli, Bok choi, cauliflower).

After the 20 minute simmer, add the carrots, leeks and cream.

Simmer for another two minutes and serve with either boiled rice (no carb restrictions) or green /low starch vegetables.

Endometriosis increases ovarian cancer risk

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Adapted from BMJ 27 July 24

Some types of endometriosis can increase the risk of ovarian cancer by almost ten fold.

Endometriosis affects 11% of the female population and causes half of all cases of pelvic pain and female infertility.

A large cohort study from Utah found that women who were diagnosed with endometriosis were 4.2 times more likely to get ovarian cancer over their lifetime than those who had never been diagnosed.

Deep infiltrating endometriosis was associated with a 9.66 fold increased risk compared to superficial peritoneal endometriosis which gave a 2.82 increased risk.

In a separate Dutch study in 2021, Adenomyosis (related to Endometriosis) was also shown to increase cancer risk, the relative risk being 1.5.

My comment: The background risk of a woman developing ovarian cancer is 2%. Many women diagnosed with endometriosis will need surgery to remove it, to divide adhesions and in severe cases may opt for a hysterectomy. If they are having extensive surgery anyway removal of the ovaries seems a very good idea. Screening women for ovarian cancer has been tried and unfortunately has not been found to be successful. I wonder if studies in the subgroup of women with endometriosis is something that will happen in future. Adenomyosis is when the endometrial deposits are located in the uterine muscle and are found at hysterectomy.

Difficult pregnancies can foretell lower maternal life expectancy

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Adapted from BMJ 27 April 2024

A national Swedish cohort study of more than two million women has found that women who have experienced difficult pregnancies can be at higher risk of early death up to 46 years later.

Preterm delivery, small for gestational age, pre-eclampsia, hypertension and gestational diabetes, all were associated with increased mortality risks. The main causes of death were cardiovascular diseases, respiratory disorders and diabetes.

These factors were independent risks for premature mortality. Siblings of the women who had normal pregnancies were not at increased risk of earlier death.

Researchers suggest that women who have experienced these problems consider enhanced health checks, put effort into prevention and get treatment for chronic disease if diagnosed.

JAMA Internal Medicine 2024