research – Page 15 – Diabetes Diet

You only need one arrow: Dr Unwin proves it again

Jul 15, 2015Jul 15, 2015 kaitiscotlandLeave a comment

Dr David Unwin has completed another study in his practice patients showing that a low carb diet greatly reduces fatty liver, weight and blood sugar. The knock on effects on the prescribing budget, secondary care referrals and complications can only be a good thing for the struggling NHS. His practice alone, compared to those in his area, is making savings when it comes to diabetes care. Currently 66-70% of the adult UK population is overweight or obese, 20-30% have non alcoholic fatty liver disease and 10% have diabetes. The low carbing community remains mystified as to how such a rational, safe and effective treatment option is still side-lined by most diabetology clinics, NICE, and Diabetes UK.

Dr Unwin estimates that between £15,000-£30,000 a year has been knocked off his prescribing budget for a single practice in which the low carb diet was routinely offered to patients. While the drug spend continues to rise in adjacent practices, his budget has not risen in the last three years. His patients are now officially thinner than in neighbouring practices and below the national average. In two years the average blood sugar has come down 10% and is now below the national average of 61.5 mmol/mol.

Here is the abstract which we are proud to present ahead of publication in Diabesity in Practice in September 15.

Unwin DJ¹, Cuthertson DJ², Feinman R³, Sprung VS² (2015) A pilot study to explore the role of a low-carbohydrate intervention to improve GGT levels and HbA1c. Diabesity in Practice 4 [in press]
¹Norwood Surgery, Norwood Ave, Southport. ²Department of Obesity and Endocrinology, Institute of Ageing & Chronic Disease, University of Liverpool, UK.³Professor of biochemistry and medical researcher at State University of New York Health Science Center at Brooklyn, USA.

Working title: Raised GGT levels, Diabetes and NAFLD: Is dietary carbohydrate a link? Primary care pilot of a low carbohydrate diet

Abnormal liver function tests are often attributed to excessive alcohol consumption and/or medication without further investigation. However they may be secondary to non-alcoholic fatty liver disease (NAFLD). Considering the increased cardiovascular and metabolic risk of NAFLD, identification and effective risk factor management of these patients is critical. NAFLD is now prevalent in 20-30% of adults in the Western World

Background Excess dietary glucose leads progressively to hepatocyte triglyceride accumulation (non-alcoholic fatty liver disease-NAFLD), insulin resistance and T2DM. Considering the increased cardiovascular risks of NAFLD and T2DM, effective risk-factor management of these patients is critical. Weight loss can improve abnormal liver biochemistry, the histological progression of NAFLD, and diabetic control. However, the most effective diet remains controversial.

Aim We implemented a low-carbohydrate (CHO) diet in a primary health setting, assessing the effect on serum GGT, HbA1c levels (as proxies for suspected NAFLD and diabetic control), and weight.

Design 69 patients with a mean GGT of 77 iu/L (NR 0-50) and an average BMI of 34.4Kg/m² were recruited opportunistically and advised on reducing total glucose intake (including starch), while increasing intake of natural fats, vegetables and protein.

Method Baseline blood samples were assessed for GGT levels, lipid profile, and HbA1c. Anthropometrics were assessed and repeated at monthly intervals. The patients were provided monthly support by their general practitioner or practice nurse, either individually or as a group.

Results After an average of 13 months on a low-CHO diet there was a 46% mean reduction in GGT of 29.9 iu/L (95% CI= -43.7, -16.2; P<0.001), accompanied by average reductions in weight [-8.8Kg (95% CI= -10.0, -7.5; P<0.001)],and HbA1c [10.0mmol/mol (95% CI= -13.9, -6.2; P<0.001)].

Conclusions We provide evidence that low-carbohydrate, dietary management of patients with T2DM and/or suspected NAFLD in primary care is feasible and improves abnormal liver biochemistry and other cardio-metabolic risk factors. This raises the question as to whether dietary carbohydrate plays a role in the etiology of diabetes and NAFLD, as well as obesity

NICE 20015 Diabetes guidelines reveal magical thinking for our diabetic youngsters (again)

Apr 19, 2015 kaitiscotland2 Comments

NICE have done a major diabetes review over all areas and the new guidelines went out to consultation recently. I was lucky enough to be sent them by the Royal College of General Practitioners but only given 2 weeks to respond to them. So far I have only managed to study the children and young people’s guideline but my critique of the others will follow.

The new guideline gets some things correct in my view. The target hbaic for one. It is now 6.5% or 48 mmol, because the group have finally realised that tight blood sugar control is the actual key to preventing complications from diabetes. (7.2) Okay, it took a long while, but at least they got there in the end. Previously target hbaic levels have been set too high at 7.5%.

