You only need one arrow: Dr Unwin proves it again

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

Your (burnt out) doctor will see you now……

There never has been some mythical golden age when every patient got the time they really needed with their General Practitioner, but seeing your GP is expected to get even harder.

Reviews by both the Centre for Workforce Intelligence and GP taskforce have concluded that the UK has too few GPs and the ones that we do have are increasingly stressed, burnt out and feel unable to deliver health care safely.

GP funding is 8.3% of the cost of the NHS in return for providing 90% of medical contacts. This percentage of funding is at an all-time low. Failure to keep pace with the aging population, complex illness, cancer survivors, the rising female workforce, the doubling of specialist doctor workforce and the tendency for GPs to prefer portfolio careers to full time General Practice all have played a part in the current workload/manpower mismatch.

Dr Veronica Wilke, professor of primary care from the University of Worcester, says, “Students and trainees who witness stressed, burnt out GPs, who feel isolated and unsupported, are unlikely to choose general practice for a career. Preventing attrition in the existing workforce is as important as recruiting new trainees. Hospitals have fewer beds, and the call is for more care in the community. GPs and primary care nurses are retiring, leaving and emigrating. Cornwall, Reading and Bristol cannot recruit enough GPs to keep practices open and training schemes remain unfilled.”

So, what can you do to prevent your GP getting sectioned into the local mental hospital or running off to Australia?

Here are my tips:

  1. Think about what you want to achieve in your consultation with your GP.
  2. You only have ten minutes, so either one big thing or two small things is realistic.
  3. Write these things down. Use the Patient Concerns Questionnaire from our book.
  4. Do you need to see a GP for any of these things? Sometimes a nurse, health visitor or health assistant would be more suitable. There are often ways for obtaining results or repeat prescriptions or immunisations that the practice has already set up.
  5. Make the appointment in the name of the person who is to be seen.
  6. Don’t ask for other family members issues to be squeezed in while you are there.
  7. If you can possibly come to the surgery instead of asking for a house call do this.
  8. If your issues can be dealt with by phone is there a way this can be sorted out by the practice?
  9. Be as well educated as you can about the illnesses you have and on keeping yourself fit and well.

Now, it’s time we heard from you.

Have you noticed any change in how your General Practice care has been affected by the manpower crisis?

Have you any other tips to help patients get efficient service from their GP team?

Any tips for these stressed GPs and practice nurses?

Based on an article by Veronica Wilkie: BMJ 2014;349:g6274