Fitter, better, sooner

From BJGP May 2020 by Hilary Swales et al.

Having an operation is a major event in anyone’s life. There is a lot a patient can do to improve their physical and mental health before surgery that will improve their recovery and long term health.

Fitter, better, sooner is a toolkit was produced by the Royal College of Anaesthetists with input from GPs, surgeons and patients.

The toolkit has, an electronic leaflet, an explanatory animation and six operation specific leaflet for cataract surgery, hysteroscopy, cystoscopy, hernia, knee arthroscopy and total knee joint replacement.

These can be seen at: https://www.rcoa.ac.uk/patient-information/preparing-surgery-fitter-better-sooner

The colleges want more active participation with patients in planning for their care.

The most common complications after surgery include wound infection and chest infection. Poor cardiorespiratory fitness worsens post op complications. Even modest improvement in activity can improve chest and heart function to some extent.  Keeping alcohol intake low can improve wound healing. Stopping smoking is also important for almost all complications. Measures to reduce anaemia also reduce immediate and long term problems from surgery and also reduce the need for blood transfusion. Blood transfusion is associated with poorer outcomes particularly with cancer surgery. HbA1Cs over 8.5% or 65 mmol/mol causes more wound complications and infections.  Blood pressure needs to be controlled to reduce cardiovascular instability during the operation and cardiovascular and neurological events afterwards.

This toolkit is already being used in surgical pre-assessment clinics but access to the materials in GP practices will also help. After all, the GPs are the ones who are initially referring the patients for surgery, and improving participation early can only be helpful.

It is hoped that this initiative will result in patients having fewer complications, better outcomes from surgery but also from their improved lifestyle.

 

Diet doctor: free online course with credit for medical professionals

This is a message from dietician Adele Hite:

I am thrilled to announce that Diet Doctor is now offering a free CME activity to all interested clinicians, patients and carers: Treating metabolic syndrome, type 2 diabetes, and obesity with therapeutic carbohydrate restriction.

Thanks to the support of our members, we can offer this CME at no cost to clinicians.

This fully referenced, evidence-based CME activity is certified for three AMA PRA Category 1 Credit(s)™. It is jointly provided by Postgraduate Institute for Medicine (PIM) and Diet Doctor and is intended for physicians, physician assistants, registered nurses, and dietitians engaged in the care of patients with metabolic syndrome, type 2 diabetes, and obesity.

The course was designed by clinicians for clinicians. As this course outline shows, it covers all clinicians need to know about dietary carbohydrate restriction and how to implement it safely and effectively with patients for whom it is appropriate. In keeping with Diet Doctor’s mission to “make low carb simple,” the course also comes with supplemental materials for clinicians and their patients to make it easy to translate evidence into practice.

We hope that this course will help reaffirm the scientific and clinical support for this approach and — along with other efforts by LowCarbUSA and expert clinicians — act as another step in solidifying a standard of care around low-carb nutrition. We would love it if you would share the news about this course with colleagues. You can forward this email to them or use this flyer to share or post.

Diet Doctor also has some new resources to help make low carb simple for patients and clinicians alike. For patients, we have:
‒ a sample menu
‒ shopping list
‒ a meal planning guide
‒ a substitutes for favorite foods handout
‒ simple meals and planned leftovers, and
‒ information about target protein ranges

For clinicians, we have handy one-pagers on:
‒ monitoring ketones
‒ fasting insulin and HOMA-IR ranges
‒ lab tests and follow-up schedule
‒ type 2 diabetes medication reduction, and
‒ a 5-day food diary for patients who need to monitor their intake

Of course, for those on the list who are not clinicians, anyone can register for and view the course. You just won’t be eligible for CME credits.

For clinicians, please let us know if we can help you help your patients in other ways. And if you are interested in supporting us as we continue to develop materials to make low carb easy for clinicians and patients, please think about becoming a Diet Doctor member yourself.

Finally, we are happy to hear suggestions for improvements moving forward. If you take the time to view the course, we’d love to hear what you think.

Best regards,
Adele

Public Health Collaboration conference online a great success

The Public Health collaboration online conference 2020  was very successful.  The videos are available on You Tube for free making the conference even more accessible for everyone who needs advice on what to eat to stay healthy.

If you are able to contribute to the PHC fund to keep up our good work please do so. Sam Feltham has suggested £2.00.  This is via the PHC site.

This year there were contributions from mainly the UK but also the USA.

Visitors to this site will be very pleased to know that keeping your weight in the normal range, keeping your blood sugars tightly controlled, keeping your vitamin D levels up, and keeping fit from activity and exercise, are all important factors in having a good result if you are unfortunate enough to be affected by Covid-19. We have been promoting these factors in our book and website for several years now, mainly with the view to making life more enjoyable, especially for people with diabetes, now and in the future. The reduction in the severity  to the effects of   coronavirus is a side effect of these healthy living practices.

Several talks went into the factors and reasons for this, but in a nutshell, if you are in a pro-inflammatory state already, you will have a much more pronounced cytokine inflammatory response to the virus than is useful for clearing the virus, and you end up with inflammed lung tissue which leaks fluid thereby impairing your blood oxygen levels.

A talk that I found particularly apt was the talk from a GP who had had a heart attack at the age of 44 despite a lack of risk factors except for massive stress. He gives a list of self care practices that helped him. I would also include playing with your animals. Emma and I are cat lovers and can vouch for this!

My talk is about VR Fitness, which was the only talk this year which was specifically exercise related. The Oculus Quest has only been out a year and has been sold out since shortly after New Year. I was fortunate enough to buy one in anticipation of my imminent retirement, and it has been great as an exercise tool over the long, cold, dark winter and more useful than I had ever anticipated over the lockdown as a social tool.

