SIGN guideline is open for consultation

Katharine

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If you would like to see more appropriate dietary advice given to all diabetics this is your chance to make your voice heard.
This is what I am sending.

If you can beef up your comments with evidence and personal experience this will help. Of course there are many other issues that require comment, particularly blood sugar monitoring for type twos.

Thank you.

Commentary on SIGN

Introduction

Contents

3.7 Should be DIETARY ADVICE OR DIETARY GUIDELINES

Specifically should not be called “Healthy Eating”.

The previous SIGN 55 guideline used the term “Healthy Eating”.

Eating in a way that will improve your health is indeed of fundamental importance for all diabetics including type twos, type ones and pregnant women.

Healthy Eating is considered to be a low fat, high carbohydrate, low protein diet with lots of fruit, fruit juice, moderate sugar, vegetables, starches and grains. The UK Food Standards agency food plate is reproduced in the Diabetes UK website. This is purported to be the optimal eating plan for ALL diabetics. The constituents of what has become to represent Healthy Eating was however not rationally, reasonably, scientifically or evidence based.

In SIGN 55 the fundamental importance sentence was placed immediately in front of the “weight loss improves metabolic control in type 2 diabetics” sentence. The weight control sentence was backed up by a reasonable reference relating to the UKPDS study. This showed that weight loss in newly diagnosed type two diabetics improved hbiacs in the first six months. Within two years however the hbaics returned to their high baseline level.

The positioning of the healthy eating sentence immediately before and without a reference of its own gives a misleading impression that the constituents of healthy eating advice was backed up by 1+ that is randomised controlled trial evidence. In fact, no evidence to support the use of “Healthy Eating” long term for all diabetics was presented in SIGN 55, was uncovered during recent excavations for evidence or exists to my knowledge. Indeed such an eating pattern is detrimental to most diabetics.

The exception is when “healthy eating” advice which results in a total caloric loss for overweight or obese types twos results in weight loss. Weight loss for this group by whatever method, except for that induced by liposuction, produces some improvement in glyaemic and metabolic control. Even then, weight loss, glycaemic control and metabolic markers for inflammation relevant to cardiovascular risk are better served on a reduced total glycaemic load diet.

On looking through the rest of the new guideline the existing detrimental, non evidence based recommendations advocating so called “healthy eating” remains and will affect type ones and pregnant women. Although type two diabetics should in future be given the option of a restricted carb diet, it would appear that unless the dietary advice throughout the guideline is changed type ones and gestational diabetics will be only given advice that will worsen their glycaemic control, increase hypos, worsen endothelial inflammatory risk markers and worsen the outcome for their babies.

This is a very important issue to address at this stage because in section 13, Implementing the Guideline, you are handing over responsibility of each NHS Board to put the so called “evidence based” recommendations into practice. This is as you say, “an essential part of clinical governance”. What this means is that a dietician or doctor or nurse who gives advice contrary to the recommendations on diet could face disciplinary proceedings and indeed lose their job. What happens when these recommendations are not evidence based and do harm?

The General Medical Council have been very clear to doctors that “The interests of your patient should be your first concern”. The “Healthy Eating” advice runs contrary to patient interest and for a health professional to disregard this is unethical. Handing over responsibility to dieticians to give the dietary advice is unethical when it is known that such advice is harmful to the patient. What is the legal standing when a patient suffers a serious hypo or a deformed baby is born? At some point a patient is going to reasonably ask, why was I not given advice on the option of a restricted carbohydrate diet? Is the health professional going to pass responsibility on to the health board and is the health board going to pass responsibility onto SIGN?

I do recall that I made strenuous efforts to have the non randomised but perfectly scientifically reasonable studies for the use of restricted carb diets in type ones, pregnant women and type twos included in the evidence assessment process. This was rejected by the SIGN hierarchy. We now have a ridiculous situation where harm will be continue to be done to type ones and pregnant women by wrong dietary advice.

The reference for the consensus on “healthy eating” for diabetics was included in the SIGN 55 guideline but was never reviewed before it was published. My critique of this document is posted as an attachment. This document is important because it does explore the evidence on both sides of the debate, something that has not occurred with the SIGN methodology as it stands.

3.6.1 Add hypertension or raised blood pressure as a side effect of sibutramine. It is the commonest reason for having to stop it.

3.7 Should be “DIETARY” ADVICE / GUIDELINES/ ISSUES.

My critique of the Lean Ha Techinical Review paper explains in great depth why.

4.11 Prevention.

In Norway women who had used ANY Vitamin D on their infants in the first year of life reduced the onset of type one diabetes 8 fold by the age of 14. This demonstrates a preventative intervention. At least you could say further research is warranted.
Dr Garland’s video about this is on you tube.

5.2.2 The Norfolk study which was originally done to see if blood sugars affected cancer (which it does) also demonstrated an increase in cardiac mortality at hbaic levels above 5%. Interested diabetics may wish to reduce their cardiac risk to normal levels.

