Tag: research

“A cross-party long-term strategy is needed to combat obesity in children” says Brian Whittle

kaitiscotlandLeave a comment

553c9c59e22f98bc5d30fa62

Brian Whittle is a gold medallist runner who aims to introduce widespread after school childcare focussed on delivering high quality exercise and physical activities. This is a long term strategy which is fun for children yet could provide immense health benefits and even enhance academic performance.

There are studies which support the validity of Brian’s aims.  But do enough politicians have the long sightedness and will to ring fence funding that is needed?

In order to prevent obesity in our youngsters and the disorders associated with sedentary behaviour a culture change is needed. The unhealthy eating, snacking and reliance on screen based entertainment needs to be replaced by three good meals a day and movement to counteract the long hours sitting in the classroom. Many parents work long hours too, and would welcome group based physical activity for their children in a safe environment.

Brian is seeking support from leaders and health ministers from all parties.  Some headmasters are highly supportive and are delighted with the improved behaviour, reduced truancy and improved grades that they are seeing in pupils who have become more engaged as a result of fun activities after school.

More than 2.3 million children in the UK are overweight or obese and even the under 12s are showing signs of high blood pressure, cholesterol abnormalities, type two diabetes and liver disease.

Dr Tim Lobstein, director of the Childhood Obesity Programme says,  “ It will be tragic if it is not tackled. Chronic diseases are moving forward at an ever increasing rate. Our kids are eating themselves into an early grave. We will have the first generation to die at an earlier age than their parents. Britain along with some other southern European countries are at the top of the list. While soft drink and confectionery sales have rocketed, and TV watching, computer games, and other sedentary media have grown, exercise has fallen. Unless the obesity epidemic is brought under control we are facing the prospect of medicating kids at primary school and for the rest of their lives. If we can just find a way of encouraging healthy growth then we can avoid an enormous amount of grief in the future. Unless we start teaching our children in schools about raising children, feeding them properly, exercise and the difference between good and bad food, then we are just going to exacerbate the problem.”

Getting children to become more physically active and achieve normal weights has been found to improve attention, planning and thus have knock on effects on academic performance. ( Davis CL et al Pediatr Exerc Sci. August 6 2015)

Children who are more active in late childhood can demonstrate lower body weight and lower risk factors for cardiovascular disease and diabetes by their mid- teens.  This means an hour of moderate to vigorous exercise a day. A national approach involving the collaboration of various government agencies would be needed to produce widespread benefit. (Stamatakis E. Pediatrics Vol 135 No 6. 6 Jun 2015)

For younger children under the age of 6, three hours of activity, spread throughout the day is recommended by the US Institute of Medicine. They hope that such recommendations can help reduce overweight and obesity which is currently at 27% in this age group.

For adults at least 30 minutes of activity a day is recommended. The good news is that the earlier you get into exercise the more the habit is like to stick.  Swimming, dancing, walking, running, yoga, jogging, tennis, basketball and football are all suitable. The fitter you are in early adulthood, the lower your total mortality rate and cardiovascular disease rate. There is a clear dose response between exercise and fitness and fitness, well-being and mortality rates. (Shah et al. JAMA Internal Medicine 1-9)

Even if you have been sedentary for years or cannot tolerate 30 minutes a day, it is recommended by the American Heart Association that you start with walking.  Apart from benefits to the individual there is a benefit in health care costs in the future. ( AHA 6 Dec 15)

Emma and I are already into the exercise habit. It certainly is more of a challenge in Scotland with our awful weather and long, dark, winter nights. What good ways have you found to keep active and support your children to be active?

 

 

 

 

Can your job cause type two diabetes?

kaitiscotlandLeave a comment

A  study of English civil servants has shown that those who earn the least are almost twice as likely to get type two diabetes than those who earn the most.

The ones who earn the least are also over one and a half times more likely to be obese and also one and a half times more likely to pursue an unhealthy lifestyle. This lifestyle includes a group of factors including smoking, drinking excessively, having a poor diet and being physically inactive.

The group comprised of over 7000 adults and equal numbers of men and women and measurements were repeated over an average of 14 years. The authors of the Whitehall II study, do not discuss what the reasons may be for the associations but I can think of a few possibilities.

Healthy food such as meat, fish, eggs, cheese, butter, olive oil, fruit and vegetables cost a lot more than unhealthy food such as sausages, sausage rolls,  bread, pasta, pizza, chips, burgers,  vegetable oil and margarine. As you will know from our book, the cornerstone to preventing weight gain and controlling diabetes is a low carbohydrate diet that is plentiful in protein, vegetables, some fruit and naturally saturated and mono-unsaturated fats.