There were several very professional cooking and baking demonstrations on the conference this year, and indeed, this could not have otherwise happened on a traditional stage format.  We had low carb “rice”, bread, pancakes and pizza demonstrations which may well help you if you prefer to see how it is done step by step or if you want to broaden your repertoire.

I was particularly taken with the pizza base idea from Emma Porter and I will follow up with this in a later post.  The whole video is available from the PHC  site which takes you to all the videos on You Tube.

 

 

 

Matthew’s Friends: a lifeline for epileptic patients

The charity Matthew’s Friends was set up by Emma Williams whose son Matthew got a great improvement in his epilepsy which did not respond to drugs but did respond to a ketogenic diet.

The charity aims to promote the ketogenic dietary option as an adjunct or alterative to drugs in children or adults whose epilepsy control is sub optimal. The hassle of following the diet often becomes much more preferable to facing a daily struggle with unpredictable and dangerous fits.

The website, Matthew’s Friends#KetoKitchen You Tube channel gives free ketogenic recipes, demonstrations and tutorials, which can be a great help to those embarking on ketogenic or low carb diets, including many diabetics. 

Professor Helen Cross from Great Ormond Street Hospital writes: Epilepsy affects 1% of all children, and in 25% of cases  there are continued fits despite considerable effort with medication. This can affect physical and mental ability, learning and behaviour. This not only affects the child but their family. The ketogenic diet has been used for almost one hundred years to treat epilepsy. There are different versions of the diet. The long chain triglyceride diet, the more liberal medium chain triglyceride diet, the modified Atkins and Low Glycaemic index diet. The best diet for an individual will be developed with the help of qualified and trained ketogenic dieticians in conjunction with the family. Such help is essential. In 60% of people who are resistant to anti-epileptic drugs, they respond, at least  to some extent to a ketogenic diet.

A three month trial of the ketogenic diet is advised to see if there is a response or not.In many cases, the response is so marked that medication can be stopped entirely. Obviously, direct clinical supervision is mandatory.

Matthew’s Friends can advise parents or people who would like to improve their epilepsy and provide contacts and materials to get started on an appropriate ketogenic diet. They are always grateful for donations to further their work.

Diabetes Digital Media launch low carb app endorsed by NHS

Adapted from The Times  January 6 2019 by Peter Evans

The better late than never NHS has finally endorsed a phone app that helps diabetics stick to a low carb diet.

Diabetes Digital Media based in Warwick have had their app, The Low Carb Program, accepted by the NHS apps library.  DDM has partnered with Ascensia Diabetes Care to allow patients free use of the app when recommended by GPs.

DDM was founded by Arjun Panesar and Charlotte Summers. Their company is on track to make sales of 1.7 m this year.

 

Public Health Collaboration Conference 2018: Achieving your optimal blood sugar target

Videos of the lectures given at the Public Health Collaboration conference 2018 which was held in May over the royal wedding weekend have now been released on You Tube.

You can see my talk, Achieving your optimal blood sugar target, as well as others, on the link below. There are a wide variety of lifestyle topics discussed. Happy viewing.

 

https://www.youtube.com/results?search_query=public+health+collaboration+conference+2018

RCGP: What doctors need to know about types one and two diabetes in young people

The Royal College of General Practitioners have recently released an educational programme for UK doctors which they have very kindly allowed me to link to our website.

I recorded this over a year ago and I think the college held off production until their type two diabetes low carb course was also released for doctors.

This means that the RCGP joins the American Association of Clinical Endocrinologists as supporters of low carbing  for both type one and two diabetes.  Surely the other clinical associations and Royal Colleges will follow in due course?

The screencast includes information on diagnosis, emergency situations, blood sugar and dietary management and contraception.

“I have also separately produced an educational screencast on Diabetes in adults (type 1), children and young people (type 1&2) for the Royal College of General Practitioners in my role as an RCGP Clinical Adviser”

http://elearning.rcgp.org.uk/mod/page/view.php?id=8368

 

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.

 

 

 

How does blood sugar control compare between pump users and insulin injecting adults?

insulin pump

If adults get the same level of education about blood sugar management there is only a tiny improvement in blood sugar control with a pump compared to a basal bolus injection regime.

The REPOSE trial was based in the UK with 315 participants across eight sites. Using small groups the patients were taught the DAFNE course, Dose Adjustment for Normal Eating. After the course the patients were randomised to either multiple daily injections which is standard UK management, or insulin pump use.

The organisers wanted to see how many people managed to get their hba1c below 7.5% after two years and what effects the regimes had on quality of life and hypoglycaemia.

Out of the original 315 patients, 260 finished the courses and entered the trial. There were small improvements in both groups for hba1c. The pump group got a 0.85% improvement in hba1c and the injectors got 0.42% improvement. This was not considered to be good enough to recommend pump provision, which is more expensive than pen injectors, to adults as a routine measure.

The pump group started with hba1s averaging around 9.5% and ended up around 8.7%. The injectors started with an average of 9.0% and ended up around 8.5%.  In addition there was no particular difference in hypoglycaemia or psychosocial outcomes.

My comment: It is a pity that DAFNE is considered the gold standard educational tool for type one diabetics when the outcomes are so underwhelming. The main problems are that although carb counting is included, carbohydrate restriction is not.  Insulin coverage of protein is not done and the seven unit rule is ignored. These are the main reasons that the outcomes are so poor. Structured education in person is expensive and time consuming for health care professionals. Why not grasp the nettle and actually teach people what they need to know to get normal blood sugars and not hba1cs of 8.5-8.7 which are certain to lead to diabetic complications?

Based on BMJ article BMJ 2017;356:j1285