Don’t rush to hospital with a burn

It’s now barbeque season, and with this in mind, new research has shown that the best first aid for a burn is to run cool water over the affected skin for at least 20 minutes.This should be started as soon as possible after the event.

In a study of 2,500 children, those given the full 20 minutes treatment were less likely to need hospital admission and half as likely to need a skin graft.

 

My comment: In my childhood my mother put butter on burns. Don’t do this! It does not work. The area that I notice most people have burns is on their wrists on the thumb side. This is from removing hot dishes from the oven and brushing their arm against the hot door or oven sides. Of course you are carrying a hot, full dish of food, so can’t pull back as fast as you would like. Although many of us then run our arms under a tap, it would be a good idea to do this for longer than it takes for the immediate pain to subside. You can also use oven gauntlets in preference to gloves or folded up tea towels as these are longer in the arm. 

BMJ 2019; 367:1572

Over eating and drinking is causing liver damage in one in five young adults

Adapted from Abeysekera KWM et al. Prevalence of steatosis and fibrosis in young adults in the UK: a population based study. Lancet Gastroenterology and Hepatology. 2020 Jan 15.

A new study highlights just how common liver disease is becoming in young adults in the UK. One in five had fatty liver, known as steatosis. One in 40 had fibrosis, also known as cirrhosis. And the average age was only 24.  These results show how harmful unhealthy eating and drinking habits can be.

Subjects for the study were recruited through the Avon Longitudinal Study of Parents and Children. Transient elastography and controlled attenuation parameter scores were used for assessment of steatosis and fibrosis.

Steatosis was found in 20.7% of the participants and this was severe in 10% of those affected. Being overweight or obese was the main factor for causing this after adjusting for alcohol intake, social class and smoking.

Fibrosis was reported in 2.7% of the participants. This risk was significantly higher in those who also had an alcohol problem or addiction and already had steatosis after adjusting for smoking and social class.

The authors conclude that the obesity epidemic is affecting the current and future health of young adults by increasing their risk of non alcoholic steatohepatitis related cirrhosis, hepatocellular carcinoma, and complications of metabolic syndrome.

 

Metformin reduces oesophageal cancer

Adapted from Wang QL et al. American Journal of Gastroenterology 1st January 2020

Metformin users were at a lower risk of developing oesophageal squamous carcinoma than non metformin users.

A growing number of observational studies have shown that metformin reduces overall cancer risk and a few specific cancer types such as colon, rectal, breast and stomach.

A population based cohort study included over 400,000 metformin and an equal number of non metformin users who were matched by age and sex.

There were 3.5 cases of oesophageal cancer in the metformin group per 100,000 person/years and 5.3 in the non metformin group. This finding was true for men, women and those in their sixties.  The odds ratio was 0.68 for metformin use.

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. 

The optimal HbA1C for non low carbing type ones could be 6.5-7%

Adapted from Lind M et al. BMJ 28 August 2019

In type one diabetes in adults and children there could be a sweet spot for blood sugar control.

Under 6.5% severe hypoglycaemia rates increase. Retinopathy and nephropathy risks are not lower however below 6.5% compared to 6.9%. My comment:  In low carbers however, they have considerable protection against severe hypoglycaemia due to more precise meal/insulin matching, although they do experience more episodes of mild hypoglycaemia.

Risks for mild complications begin at levels over 7.0% and severe complications rise with levels over 8.6%.

Current guidelines vary in their HbA1C recommendations, anywhere from 6.5% to 7.5%.

The complication rates were based on 10,398 adults and children with type one diabetes on the Swedish National Diabetes Registry who were diagnosed between 1998 and 2017.

 

 

 

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.