Adapted from BMJ 23 April 2023 and Medscape 20% of patients with Diabetes in Drug Free Remission with Low Carb Program by Becky McCall Nov 21 2022.

Diabetes UK say that the number of people with diabetes in the UK has reached 5 million for the first time. They say there is ” a rapidly escalating diabetes crisis”. They want the government to limit junk food advertising to children. 90% of those diagnosed have type two diabetes. The major risk factor for this is overweight and obesity. 64% of the adult population have this risk factor.

148,000 people under the age of 40 have been diagnosed with type two diabetes. The rate has increased by 23% over the last five years. Diabetes UK think that more people need to be referred to the NHS Diabetes Prevention Problem to reduce the year on year increase in the disease.

My comment: It is a pity that Diabetes UK did not heed the advice to ignore the detrimental Food Standards Agency so called “Eat Well Plate” recommendations decades ago. We are suffering the effects of pushing high starch, high fruit/juice diets that contain refined vegetable and seed oils and not enough protein and full fat dairy on the general population. With the increase in food prices, energy and housing in the last few years, that wages have not kept pace with, we are seeing more people sink into poverty. This means that they work longer hours to compensate, with less time to make healthy, non processed meals, and to undertake physical activity, and get sufficient restful sleep. I can’t see the situation being reversed for the foreseeable future.

At the Diabetes Professional Care Conference in 2022, Dr David Unwin presented the results of the low carbohydrate approach. 20% of his diabetic patients have gone into remission and no longer need any glucose lowering medication. His practice is in Southport. He has found that 50% of his patients will go into remission if they adopt a low carb diet. He has saved £68,000 on these drugs a year.

Weight dropped 10.3%, HA1c dropped by 33%, and blood pressure by 8.6%. Blood lipids also improved.

Remission was achieved in 77% if they started the diet in the first year after diagnosis. Rates after this fell, probably due to declining beta cell function, but 11% still went into remission even after 6 to 15 years after diagnosis.

Dr Unwin’s practice had 57 patients with type two diabetes in 1986 out of a list of 9,000. This is now 530, a tenfold increase. (Some of this could be due to better case finding). The UK spends around £10 billion a year on diabetes, 80% of this is to treat complications, and this is 10% of the health budget, similar to the budget for treating cancer.

Dr Unwin has been using the low carb approach since 2012, I was using it in my own practice about eight years before that. Without any extra funding, he has been educating his patients about this approach. He has found that the higher the person’s blood sugars, the more they improve on a low carb diet. He has had patient stay in remission for over ten years now. His oldest patient in remission is 92 years old. To his surprise, he has often found that older people do better on the diet, because they are organised, have time, and know how to cook.

His wife Jen Unwin, a psychologist says, “Older people are motivated to stay well. They don’t want to be ill. Their memory, energy and sleep, all improve remarkably. Some young people understand the diet and can implement it without too much trouble. But for others carbohydrate addiction really gets in the way. They are markedly affected by the obesogenic environment that has changed dramatically since the 70s. If you are really addicted to bread, as many people are, you can’t moderate it. Same for chocolate. Some people can’t have one biscuit. They have to eat the whole packet. They only way for these people is abstinence.

Jen continues, “Eating carbohydrates makes you hungrier. It also raises your blood sugar. When patients understand this they can sometimes make great improvements but teaching and learning takes effort and resources.”

The Public Health Collaboration have an online course that teaches the fundamentals of a healthy food approach. There is a link to the programme in a previous article in this blog site.

Adapted from JAMA Cardiology/ Original Investigation

Association of Lipid, Inflammatory and Metabolic Biomarkers With Age at Onset of Incident Coronary Heart Disease in Women. Sagar B. Dugani MD PhD et al. 2021.

A prospective group of US women health professionals, in the Women’s Health Study was conducted over 21 years. At the start over 28,000 women aged 45 years or older without known cardiovascular disease were recruited between 1993 and 1996. Data from over 50 biomarkers were tracked. Data was grouped from the under 55s, 55-65s, 65-75s and over 75s.

Results showed that diabetes and insulin resistance, hypertension, obesity and smoking were the strongest risk factors to cause premature onset cardiovascular disease. Risk factors became less important as later ages approached.

The relative risks for the various factors were:

Diabetes 10.7 in under 55s and 3.47 in the over 75s.

Metabolic syndrome 6.09 in under 55

Hypertension 4.58

Obesity 4.33

Smoking 3.92

Myocardial infarction in a parent before the age of 60 gave a 1.5-2 factor risk of a heart attack up till the age of 75.

Blood results (not all of these are tested for in the UK)

Lipoprotein insulin resistance 6.4

LDL cholesterol 1.38

Apoliprotein B 1.89

Triglycerides 2.14

Inflammatory biomarkers 1.2-1.8

For the group of women under 55, the average age was 48. Almost all were white. The mean BMI was 28.9. 38% of them were smokers. The average systolic blood pressure was 135. 57% were physically inactive. 30% reported that a parent had had a myocardial infarction under the age of 60. Of the 24 women who were post-menopausal, 17 were on HRT.

My comment: I’m surprised that even in the mid-1990s so many of this group of educated, white, female health professionals, were considerably overweight, physically inactive smokers! I wonder what a similar group would be like now?

Looking at the group over the age of 75, the average BMI had dropped a little to 26.1. Smoking was less at 12.8%. Physical inactivity was still high at 46.5% despite all of these women being retired. All would be post -menopausal and 35% of them were on HRT.

Premature coronary heart disease generally refers to the age under 65 in women and 55 in men. Mortality rates in this group reduced by 5.5% in men and 4.6% in women between 1979 and 1989. But over the next 20 years mortality for women went unchanged. Between 2010 and 2015 in the USA CHD mortality declined in all groups except for those aged between 55 and 65.

In Western Australia from 1996 to 2007 the yearly heart attack rate for women aged 35 to 54 increased by 2.3%. In British Columbia, Canada there was a yearly increase in acute MI of 1.7% in women aged 20 to 55. This increase was not seen in men. In the UK cardiac deaths also showed none or minimal improvement from 1985 to 2005.

Favourable factors that reduced cardiac risk were increased levels of HDL and higher levels of particle HDL size. Lower creatinine levels were also favourable. This is a measure of renal function.

The strongest associations for LDL were seen for small LDL particles, total LDL particles and smaller average LDL size. Large and medium LDL particles had almost no correlation to cardiovascular risk (1.02 and 1.13) . LDL particle average size indicated reduced risk at 0.64. Small HDL particles were associated with higher cardiovascular risk (1.60) and average to larger particles were associated with reduced cardiovascular risk (0.65 and 0.74).

458 moderate to heavy smokers joined the study. 12 weeks of treatment produced non-smokers at the six month point. Both active treatments were twice as effective as placebo. The rates were 40.4% for e cigarettes, 43.8% for Varenicline and 19.7% for placebo. There were no serious side effects.

The researchers think that on balance Varenicline is the one to go for. It weans people off of the habit of smoking and does not contain nicotine.

Jama Internal Medicine 2024.

Adapted from BMJ 13 May 23

Walking a well behaved dog in the countryside, green space or park can be a real joy. Dog owners are less lonely, make more friends, are fitter and slimmer than those who don’t walk their dog regularly. They can, however, sustain injuries in the process.

Researchers from John Hopkins University say that most accidents occur due to leads. If a walker is pulled forcefully, particularly when not expecting it, they can fall, and also their legs can get tangled up in leads. Therefore using short, non-retractable leads are suggested for all age groups of walkers. Those over the age of 65 are recommended to consider resistance and balance exercises to minimise falls. Older adults and women are particularly likely to be injured.

The researchers looked at 20 years of data from one hundred emergency departments in the USA. They found that 422,659 people had been injured in dog/lead related accidents. More than half the injuries were musculo-skeletal including fractures, muscle tears and abrasions. The commonest sites were the fingers, traumatic brain injury and shoulders.

Nutrition and Health News This Week by Nina Teicholz and Gary Taubes 20.4.24

What’s the Best Diet for IBS?

A clinical trial in Sweden published this week in The Lancet Gastroenterology and Hepatology, found that a low-carbohydrate diet was just as effective as the “low-FODMAP” approach for reducing symptoms of irritable bowel syndrome (IBS), and both were more effective than drug treatment.

Widely considered the standard of care for IBS, low-FODMAP diets restrict nuts, most dairy products, and several types of “fermentable” carbohydrates such as wheat, legumes and many fruits. The approach is usually combined, as it was in this trial, with general IBS dietary advice: to chew food thoroughly, eat regularly, and avoid excessive fat. 

For the Swedish subjects, food was delivered to their homes for a month. The results were impressive for both diet groups: 71–76% of participants reported significant improvements in their gastrointestinal symptoms. Only 58% did in the drug treatment group. Six months later, the diet-group participants still had fewer symptoms than they did at the start of the trial, even though they followed the diet less closely. 

The fact that both dietary approaches had similar benefits raises new research questions. FODMAP stands for “fermentable oligosaccharides, disaccharides, monosaccharides and polyols,” all short-chain carbohydrates that are absorbed poorly by the small intestine. These are thought to be the cause of IBS, yet people in the low-carb group continued to consume some fermentable carbs while still experiencing significant improvement in gastrointestinal symptoms. Additionally, they increased their fat intake, which is believed to exacerbate IBS. 

The trial was funded by the Dietary Science Foundation, a Swedish non-profit whose mission is to fund clinical trials on diet and health. Since our own government has largely abandoned funding meaningful clinical trials on this important topic, grassroots science is now our best bet.

Adapted from BMJ 10 Sept 22

A large UK study using general practice records has found that cardiovascular diseases were around 50% higher in people who had autoimmune conditions.

The risk increased as the number of conditions increased. Systemic Sclerosis, Addison’s disease, Systemic Lupus Erythematosus and Type One Diabetes carried the highest risk.

The study compared half a million people who had been diagnosed with an autoimmune condition and matched them to a control group to age, sex, socioeconomic status and area of residence.

Published in the Lancet.

Nutrition & Health News

Food-As-Medicine trial ‘fails,’ Latest from the Diet-War Frontlines, and more.

Nina Teicholz and Gary Taubes Apr 13 ∙ Preview

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“Food-As-Medicine” Trial Fails to Improve Health

The current “Food As Medicine” movement harkens back to the adage “Let Food be Thy Medicine,” attributed to Hippocrates, yet maybe even the ancient Greeks sometimes wondered, ‘sure, but which foods?’ Fruits and vegetables, whole grains and lean proteins, aka, the cornerstone of the U.S. Dietary Guidelines, is now the usual answer, yet many experts believe that Americans, especially those of low socio-economic means, don’t have the knowledge or resources to follow this advice. For Food-As-Medicine advocates, one solution is to improve access, mainly to fruits and vegetables, by delivering free food— directly to people, in their homes.

The concept is championed by a powerhouse alliance of top-rank government, public health and industry actors. Rooted in a long history, the current movement started in about 2018, with a “Food As Medicine” working group on Capitol Hill. This led to a 2022 White House conference on Hunger, Nutrition & Health, resulting in a report recommending “food as medicine interventions for people with diet-related diseases.” In that same year, the Aspen Institute published its first “Food is Medicine” action plan, with a heady list of advisors. There’s also been “Food as Medicine” summits occurring nationwide since 2021. I (NT) have written with some skepticism about these efforts since the food industry has been central to virtually all of them.

From a scientific perspective, though, there’s the not-so-small problem that the Food-As-Medicine concept has barely been tested, and the few randomized, controlled clinical trials (RCTs) to date have yielded mixed results. This dearth of evidence was acknowledged in the 2022 Aspen report; An effort to get Congress in 2023 to spend $2 million on a “Food As Medicine” pilot program failed. 

Then, on December 26 2023 – the day after Christmas always being a good day to bury bad news – results from the latest RCT on the concept were published in JAMA Internal Medicine.  They were, to put it politely, not as expected. Five hundred “food insecure” adults with type 2 diabetes (HbA1c of 8.0% or higher) had been randomly assigned either to a control group that got “usual care” or an intervention group that received a year-long comprehensive program of dietitian consultations, nurse evaluations, health coaching, diabetes education and the delivery of “healthy” groceries for 10 meals per week for the entire household. 

The groceries included “whole grains, fruits, and vegetables (with an emphasis on fresh as opposed to canned and frozen), lean proteins and low-fat dairy products, as well as staple items including salad dressing, cereal, brown rice and bread that are tailored to patients’ needs in consultation with the dietitian.” The dieticians used the American Diabetes Association “plate method,” which advises that one quarter of the plate be starches (carbohydrates). 

If the food-is-medicine concept worked, the group getting free groceries along with the consultations and coaching should have seen their health improve noticeably. Yet they did not… at all. Their average blood sugar (the study’s primary outcome) remained no better than the controls; their LDL-cholesterol and HDL-cholesterol appeared, if anything, to worsen. 

The study authors – public policy researchers, not nutritionists – relied on the dietary approach recommended to them by the large healthcare system with which they partnered for the study. “We are interested in health delivery systems,” Joseph Doyle, a professor at the Sloan School of Management at MIT, stressed in an interview. “I was hoping we would show improved outcomes, but the way to make progress is to do well-randomized trials to find out what works.” We agree with Doyle, of course, and his experiment should put to rest some of the chatter that proper clinical trials in nutrition can’t be done.

Yet Doyle’s trial can’t inform public health strategies if its results are ignored. Despite a news item on the study in JAMA this week, the “null results” have had little noticeable effect so far on the Food-As-Medicine juggernaut. In February, the Department of Health and Human Services hosted its first “Food As Medicine” summit, with three public-private partnerships already in place, while a dozen projects are underway at the new, partially industry-funded Food Is Medicine Institute at Tufts University. 

Lamentably, until these programs better understand which foods are truly medicine, they will follow in the footsteps of other non-evidence-based programs, like listing calorie counts on menus, i.e., they’re very likely to fail…

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Adapted from BMJ 4 May 2024 Weights, resistance bands, and rest days are best for tendinopathy.

A systemic review and meta-analysis by Pavlova and Shim, published in the Journal of Sports Medicine 2023, indicates that planned exercise using weights or resistance bands with rest intervals gives better results than exercising every day, particularly with body weight exercises.

People with diabetes are considerably more prone to tendinopathy than the general population, so these findings may be helpful to them.

Tendinopathy is diagnosed when tendons become painful, stiff or swollen. It can affect both adults and children and tends to occur in the Achilles tendon at the heel, shoulder, elbow, knee and hip.

Although exercise is recommended it hasn’t been clear what specific exercises help the condition and what the training pattern should be to maximise effectiveness. Improving disability, function, pain, movement and quality of life are important for people who suffer from these conditions.

This study included 110 studies covering 4,000 people from Europe, Australia and the USA. Most of the exercise regimens had been prescribed or delivered by physiotherapists.

The study found that people improved more if they used dumbells, loaded backpacks or resistance bands rather than bodyweight only in resistance exercises. Also, rest days between sessions gave better results than daily exercises. The results were the same no matter the tendon damage site.

The authors suggest that at least one day of rest between the exercise sessions is necessary to maximise improvement. The number of repetitions and sets necessary did not become clear after the analysis.

My comment: So many people suffer from musculo-skeletal pain and research like this is very helpful. I’m a daily exerciser and I found that my chronic back pain got better by having more than one day between intense resistance workouts. Previously it had been alternate day resistance exercise alternating with either aerobic exercise or yoga/stretching. So many of us have the idea that more is better when really we would be better off doing less. Weights and resistance bands give more flexibility regarding the force exerted on the muscle and tendon so may lend themselves to progressive overload than body weight exercise.

Adapted from Statins: the risks and statistics by George Winter, Freelance writer and Fellow of the Institute of Biomedical Science. British Journal of Nursing 2023 Vol 32 No 20.

In a randomised trial of 3000 participants, Carling et al in 2009 concluded that when presented with the benefits of taking statins as a relative risk reduction, participants were more likely to accept treatment compared to when the absolute risk was given.

In a meta-analysis of 21 randomised controlled trials, Byrne et al in 2022 found reductions in AR of 0.8% for all cause mortality, 1.3% for myocardial infarction, 0.4% for stroke in those randomised for treatments with statins compared with control. The RR reduction for these were 9%, 29% and 14% respectively.

Diamond and Leaverton in 2023 consider that undue emphasis on RR reduction compared to AR reduction has led healthcare providers and the public to overestimate concerns about high cholesterol and to be misled as to the magnitude of the benefits of cholesterol lowering therapy.

Diamond and Leaverton re-evaluated the JUPITER trial of rosuvastatin. There were 18 thousand participants and there was a reported RR of 54% for fatal myocardial infarction. In absolute terms, the incidence of fatal MIs was 0.76% in the control group and 0.35% in the rosuvastatin treated group.

It would seem reasonable and good practice for both RR and AR to be discussed with patients when it comes to initiating treatments such as statins.