5.2.5 A target hbaic of 6.5-7% is NOT “normal”. Problems such as weight gain, markers of cardiovascular risk and hypos are reduced by low carb diets. ( Eg Neilsen)
Hbaics in the fives are easily achievable on a restricted carb diet.

6.4 Dietetic advice should aim to reduce hypos and normalise blood sugars. Dr Lois Jovanovich of the Sunsum Research Center in Santa Barbara advocates up to 30g of carb with each meal and a limit of 15g on any snacks eaten in between for pregnant women. Eating lots of starch and reducing saturated fat to low levels doesn’t normalise blood sugars and puts insulin users at risk of more frequent and severe hypos if they attempt normal blood sugars. The blood sugar targets 3.5-5.9 before meals, no more than 7.8 one hour after eating and 6.7 two hours after eating are very difficult if not impossible to achieve on a high starch / low fat diet. Lois is photographed with 50 consecutive normal babies of diabetic pregnancies and their mothers on a lecture you can see at http://www.presentdiabetes.com


6.6.1 Complications during pregnancy and delivery are reduced by restricted carb diets. (CA Majors)

Hypoglycaemia was reduced 20 fold in type ones on a restricted carb diet of 70-90g a day. (Neilsen).

6.8 You correctly state that gestational diabetes can be defined as carbohydrate intolerance. Why advocate a high carb diet then?

7.2.1 What about high triglycerides and low HDL as risk factors for cardiovascular disease. I understand these factors are four times more likely to predict cardiac risk than total cholesterol / LDL. (Taubes).

Furthermore high total cholesterol is not a risk for mortality in women, and it is only a modest risk for men.

Particle size of LDL is much more relevant than total LDL. (Krauss) Raised triglycerides and low HDL occur with high levels of small dense LDL and low triglycerides and high HDL occur with high levels of large particle non atherogenic LDL.(Eades)

7.3.1 Lifestyle modification is indeed important especially the diet. Post prandial blood sugars are also very important as an independent marker for cardiovascular risk. The most effective ways of reducing post prandial blood sugars is to reduce the total carbs eaten at the meal, reduce the glycaemic index of the carbs that are eaten, and add fat to the meal.

7.4.8 Lipid lowering. Increased levels of triglycerides, reduced HDL levels and an increase in small dense LDL are all reversed by a low carb diet with moderate to high amounts of saturated fat. Inflammatory markers are also all normalised. (Volek).

Vitamin D also reverses arteriosclerosis. (Davis).

8.5.8 Low carb, low iron diets are beneficial in diabetic kidney disease. (Facchini and Saylor). We also reviewed another paper in the dietary section which confirmed this but we were told to leave it out because you would be dealing with this. I didn’t know that you didn’t know. Now we both know.

9.3.4 Retinopathy can be reversed with a low carb diet.

10 Nephropathy, if not too advanced, can be reversed by a low carb diet.




Dear Colleagues



Open consultation on the draft SIGN Guideline on Management of Diabetes



The draft SIGN guideline on Management of Diabetes is now available for comment on the SIGN website http://www.sign.ac.uk/guidelines/drafts/index.html The consultation period will end on Friday 16th October.

This guideline is a selective update of SIGN 55, which was published in 2001, and provides updated information across a range of areas relevant to the care of people with diabetes.

Your comments and feedback are welcome and should be submitted via the online proforma at http://www.sign.ac.uk/guidelines/drafts/index.html

Please feel free to forward this invitation to comment to your colleagues.



With best wishes,

Roberta James, Moray Nairn, Ailsa Stein

SIGN Diabetes Programme Managers

http://www.sign.ac.uk
 

graham64

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Thanks Katharine, it's good to see some recognition of the Low Carb diet in the Sign guidelines, it's a small but significant step in the right direction.

It was interesting to see amongst the references a study that showed that Desmonds had little impact on HbA1c levels, as this course promoted the “ healthy diet “ is this not more proof of the inadequacies of such a diet in the control of blood glucose.

http://www.bmj.com/cgi/content/abstract/336/7642/491

Another concern is the issue of SMBG for T2s, without testing I would have no way of knowing the effects of the so called ” healthy diet “ and yet Sign states routine testing is not recommended for T2s, and that HPs should be aware of the potential negative effects on patients psychological well being. No mention of the potential negative effects of complications brought on by poor glycemic control through not testing.

Thanks again Katharine your efforts on our behalf are appreciated, I just wish more HPs had the courage to challenge the NHS dogma.

Regards
Graham
 

Spiral

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Is there anything similar happening for England and Wales? Although I will respond to this :D Thanks for the link.
 

Manogwent

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Type of diabetes
Type 2
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Tablets (oral)
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carling lager
i asked to see a dietitian after i was DX as type 2. I became member here before my appt so was able to see how the 'user interface' was actually doing to maintain good control. i saw a student dietitian who was still promulgatingthe ' healthy diet doctrine' and this 2009 and years after these guidelines were proposed. seems the NHS is still ' sticking its head in the sand' with regards to thje type of diet beneficial to Diabetics, especially type 2's. :lol: :lol: