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

Giant fatty liver cut down to size in one week

For many years we have known that to get a good going fatty liver we should treat ourselves like the farmers who feed the geese that make pate de fois gras.  That is, eat lots of dietary carbohydrate, particularly grains and other refined stuff like sugars and starch.

For most patients afflicted with fatty liver, the changes that come on are insidious, and are only picked up on abnormal liver function tests, particularly AST and ALT, or perhaps an ultrasound scan, that reveals the bright echo appearance that all that extra fat in the liver gives.The problem is that fatty liver can progress eventually to cirrhosis. In my practice we have already had one death from liver failure from cirrhosis brought on by non-alcoholic fatty liver disease.

One of my patients, not a diabetic, was sent home from hospital recently with a diagnosis of alcohol induced fatty liver. She was very distressed, not only because she had a massive abdominal swelling, but also because she had been labelled as an alcoholic.

She had gone into hospital with severe inflammatory bowel disease. She had been feeling so poorly that she had lost her appetite and had been drinking about 6 bottles of fizzy, sugary juice a day. At the same time, in an effort to gain control of her symptoms, she was on immune modifying drugs and a very large dose of oral steroids.  Indeed she still is. Her blood results showed no hepatocellular injury, a bit uncommon with fatty liver disease, but a huge fatty liver on ultrasound. On examination it was nearly at her pelvic bone but I was able to put my fingers below it. It was very tender but smooth with no irregularities.

I advised her that she needed to go on a very low carbohydrate diet to get the best chance of reversal of the fatty liver. She was to have no sugar, no starch and no alcohol. She was to eat freely of meat, fish, eggs,  cheese, butter, cream, olive oil, low starch vegetables and could have up to two portions of fruit a day.

She was due to return in two weeks for examination and blood testing but came back after only a week because she was finding the diet really tough going.  Surprisingly her liver had shrunk to only two finger breadths below her rib cage and the tenderness was much reduced. Her abdomen was looking almost normal.

She had been eating mainly tuna and lettuce and drinking water. Given the massive improvement, I then gave her some advice on expanding her diet, but advised that she learn carb counting, and keep the total amount to 20g or under per meal. She has a diabetic relative who has carb counting books and she was assured of family support in this regard.

What I think was happening is that the steroids were making her extremely insulin resistant and particularly prone to storing fat in the liver. Her pure sucrose diet compounded the problem and ended up in her liver. I have not yet seen such an acute and extreme case of fatty liver as this.

Fortunately I had heard of the beneficial effects of carbohydrate restriction for this condition. I am still amazed how well the diet worked in such a short time.

This woman is still at risk from fatty liver because of the ongoing steroids, but as her gut symptoms have finally settled, we hope that the dose reduction can continue.

I wonder how long it will take for hospital physicians to tell patients with fatty liver that they should stop ingesting refined carbohydrates as well as alcohol.