Even NICE however are concerned that children and young people will find this terribly hard to attain. They certainly will, especially, if they attempt to follow the unchanged and still illogical, non-evidence based, consensus plans which are to eat lots of carbohydrate and make sure you avoid saturated fat. Yet they have a sense of humour about themselves and state that children and parents “should develop a good working knowledge of nutrition and how it affects diabetes”. (3.4)

Obviously Emma and I think you should too, and this is why you should read our book and not pay too much attention to what an NHS dietician or diabetologist tells you about what to eat.

There was only 0.3% improvement in hbaic after learning about carbohydrate counting. Not a single low GI study showed a 0.5% improvement in hbaic. Unless you specifically understand to greatly limit carbohydrate intake, no significant improvements in blood sugar control will be made.

The entire report is littered with study after study which show that our diabetic youngsters have very high hbaic levels indeed. Mean levels of 8.5 to 11.5% are common in diabetic children and adolescents no matter what parameters are under scrutiny. Meanwhile, although structured education is increasingly popular, and costs £683 per person, it too fails to make any changes to hbaic over 6 months or 12 months. (20) None of the structured education programmes could produce even a 0.5 % reduction in hbaic though one study did show a reduction in severe hypoglycaemia. Could it be the lousy rubbish they teach about what constitutes a healthy diet perhaps?

There is no longer a consensus view that diabetics should “eat the same healthy diet as everyone else”. The American Association of Clinical Endocrinologists has been the first major group to tell diabetics to limit carbohydrate to 90-120g per day and to adjust this if they are not reaching target blood sugars. Consensus opinion in this context is just another word for a bunch of bullies and failure to remove these appalling dietary recommendations is in my opinion reprehensible, immoral and disgusting. They don’t have to keep consensus opinions. SIGN got rid of them. So can NICE.

Meanwhile, NICE, seem to let diabetologists off the hook and explain that the avoidance of undue hypoglycaemia, is a barrier to attaining decent hbaic levels. (5.7) They have again refused to see that a low carb diet can be a straightforward way of minimising blood sugar variability and that it has been proven by Dr Bernstein and Dr Neilsen. Why? Because they did not look at this sort of evidence. Indeed no new dietary evidence was looked for at all, before they embarked in a hugely expensive operation into researching the current guidelines.

They notice that even kids realise that their blood sugars are not under control and that young though they may be, this affects them poorly psychologically.( 7.7) It must be very disheartening to be doing everything you are told yet not achieving single figures on your meter. You feel tired and out of sorts when your blood sugars are high, but at least it doesn’t “show”. Low blood sugars single you out as different from your friends, and continually remind you that you are a patient. Indeed NICE have the proof that depression can result from poor glycaemic control. (10.3)

Albuminuria is correctly recognised by NICE as the first sign that the kidneys are being damaged by high blood sugars. Yet the recommend a low protein diet to “prevent” it. (11.43) Why? High blood sugars from high carbohydrate diets are the major cause of the kidney damage in the first place. Again, the recommendation is neither evidence based or thought out at all. They again have ignored research by eg Facchini and Saylor who showed that high protein, high polyphenol, low carb diets improved kidney disease in diabetics.

One of the useful things this review stated was that there was no harm found in injecting insulin through clothes. I know this can sometimes facilitate insulin injections in public places.

Another is the unusual but serious issue of Diabetic Ketoacidosis. It can occur even when diabetic kids on insulin have normal blood sugars. (18 recommendation 177). DKA should be suspected if there is nausea or vomiting, abdominal pain, fast breathing, dehydration and a reduced level of consciousness. Blood ketone testing is preferable to urine testing.

After an episode of DKA, NICE recommends that the factors that could have led to the episode are explored with the diabetes team. (18) Non adherence to therapy needs to be considered especially if DKA is recurrent. Diabetics should get advice on how to reduce future episodes and the management of intercurrent illness is particularly important. We cover some of these aspect in our book but for the best possible advice on this I recommend Dr Bernstein’s Diabetes Solution. I also recommend that you become familiar with this well before you get ill.

When it comes to the increasing numbers of children and adolescents with type two diabetes, the blood sugar targets have been similarly set for a hbaic of 6.6% or 48 mmol/mol. (14).

The dietary advice is the same rubbish as for type ones. NICE states that “healthy eating” ie high carb, low protein, low fat diets, “can reduce hyperglycaemia, reduce cardiovascular risk, and promote weight loss”. They don’t produce any evidence to back this up of course, it’s neatly packaged as “consensus”. (13.17)

Albuminuria was present in 29% of this young population independent of the duration of the diabetes. First morning samples are preferred for testing. (17).

