The paper was published by a registered dietitian, a consultant endocrinologist and a general practitioner. Led by Diabetes Digital Media’s dietitian, Tara Kelly, the paper outlines a number of key areas of controversy surrounding the use of low-carbohydrate diets amongst the medical and scientific community.

The authors describe the field as “rife” with controversy:

“However, this is a scientific area that is rife with controversy and conflicting findings which have polarised expert opinion and can cause confusion for health care professionals and their patients.”

Dr Unwin, a GP from Southport, has been advocating the low carbohydrate approach to his patients living with type 2 diabetes, with an impressive cohort of ‘real world’ data, where 73 patients are in drug-free remission.

Professor Francis Finucane, a consultant endocrinologist in Galway, Ireland was the senior author on the paper. Professor Finucane leads the Bariatric service in Galway. His team run a pragmatic service where low-calorie diets, low-carbohydrate diets and bariatric surgery are all used for the treatment of obesity and type 2 diabetes.

The authors sought to “bring the reader on a journey through the controversies surrounding the approach”, says Kelly. Kelly also comments that “many clinicians, especially those not specialist in these areas are not aware of this approach as a viable option”.

We acknowledge this approach is not for everyone and encourage clinicians to have this as “one option in their toolbox”, she says. The authors refer to the current guidelines supporting the use of this approach.

This article outlines 5 points for clinical considerations when using this approach;

1) Guidelines support the use of this approach

“Doctors, nurses and other health care professionals ought to be aware that the use of low-carbohydrate and VLCKD diets in patients with obesity or type 2 diabetes is in fact supported by several sets of guidelines from international bodies and professional groups”

2) Early de-prescription of medication is important

“We have found that early and intensive de-prescribing is often required, particularly in patients with diabetes”

3) Calorie counting is not required

“Rather than emphasizing the need for patients to quantify their calorie intake, we ask them to focus on eating to comfortable satiation and then stopping”

4) Monitor cardiovascular risk factors

“We routinely measure blood pressure, lipid profile and HbA1c in patients adhering to a low-carbohydrate or VLCKD and treat abnormal findings as we would in routine clinical practice, where they have not improved over time”

5) Ensure adequate fibre intake

“We have found in practice that adopting a low-carbohydrate diet which limits ultra-processed foods and includes nuts, seeds, non-starchy vegetables and low-carbohydrate fruits tends to lead to a net gain rather than a reduction in patients’ dietary fiber intake compared to baseline.”

There is clearly much interest in the area, with the paper having over 27,000 views and 7,000 full text downloads since its publication in April. You can read the full paper here, which is available for free download.

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Type 2 diabetes and hypertension (high blood pressure) are the most common underlying health conditions in patients with SARS. [2] There is also evidence that people with type 2 diabetes and the metabolic syndrome (a combination of diabetes, high blood pressure (hypertension) and obesity) may have a higher risk of being seriously ill if they develop COVID-19. There are also specific features of coronavirus infections which could increase this risk.

One type of coronavirus infection, Severe Acute Respiratory Syndrome (SARS) was found to cause more serious disease in those patients who had hyperglycaemia (increased blood glucose levels) and type 2 diabetes. This could be because these patients tend to have metabolic inflammation, which is inflammation that affects the metabolic tissues, such as the liver and the pancreas. This makes these patients more susceptible to enhanced release of cytokines (molecules that circulate in the blood and signal for the body’s immune cells to fight the infection). During an infection the immune system increases the release of cytokines. A cytokine storm (an excessive release of cytokines) occurring in COVID-19 patients can damage tissues and organs and can even cause multi organ failure [3].

Inflammation of the metabolic tissues also affects the immune system, which means it finds it harder to fight infection and slows recovery. A study in animals has shown that type 2 diabetes results in breakdown of control of the immune system and enhances disease severity following infection with a type of coronavirus called Middle East Respiratory Syndrome (MERS) [4]. Although these findings have not been replicated in humans  this data  may support the theory that developing a coronavirus infection with type 2 diabetes causes more serious symptoms.

What are the specific mechanisms in the endocrine system linked to coronavirus infection?

The endocrine system refers to a number of different glands which secrete hormones into the blood and around the body. The Covid-19 virus uses a protein on its surface, which binds to a type of receptor called angiotensin-converting enzyme 2 (ACE2) to enter cells in the body of the infected person. [5] ACE2s purpose in the lungs is to break down a hormone called angiotensin II into another hormone angiotensin 1-7. When ACE2 is blocked and angiotensin II builds up this can cause problems such as an increase in blood pressure and hypoakalemia (low potassium levels in the blood) and increases risk of respiratory distress syndrome (the lungs not being able to provide the body with enough oxygen).

Angiotensin 1-7 leads to anti-inflammatory and anti-fibrotic (reduces scar tissue build up) responses, both of which are required for the recovery of COVID-19 [6].

What is the metabolic link to coronavirus infection?

There is an association between serious complications from the coronavirus and hypertension (high blood pressure), and also to type 2 diabetes. In the pancreas, evidence shows that the SARS coronavirus binds to the ACE2 receptor, which reduces insulin release (7). One study found that patients with the SARS infection with no history of type 2 diabetes became temporarily hyperglycaemic during hospitalisation for the infection. As the human endocrine pancreas expresses ACE2 the coronavirus could enter the cells, leading to acute hyperglycaemia (high blood sugar levels) and temporary type 2 diabetes.

Type 2 diabetes also induces expression of the angiotensin hormone converting molecules (such as ACE2) in other tissues such as the lung, liver and heart, this may help explain why type 2 diabetes could cause higher risk of developing multi-organ failure in coronavirus infections such as SARS [8].

How could this effect treatment for patients with COVID-19?

The data suggests that metabolic control of type 2 diabetes and associated metabolic parameters in patients with COVID-19 may be important. This could help reduce the risk of complications in patients with type 2 diabetes and a severe infectious disease [1].

The article concludes that good metabolic health is more important than ever for us living through the COVID-19 pandemic

References

1. Bornstein,S.R., Dalan, R., Hopkins,D., Mingrone, G. & Boehm,B.O.(2020) Endocrine and metabolic link to coronavirus infection. Nature Reviews Endocrinology. [Online] Available at: https://doi.org/10.1038/s41574-020-0353-9 [Accessed 07 May,2020]
2. Yang, J. K. et al.(2006) Plasma glucose levels and diabetes are independent predictors for mortality and morbidity in patients with SARS. Diabet. Med. 23, 623–628 [Online] Available at: https://doi.org/10.1111/j.1464-5491.2006.01861.x Accessed 07 May,2020]
3. Mehta, D. et al. (2020). Across Speciality Collaboration, UK. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. [Online] Available at: https://doi.org/10.1016/S0140-6736(20)30628-0 [Accessed 07 May,2020]
4. Kulcsar, K. A., Coleman, C. M., Beck, S. E. & Frieman, M. B. (2019). Comorbid diabetes results in immune dysregulation and enhanced disease severity following MERS-CoV infection. JCI Insight. 4, 131774. [Online] Available at: 10.1172/jci.insight.131774 [Accessed 07 May,2020]
5. Hoffmann, M. et al. (2020). SARS-CoV-2 Cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell. [Online] Available at: https://doi.org/10.1016/j.cell.2020.02.052 [Accessed 07 May,2020]
6. Simões e Silva, A. C., Silveira, K. D., Ferreira, A. J. & Teixeira, M. M. (2013). ACE2, angiotensin-(1–7) and Mas receptor axis in inflammation and fibrosis. Br. J. Pharmacol. 169, 477–492 [Online] Available at: https://doi.org/10.1111/bph.12159 [Accessed 07 May,2020]
7. Roca-Ho, H., Riera, M., Palau, V., Pascual, J. & Soler, M. J. (2017). Characterization of ACE and ACE2 expression within different organs of the NOD mouse. Int. J. Mol. Sci. 18, E563 [Online] Available at: https://doi.org/10.3390/ijms18030563 [Accessed 07 May,2020]

A review and summary of the findings of this report, titled Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China, was published on 24 February 2020 by the Journal of the American Medical Association (JAMA). [2]

This review summarises and emphasises the key findings and lessons from the cases from China. The key findings are broken down to:

• Patterns and outcomes of the COVID-19 cases (epidemiologic characteristics)
• Comparisons with previous viral outbreaks
• The response and learnings

Patterns and outcomes of the COVID-19 cases

Table 1 shows the breakdown and outcomes of the cases recorded. Out of the 72,314 cases, 62% of these were confirmed cases, where the patient tested positive from throat swab samples. 22% were suspected cases, where the diagnosis was based on the patient’s symptoms, 15% were diagnosed cases, where the diagnosis was based on the patient’s symptoms – this was used for the Hubei province only, and 1% of these were asymptomatic cases, where the patient tested positive but lacked the typical symptoms.

The age breakdown of the cases can be seen in Table 1, mostly grouped in the 30-79 age range.

Most of the cases recorded were mild cases (81%) where the patients developed mild symptoms such as a cough or sore throat or only mild pneumonia, a lung infection where the alveoli (air sacs in the lungs) are inflamed.

14% of the cases were severe which meant the patients developed more serious pneumonia or lung infection. This could mean the alveoli in the lungs filling with mucus or fluid making it harder for the body to take in oxygen causing dyspnoea (shortness of breath) or difficulty breathing.

5% of the cases recorded were critical, which meant that the patients developed respiratory failure (when the lungs can’t get enough oxygen), septic shock (where the infection spreads throughout the body), and/or organ failure.

The overall death rate from the cases recorded was 2.3%. Elderly patients and those with underlying health conditions were more likely to be more seriously affected. The death rate changed depending on the age group, which ranged from 0 deaths in the under 9-year olds, to a 14% death rate in those aged over 80 years. Those with underlying health conditions such as heart disease, diabetes, cancer and lung disease had higher death rates reported. [2]

The virus also rapidly spread from a single city of Wuhan to the entire country in 30 days overwhelming the healthcare system. [1,2]

COMPARISONS WITH PREVIOUS VIRAL OUTBREAKS

The JAMA review looks at the comparisons between the COVID-19 outbreak in China and 2 previous viral outbreaks. These are the Severe Acute Respiratory Syndrome (SARS) from 2002 to 2003 and Middle East Respiratory Syndrome (MERS) from 2012 which is ongoing [2].

Similarities:

• Both SARS and MERS can be traced to zoonotic transmission (when a pathogen such as a virus is passed from an animal to human). These were both novel coronaviruses, the same as COVID-19.
• All 3 of these viruses cause similar symptoms such as a cough and lung infections and affected the elderly and those with underlying health conditions more seriously
• Testing involved throat swabs to extract nucleic acid, which holds the virus’ genome (genetic material)

The main differences observed so far are the death rates appear higher for both SARS (9.6%) and MERS (34.4%), according to the World Health Organisation (WHO), than the current data suggests for COVID-19 (at 2.3%). However, COVID-19 has caused many more deaths due to the larger number of cases. The JAMA review suggests that the case number may even be higher than recorded due to the difficulty in testing the population and also identifying and counting those cases which may not develop any symptoms [2,3]. Further research and data collection is required to fully understand the death rate for COVID-19.

The current data from the report from China CDC suggests that COVID-19 is more transmissible or easily spread than SARS or MERS, where transmission often occurred in hospital when the patients were being treated [1]. The data for COVID-19 suggests virus transmission is occurring in hospitals, as cases are being seen in health workers, however more cases are spreading in the community and in households. 64% of clusters (cases closely grouped in time and place) documented have been in family households (data from the Chinese Center for Disease Control and Prevention presentation made to the WHO Assessment Team on 16 February 2020).  However, the JAMA review concludes that more research is still needed to determine exactly at what rate COVID-19 is spreading. [2]

Response and learnings

The JAMA review also looks at how the Chinese government responded to COVID-19. In comparison to the SARS outbreak in 2002, the WHO was notified of the outbreak much earlier for COVID-19. [2]

The initial Chinese government response was focused on isolating and quarantining the cases, social distancing and community containment (lockdown measures). Large gatherings were cancelled, and travel restricted around the country. [1]

These approaches aimed at reducing infections and deaths have also caused economic damage to the country. There have been questions if these potential benefits outweighed the costs, however more and more countries around the world have had outbreaks since and enforced similar measures to China. [4,5]

A goal of the responses enforced by the Chinese government was to buy more time for more research and data to be collected on this new disease. The report of the cases published by the Chinese CDC was to help inform health workers in other countries dealing with COVID-19 of the characteristics and patterns [1]. As the rest of the world deals with the spread of COVID-19, more evidence is emerging every day which can help to inform the tactics governments and health workers need to follow in responding to this pandemic.

Read more:

• A general guide to diabetes and coronavirus
• Coronavirus: should I be worried
• Update for those vulnerable to Coronavirus
• Dr Dipesh Patel on diabetes and vulnerability to COVID-19
• Rhonda Green: Working on the frontline with type 1 diabetes
• Laura Thornton: a diabetes hero on the Coronavirus frontline
• Grandad with diabetes recovers from COVID-19

References:

[1] Novel Coronavirus Pneumonia Emergency Response Epidemiology Team.  Vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020. China CDC Weekly. [Online] Available at: http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51 [Accessed 24 April, 2020]

[2] Wu Z , McGoogan J M (2020). Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China. JAMA. [Online] 2020;323(13):1239-1242. Available at: https://jamanetwork.com/journals/jama/article-abstract/2762130 [Accessed 24 April, 2020]

[3] Battegay  M , Kuehl  R , Tschudin-Sutter  S , Hirsch  HH , Widmer  AF , Neher  RA (2020) .  2019-Novel coronavirus (2019-nCoV): estimating the case fatality rate: a word of caution.  Swiss Med Wkly.[online] 2020;150:w20203. Available at: 4414/smw.2020.20203 [Accessed 24 April, 2020]

[4] Lacobucci, G (2020). Covid-19: UK lockdown is “crucial” to saving lives, say doctors and scientists. BMJ. [online] 2020; 368. Available at: https://doi.org/10.1136/bmj.m1204 [Accessed 24 April, 2020]

[5] Lazzerini M, Putoto G (2020). COVID-19 in Italy: momentous decisions and many uncertainties. The Lancet. [online] Available at: https://doi.org/10.1016/S2214-109X(20)30110-8 [Accessed 24 April, 2020]

He takes a look where the world is in terms of improving metabolic health and injects a strong dose of humour into his presentation.

Peter is a medical doctor and sports and exercise medicine physician with a key interest in nutrition. Peter has been team doctor for a number of teams including Liverpool Football Club.

Statistics, research and conferences

Peter opens his talk by sharing a number of stats, from the proportion of people that are overweight to headlines and statistics relating to difficulties in affording healthy food.

One striking statistic is that, in the US, just 12% of adults are regarded to be metabolically healthy.

The statistics show the world to be struggling with health, but Peter is keen to point out the positive changes in direction.

He draws attention to research that has showed a dramatic improvement in depression and anxiety with a low carb, ketogenic diet.

Peter touches that the majority of disease now is due to chronic low-grade inflammation and that dietary change is one of the main ways to combat low-grade inflammation.

He provides a review of a range of conferences that are recognising the benefits of a low carbohydrate approach.

One of these was a conference in conjunction with the British Medical Journal that paired different groups of researchers together. This meant that researchers with different approaches to lifestyle were brought together and it presented a great way for the researchers to see how much the different approaches they had agreed with one another.

Veganism and the EAT Lancet diet

Peter next takes a look at the EAT Lancet diet which was a big talking point in nutrition research within the last year. The EAT Lancet was designed to be a diet that would be more sustainable for the planet. However, there is significant debate as to whether the diet achieves this aim and moreover, whether it would promote long-term health.

The EAT Lancet diet recommends a switch away from fish and animal-based foods towards greater intake of plant-based foods.

Peter raises an issue regarding conflicts of interest among authors of the EAT Lancet diet and shares a review by Zoe Harcombe that showed the diet to be deficient in a number of key vitamins and minerals.

The next report Peter turn to is about the World Health Organisation withdrawing their sponsorship of the diet initiative after an Italian official raised a number of key concerns about the diet.

Peter states he personally has no issue with the ethical considerations people have. He questions the environmental benefits of veganism and states that there are two sides to the story.

In terms of whether there are health benefits, Peter is fairly convinced that a vegan diet is not a healthier approach for people.

Diabetes

Next, Peter turns his focus towards diabetes. “Diabetes is a great battleground for us and we’re winning,” he states.

Peter sees it as important that the American Diabetes Association (ADA) is recognising low carb as being ok for people with diabetes.

He shows consensus recommendations published by the ADA which emphasise eating non-starchy vegetables, minimises added sugar and refined grains, and recommend to choose whole foods over highly processed foods.

The recommendations also recognise that reducing carbohydrate intake for people with diabetes has shown the most evidence for improving blood glucose levels.

Peter states that some of the changes being made is “massive progress”. He also mentions though that the ADA is still struggling to accept the notion that fat (or as Peter puts it – the f-word) can be perfectly healthy.

In Australia, the Dietitians Association of Australia (DAA) has stopped taking sponsorship from the processed food industry. Furthermore, the state of Western Australia has recognised the benefits of both low calorie and low carbohydrate approaches in the management of type 2 diabetes.

Difficulties faced

In his next part of the review of the year, Peter turns his attention to some of the major difficulties in helping the world choose healthier nutrition.

Large, multi-national food corporations are funding health and nutrition research and they are allowed to play a leading role in developing dietary guidelines.

Peter shares the news that one US state has even passed a law preventing cauliflower rice from being sold.

Lifestyle change taking place

Peter next takes a look at survey findings that show that 58% of Americans blame either sugars or carbohydrate chiefly for weight gain, while only 16% blame fat.

He also draws attention to that fact that 16% of Americans say they are following a carbohydrate-restricted diet.

Peter notes how continuous glucose monitoring is changing the way people are looking at what they eat, stating: “When you wear a continuous glucose monitor, you’ve got instant feedback on what is happening to your blood glucose”

Peter encourages the audience to give continuous glucose monitoring a try for two weeks so people can see what is happening to their glucose levels when they eat different types of foods.

Peter concludes his talk by looking at how well accepted the low carb approach is in society and he believes that the world has got to a point whereby the diet is starting to get recognised by an ‘early majority’ of the public that are now seeing the diet as pragmatic.

The Caldesi couple present their story, together with nutritionist, Jenny Phillips, at the Public Health Collaboration conference in May 2019.

Katie and Giancarlo Caldesi together run restaurants in Marylebone, London and Bray, Berkshire, and have authored a range of cookery books. Their latest book, The Diabetes Weight Loss Cookbook: A Life-changing Diet to Prevent and Reverse Type 2 Diabetes, was developed in collaboration with nutritionist Jenny Phillips, Dr Jen Unwin and Dr David Unwin.

Katie and Giancarlo met in 1997 and bonded over her love of his Italian cooking and his love of her painting.

Katie Caldesi

Katie opens the talk, telling us when she met Giancarlo, he had “mad energy” and was full of life. They were married in Tuscany, in 2005, under the lenses of TV cameras. The couple won awards for their books; however, Giancarlo’s health began to become an issue.

Katie tells a story of how her husband, who had been driving home, had called her, saying: “something really scary has happened, my vision has suddenly gone blurry.”

This was in 2011, and this resulted in Giancarlo being diagnosed with type 2 diabetes. It didn’t strike the couple as a big issue at first but Giancarlo’s health steadily worsened.

His dietitian had said to reduce pasta portions a bit and to cut back on sugar.

Giancarlo’s feet hurt, he had put on weight, he was hangry (hungry and angry), he would devour a fruit bowl, has always tired (and asleep if he wasn’t eating), he couldn’t play football, and he was always rushing off to the loo.

In 2014, Giancarlo had gained weight and was then weighing 108kg (17st). His HbA1c level had also climbed from 49 mmol/mol (6.6%) at diagnosis to 79 mmol/mol (9.4%).

Katie shares how he had IBS at the time and was also overweight from partying, eating and cooking. After reading the book ‘wheat belly’, they both decided to give up wheat. Katie experienced no significant change in her health, but Giancarlo felt ‘amazingly better’.

Giancarlo had struggled with arthritis and his knuckles were swollen. Since cutting down on wheat, his hands completely changed within three days.

At this point, Katie took up the recommendation of seeing the nutritionist, Jenny Phillips. Jenny ran blood tests and concluded that Giancarlo needed to stop eating wheat right away.

So, Italian chef Giancarlo could no longer have pizza, pasta, no more sugar in his cappuccino, and no more buns or bread. He tried gluten free pasta and bread but really didn’t take to it.

“Luckily I like a challenge,” Katie says, “so I started cooking all sorts of things he could have with his pasta sauce.”

They used almond flour to make bread and cakes and started eating lots more vegetables. Fortuitously, around the same time, they were commissioned to write a cookbook called ‘Around the World in Salads’, which was therefore very good timing.

Katie adds, “coincidentally, and we didn’t actually know it at the time, we were actually following a low carb diet.”

Giancarlo Caldesi

Giancarlo takes up the microphone next.

“I’m 67 years old and I can stand on one leg. You may wonder why I say this.”

Giancarlo then explains how the neuropathy he had meant he couldn’t feel his feet. He illustrates how he used to walk with difficulty without being able to feel his feet, he would need help getting up from seated and also needed to have his shoelaces tied for him.

He states how he sees the problem that people can have is that they accept what they can’t do and forget what they used to be able to do.

Giancarlo discusses how, with a performance car, you take care to put in the right fuel, so why do we not do that with our own selves, he asks.

While it took Giancarlo 16 months to lose 3 stones, he notes that it took him three years to adjust his mindset as to the way he wanted to live his life.

Giancarlo walks us through the struggle of trying to avoid the temptations of sweets and desserts when visiting shops.

He then shares the terrifying moment he had when driving. He’d stopped for petrol and bought a bar of chocolate, intending just to have a square, but ended up eating the 100g bar.

Feeling satisfied he continued his journey, and on the motorway his vision only showed the lights he could see. So, he eased off the accelerator, tried to keep cool, guided the car left and managed to stop safely.

Giancarlo uses the story to illustrate how we need the right knowledge to choose the right path to health.

It’s food that got him into trouble, he says, and it is food that has got him back out of trouble.

Giancarlo says his own strategy is based on:

• Getting the right quality of food
• Having the right quantity of food
• And incorporating the right amount of physical movement

He shares that his biggest regret was not knowing that certain foods were damaging for him in the first place.

Jenny Phillips

Next to the microphone stand is nutritionist, Jenny Phillips.

Jenny starts by talking about Giancarlo’s health and that the tests he had indicated problems with the wheat he was eating.

Jenny tells us how Katie was able to transition typical Italian, carbohydrate-based foods into low carb versions, and they then developed the idea of writing a book together.

Helping to take things a step further, they also met Jen and David Unwin. From this point, they brainstormed the messages for the book and how to incorporate the delicious recipes.

Jenny shares how useful it was to have the science aspect in the book and how readers have praised this aspect.

The human body has two types of fuel, Jenny says. You can run on glucose and you can also run on fat. You can eat well, but eat less often.

Jenny mentions how Giancarlo did not like having breakfast, and now he doesn’t feel like he has to. He knows now that by eating the right food, he can go longer without eating and can burn body fat for energy.

“Some people think that if you don’t have carbs you’re going to keel over, and it’s just not true,” she adds.

Jenny shares a page from the book that helps people to evaluate how well they feel on carbs. She explains: “It’s not just about low carb and no other way, it’s about the quality of food and eating right for your type.”

Jenny shares a visual of how high carb foods can be replaced with lower carb alternatives.