I’m not sure if the studied civil servants all worked in central London or not. If they did, it would be logical for those who earned more to be able to afford housing nearer their place of work, thereby having to spend less time commuting.

Spending more time travelling to work each day certainly can eat into time that could otherwise be spend on planning meals, shopping and undertaking planned exercise. Being able to have flexible working hours can also help people spend less time commuting and undergo less stress while they do so.

As employees rise higher in the civil service the annual leave time allowed tends to rise as well as the pay. This could also affect the time that could be spent on exercise as well as enjoyable pursuits.  As we know, many exercise options are free, but some are not, and with poor weather outside, exercise plans can slide.  Being able to go to a gym, tennis club or golf course can provide a social outlet as well as an opportunity to exercise. Exercise helps improve mood and relief stress as well as being an opportunity to gain muscle and being able to eat more calories a day and get away with it.

What about smoking and drinking then? Why are these behaviours more common in those who are paid less?

It has been known for a long while that those with less money tend to smoke more.  As for drink, the more affluent can certainly put away plenty of drink too, particularly the more affluent, executive middle class woman, compared to her shop assistant or factory working sister. Greater workplace stress and difficulty with the elusive work/life balance are thought to be factors for the higher earning woman.

What about mental health factors? It has been found that the lower choice someone has about their job role the higher their stress and the greater their chances are of becoming depressed. Perhaps the lower the job status the less autonomy civil servants have at work?  From my work in the police force and the NHS I have seen the opposite scenario as well. I have seen very able people refuse promotion because of the necessity to do a lot of unscheduled extra work and take on responsibility that seems relatively poorly rewarded financially as people rise up the hierarchy.

Television watching also tends to increase the amount of sugary food and drink consumed across all age groups according to a study. Do the more affluent watch less telly? Perhaps having a dining table and using it for family meals can be a factor in reducing our waistlines?

The reasons for the socio-economic differences in the causation of type two diabetes are up for discussion. But also up for discussion is what can we do to lessen the chances of being affected?

Being aware that your job could be putting you are more risk of type two diabetes is a first step. How can you get more control over how you do your job? Can you get flexi-time so as to make home arrangements and commuting less stressful?  Can you eat in a more healthful way? Can you make more time for exercise or incorporate physical activity into your working day? Are those self- soothing habits such as smoking, drinking and watching the telly stealing years from your life?

Sadly it looks like the workplace subsidised canteen and gym perks are becoming less likely rather than more likely. I would not be surprised to see these socio-economic differences between civil servants greatly amplified between people who are unemployed and those workers who are just scraping a living wage compared to  more affluent workers. And where type two diabetes goes so does the increased rates of complications, cardiovascular disease and cancer.

Based on Contribution of modifiable risk factors to social inequalities in type 2 diabetes: prospective Whitehall II cohort study. Silvia Stringhini et all. BMJ Sept 12 and BMJ learning module: The effect of television watching on dietary intake.

You only need one arrow: Dr Unwin proves it again

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)

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!

X-Pert Advice for Healthcare Professionals

EmmaLeave a comment

trudiAre you a healthcare professional who is worried about advising patients to try a low carb/high fat diet?

Hi there, I’m Dr Trudi Deakin, chief executive of the charity X-PERT Health which develops, implements and evaluates structured education for the prevention and management of diabetes.

We strive to keep abreast of the latest research so that healthcare professionals and patients obtain the most up-to-date lifestyle management information. Literature reviews are undertaken on an annual basis and the research papers critically appraised to draw accurate and meaningful conclusions. The following hierarchical system for levels of evidence is used [1]:

Grading of evidence:

  • Ia: systematic review or meta-analysis of RCTs.
  • Ib: at least one RCT.
  • IIa: at least one well-designed controlled study without randomisation.
  • IIb: at least one well-designed quasi-experimental study, such as a cohort study.
  • III: well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies.
  • IV: expert committee reports, opinions and/or clinical experience of respected authorities.

Grading of recommendations:

  • A: based on hierarchy I evidence.
  • B: based on hierarchy II evidence.
  • C: based on hierarchy III evidence.
  • D: directly based on hierarchy IV evidence.

Continue reading “X-Pert Advice for Healthcare Professionals” →