Belinda Fettke: The origins of the food companies behind the grain based diet

This is part one of a three part series on how we have ended up with a cardiovascular disease epidemic, what treatments we are using which don’t work, and what treatments do work.

The in first episode Belinda Fettke discusses the history behind the 7th Day Adventists who genuinely believed that they were bringing health to the USA population by promoting a grain based diet.

This is a long video but entertaining as well as informative.

 

Monthly lifestyle counselling improves heart outcomes

Adapted from Intensive lifestyle counselling and cardiovascular outcomes in patients with diabetes. September 14 2019  Diabetes in Control by Nour Salhab. Pharm. D from Zhang et al Lifestyle counselling and long term clinical outcomes in patients with diabetes. Diabetes Care. Aug. 2019.

Intensive lifestyle counselling has been shown to improve blood sugars in the Look AHEAD study but it was too underpowered to show any significant conclusions regarding cardiac outcomes.

This new study looked at patients with both type one and type two diabetes who had HbAICs over 7% and were over the age of 18. Lifestyle counselling involved diet, exercise and weight loss management. The goal was to get the patient’s HBAICs under 7%.

19,293 patients were involved and the mean HbAIC at the start was 7.8%. My comment: This is a very good average compared to British diabetics! 

The mean counselling sessions were 0.46 a month and the study ran for 5.4 years.

HbAIC reduced by 1.8% for patients who got monthly counselling and 0.7% for those who got less than monthly counselling.

The primary end point was time to the first episode of angina, heart attack or stroke or death from any cause. There was a small but significant decrease in the group who had monthly counselling compared to three monthly counselling.

The counselling occurred in academic centres so may not be applicable to other settings.

My comment: This level of counselling is much more intensive than can probably be delivered in the NHS population. The blood sugar levels in the patients was also much better to start with compared to the UK population. 

A little care goes a long way

Adapted from Annals of Family Medicine 2019 doi:10.1370/afm.2421

People diagnosed by their GP with type two diabetes had a 40-50% lower mortality rate over the next ten years if they experienced their GP and practice nurses as empathetic during the year after diagnosis, compared to those who considered that their primary health carers had low empathy.

This study looked at 879 patients recruited from 49 GP practices in the east of England.

My comment: The first year is when patients get their head round the fact that they have a long term condition that could affect how long they will live and the quality of the life they have left. At diagnosis many are willing to look at lifestyle changes. Encouraging them, helping them, and helping them set appropriate goals makes a good difference to a person’s ability to change their daily routines. If you are newly diagnosed and don’t get on with your health care providers for any reason, then maybe a change of provider makes sense in the light of this research. 

There are benefits to that pre-breakfast workout

Adapted from Edinburgh RM et al. Journal of Clinical Endocrinology and Metabolism 21 Oct 2019 

Research suggests that blood sugar levels can be better controlled by planned eating and exercise timings.

This study was conducted in Bath and Birmingham and involved a six week trial of 30 overweight or obese men. They were divided into three groups. One group ate breakfast before exercise, one group after exercise and the third group made no changes to their diet or exercise (or lack of it). Groups one and two swapped over after the first six weeks.

The researchers showed that you doubled the amount of fat burned during exercise if breakfast was delayed. This was mainly because the group had lower insulin levels due to their prolonged overnight fast. They could therefore burn more fat in their fat stores or muscle. The groups did not do more exercise than the pre-workout breakfast group.

Groups one and two swapped over after the first three weeks. The men’s BMI averaged at 30 and was closely matched in each group. Although insulin sensitivity was improved in the longer fasting group, there was not any significant weight loss.

Soldiers improve their physique on a ketogenic diet

Adapted from Military Medicine January 2019 by Richard Al LaFountain et al of Ohio State University.

This is the first study of a ketogenic diet in military personnel. Daily ketone monitoring was done to personalise the diet. 29 subjects from various branches of the military took part over the 12 week study.

15 self selected to go on the ketogenic diet (KD) monitored by blood ketones daily. 14 continued their mixed diet (MD). Various measurements were done at the start and end of the programme.

All of the KD group were in ketosis throughout the 12 weeks as assessed by beta-hydroxybutrate levels. The KD group lost 7.7kg more (range -3.5 to -13.6kg) despite no calorie restriction. They lost 5.1% body fat (range -0.5 to -9.6%). 43.7% was visceral fat (range – 3.0  to – 66.3%) and had a 48% improvement in insulin sensitivity. There were no changes in the MD group.  There were no changes between the groups in aerobic capacity, maximal strength, power and a military specific obstacle course.

The authors conclude that this was a very well accepted intervention which showed remarkable improvements in body composition and weight without compromising physical performance in exercise training.

In the USA two thirds of active military personnel are overweight or obese which mirrors the general population. Nearly three out of four young people aged 17-24 fail to qualify for military service mainly due to obesity and failure to meet fitness standard thus posing an impending recruitment crisis.

The military usually follow the USDA’s dietary guidelines that advocates low fat, high carbohydrate foods. Americans have followed these recommendations for decades and have seen a marked rise in obesity at the same time. A diet that emphasises carbohydrate has the effect on suppressing fat oxidation and the production of ketones. Over half of active military personnel report drinking sugar and caffeine containing energy drinks in the past month.