The age of transfer to adult clinics is discussed in the new document. As an example of typical blood sugar levels, in Finland the mean age of transfer to adult clinics was 17.5 years. Average hbaics one year before transfer ie at age 16.5 was 11.2% + or – 2.2% and at age 17.5 the average hbaic was 9.9% + or – 1.71%. These kinds of averages litter the report and indicate that diabetic complications are inevitable for our young diabetics unless they radically change what they are doing regarding diet and blood sugar management.

Health economists have been busy bees regarding diabetes expenditure and costs. For your typical person on multiple daily injections the cost is £2,155 per year. (20) This includes initial instruction and seeing consultant diabetologists and nurses at typical hospital clinics in the NHS. For those who inject 2 or 3 times a day the cost is £1,500. The MDI was shown however to be cost effective compared to the less frequent injections, which use mixed insulins, due to the long term reduction in complications. The typical baseline hbaic was 11.4% in 10-14 year olds in England and Wales. Scary, isn’t it! (Adhikari 2009). All sorts of cost for complications are listed and these make interesting if somewhat gruesome reading. An amputation with the provision of a prosthesis for example costs £15,000.

Reduction in complications occurs with every reduction in hbaic. Similarly lifetime complication costs are reduced with adequate monitoring. Five times a day seems to be the optimal, minimal testing frequency.

NICE have been very good at telling us what is going on in the UK with diabetes management of children and young people. They have a lot of new, sensible and research based recommendations. Unfortunately they chose NOT to review dietary recommendations and until they do this, hbaics of 6.5% will remain pie in the sky. Unless you just ignore them and eat low carb of course!

Diabetes in the News – the Perils of Being a Woman and “Smart Insulin” Trials

Mar 11, 2015 EmmaLeave a comment

Animals may have been harmed in the makings of this research.

It’s difficult to avoid news about diabetes, as there are regular articles in the press – from the doom and gloom predictions about burdens on the healthcare system to simplistic pieces about “cures”, diabetes makes the news on a regular basis.

Two news items caught my eye recently: one which talked about the greater risks faced by women with type 1 diabetes, and one about “smart insulin”.

As an optimist by nature, I prefer to ignore the first and concentrate on the second and its potential; however, if you are interested – there’s a good discussion of it on the NHS news website, which separates the attention-grabbing headlines from the facts and discusses the origins of the research.

[In short, the NHS reckons the Daily Telegraph’s coverage of the study which was carried out by the Universities of Queensland and other universities in Australia, the Netherlands, the UK and the US, expressed the results in way that could be misleading. Saying for example that “female patients are twice as likely to die from heart disease than men with [type 1 diabetes]” was too simplistic an explanation because men do not generally live as long as women.

The researchers did not directly compare rates of death in men and women – they compared risk of death over a given period in women with type 1 diabetes, compared to that of women in the general population and then made the equivalent comparison with men.]

The other piece of news was about the development of “smart insulin”: i.e. an insulin which can respond to blood sugar levels directly and bring them under control. Type 1 diabetics and some people with type 2 diabetes take insulin to control blood sugar levels, but it can be tricky to work out how much to take, as there are many different things that have an impact on your blood sugar levels – from doing exercise, to missing a meal, from feeling ill to feeling stressed, under or over estimating the number of carbohydrates in a meal, drinking alcohol, hormonal fluctuations in the lead-up to getting your period (women of menstruating age) and more.

The smart insulin study was carried out by researchers from Massachusetts Institute of Technology in the US, funded by donations from the Leona M. and Harry B. Helmsley Charitable Trust and the Tayebati Family Foundation.

An animal study on mice found that “smart insulin” containing a molecular switch could directly respond to blood glucose levels (high levels) and bring them under control for as long as 13 hours after the initial injection. The study involved giving mice with type 1 diabetes a sugary drink. The “smart insulin” was a modified insulin containing two small chemical molecules that bind to insulin, one of which was a glucose sensor. Having taken sugary solutions, the mice with diabetes who had been given the modified insulin were able to rapidly normalise blood glucose levels – in a similar way to healthy, non-diabetic mice.

The NHS news site called the results “promising”, but pointed out that the research was in its very early stages and that it had been carried out on mice. Years of research and clinical trials would be needed – developing the treatment for humans, seeing if it was safe for humans, carrying out research on large numbers of people – before “smart insulin” could be used by humans. Promising research into the treatment of mice with diabetes does not equate to effective results for human beings.

In short, a simple, take-home message is: don’t wait out in the hope of the appearance of smart insulin any time soon, and in the meantime those with type 1 and type 2 diabetes (male OR female) should look to controlling their diabetes as best they can.

You can read about research and low-carbohydrate diets and their effect on health and reducing blood glucose levels here. And if low-carbohydrate dieting is something you want to explore, please see The Diabetes Diet.