Ketones produced while following a ketogenic diet have been shown to improve fat oxidation, enhance gene expression, inflammation, antioxidant defense and  healthspan. Fat loss without the explicit need to restrict calories is a benefit. Reversal of metabolic syndrome and obesity occurs. Previous studies have shown no detrimental impact on endurance and resistance training performance. The study was done in the military to see if this was a feasible approach.

The success of a ketogenic diet depends on commitment so we did not randomise the subjects. Both groups took part in identical physical training that emphasised strength and power.

Participants were recruited from the Ohio State Reserve Officer Training Corps and other local groups with a military affiliation.  We wanted people as similar as possible to the demographics of serving soldiers regarding age, sex, race and body mass. Participants were excluded if they had had previous experience of a ketogenic diet, were over 50, had certain illnesses, conditions, medications or allergies or who could not exercise safely.

The KD group were coached and were provided with unlimited frozen, pre-cooked meals and grocery supplies.  Carbohydrate was limited initially to 25g per day and protein to 90 g/d until ketosis occurred. Thereafter they could increase the amounts in their diet provided they stayed in ketosis. They were encouraged to use salt.  Carbohydrate was targeted at less than 50g per day including non starchy vegetables, nuts, seeds, selected fruit and berries. Protein goals were 0.6 – 1.0g g/kg of lean body mass. Total energy intake was not restricted. Non starchy vegetables and fats were encouraged to reach satiety. Alcohol over 2 drinks a day was discouraged in both groups.  Participants checked their blood ketones every morning and sent pictures of their readings to the research team.

The mixed diet group had a minimum consumption of 40% dietary calories from carbohydrate.  All participants met with registered dieticians and were encouraged to eat to satiety with no specific caloric limit. Dietary supplements were not allowed.

All groups undertook a progressive resistance training programme two days a week for an hour at a time. They had one additional cardio training session a week consisting of running and body weight circuit training for at least 30 minutes. Each resistance training session ended with 15 minutes of whole body, high intensity circuit training.

Body mass and body composition was measured by DEXA. Fat was assessed by MRI. Indirect calorimetry was used to evaluate resting metabolic rate and the respiratory exchange ratio.

The most noteworthy result was a spontaneous reduction in energy intake resulting in a uniformly greater weight loss for the ketogenic group.  The visceral fat was also markedly reduced which leads to a reduced risk for insulin resistance and cardiometabolic disease.  Insulin sensitivity improved in the ketogenic group.

Normalisation of weight is important for soldiers because non combat musculoskeletal injury is 33% more common in this group.

Subjects in this study were overweight but not obese, so the weight loss effect could be expected to be even more in obese subjects.  Release of fatty acids and ketones are likely the cause of the satiety effect leading to less hunger. The weight loss in the ketogenic group was 80% from body fat mass.  44% of the fat lost was from the viscera, largely in the middle of the body.

Because the subjects decided what diet they would follow, selection bias can’t be ruled out. The KD  group was also slightly heavier at baseline than the MD group.  The two women in the KD group responded similarly to the men.

 

 

 

 

Sam Everington: I moved the diabetes consultant into the community and greatly improved results

Adapted from BMJ 26 January 19, Five minutes with Sam Everington,  by Susan Major

Sam Everington worked as a lawyer before re-training as a GP. He is now the chair of Tower Hamlets Clinical Commissioning Group, has served on the Kings Fund, and gained a knighthood.

Tower Hamlets is a very deprived area in east London, despite this they have achieved the best rates of blood pressure control and cholesterol in patients with type two diabetes.

Sam puts this down to a much closer involvement by the hospital diabetes consultant with patients directly in the community instead of the hospital ivory towers which is traditional in the UK.

By mainly giving telephone advice to local GPs and pharmacists, he was able to give quick decisions on optimal treatment.

Sam says, “Diabetes is a complex disease, so you have to have a comprehensive approach, using everything you can to improve lifestyle and motivate patients by focussing on what is important to them. It is key to have a care plan that is individualised to each patient, systematically going through with a nurse and creating the plan in partnership with them.

“If you accept that social factors are responsible for 70% of a person’s health and wellbeing, then there is a big gap in primary care. If we don’t tackle social factors, we are really only having access to 30% of the therapies that we really need. Therefore we have introduced social prescribing in every practice in Tower Hamlets.

“We use a referral form, ticking boxes on lifestyle, environment, social and mental health. Patients then see the social prescribing advisor and talk through what will motivate them. They are then connected to one or more of 1,500 voluntary sector organisations in Tower Hamlets.

“We also encourage patients to access their own notes so they can see their results and take control. All the evidence shows that when patients manage their own illness the outcomes are better. All our patients are offered a half or whole day diabetes education workshop.”

My comment: Well done Sam. A great example of joined up thinking being adequately resourced to achieve great results.

 

 

NICE recommends UrgoStart dressings

From BMJ 9 Feb 19

NICE have recommended that a new dressing, UrgoStart, may be used to treat non infective diabetic and vascular ulcers.

The dressing contains material that inhibits enzymes from the tissues that inhibit wound healing. They estimated that these dressings can speed up healing and save the NHS £342 per patient per year. This takes into account the savings on dressings, nurse, GP and out patient visits.

They estimated that if a quarter of all diabetic ulcer patients were changed to this dressing that the NHS could save £5.4 million a year.

My comment: We are not using it in our surgery yet.