“Think like an italian”, she says. It will involve more time in the kitchen but rather than seeing cooking as a chore, if you can embrace it as a hobby, it is less tiresome.

Katie then presents the book they have all three done together with the help of Jen and David Unwin too.

She shows a selection of the dishes from the cookbook and shares how they now offer low carb options in their restaurant.

Giancarlo then closes the talk sharing how he no longer feels the need to graze and how a quality treat in small portions can be a saving grace.

Medical doctor and nutritionist, Prof Ray, presented his talk at the annual Public Health Collaboration in May 2019.

He is the Founding Chair and Executive Director of the NNEdPro Global Centre for Nutrition and Health based in Cambridge, as well as the Co-Founder and Chair of British Medical Journal of Nutrition, Prevention and Health.

Knowledge-to-action cycle

Prof Ray starts the talk by outlining the knowledge-to-action cycle which includes:

• The quality gaps to address.
• The evidence-based interventions that are available.
• How strategies are implemented.
• Where, or in what context, they are implemented.
• The partnerships needed to make them happen.

Sumantra guides us through the importance of training and how education differs to training. He tells us how training is a strategy that can change knowledge, attitude and practices providing it is delivered effectively.

Whereas training provides tools and skills, education has a greater focus on the ‘why’, such as why those skills are needed and why the tools are useful.

James is a practising dentist and clinical director of the Bow Lane Dental Group in London. He has twice been voted the UK’s most influential dentist by the dental community.

As a dentist of 27 years, James is well aware of the problems that sugar can present. In this talk at the Public Health Collaboration conference of 2019, he guides us through the problem of bad rewards and his work to improve this.

“We can’t keep carrying on what we’re doing”

James starts his talk with a question: What is the number 1 reason for children aged 5-9 to be admitted to hospital in the UK?

The answer may be on the tip of your tongue because the reason is to do with teeth.

James explains why sugar lies at the root of the problem. He tells us that bacteria eat sugar and then produce acids which rot teeth and gums. The result is tooth decay, he tells us, and that it’s one hundred per cent preventable.

“As a parent of two children, I’m constantly trying to fend off the sugar that is pushed onto children,” he states, adding, “We can’t keep carrying on what we’re doing.”

“Why is it always sugar as a reward?”

James recounts the story of the time his two-year-old daughter had her first haircut at a hairdresser’s. He describes how excited his daughter was and yet sat still the whole time.

When her haircut was all done, how did the hairdresser reward his daughter? With a giant lollipop which James says was bigger than his daughter.

Surely it would have been better, he opines, to give something like a certificate that could be better treasured and could also advertise the hairdresser’s for as long as the certificate is kept.

He shares this personal story to illustrate how sugar is so ubiquitous when it comes to rewards for children. In addition to sweets for good behaviour, children are given cakes each time a child in a class has a birthday at school, sugar cubes are given following receiving a jab, and grandparents typically hand around sweets each time a child comes over.

“Why is it always sugar as a reward? There must be a better way,” he proposes.

A better way

James has been tackling the problem in a number of ways. He has set up Rewards Project, a registered charity, dedicated to replacing sugary rewards with meaningful substitutes.

He has compiled a team for his charity which includes Dr Joanna McCormack who has given a number of talks at the PHC conference herself.

The Rewards Project has worked with over 550 schools to discover best practice for rewarding children for behaviour and performance.

“Some schools are doing amazing things out there”, he shares adding that his project is all about sharing good practice.

His next area of focus has been to set up Sugar Quiz. The online quiz can be taken by children and adults and encourages you to think about where hidden sugar is in your daily lives.

A third method has been to encourage people to clear the sugar out of their homes. The #sweetsweeper campaign encouraged people to share, via social media, their commitment to trashing foods with hidden sugars.

James rounds up his talk by inviting viewers to check out the Rewards Project and join the conversation in how we can make a difference as to how we reward our children.

Dr Powell is the medical director of Willowbrook Hospice in Merseyside. The hospice is a 12-bed in-patient unit for people with life-limiting conditions of all causes. She has been a clinician for 30 years, starting as a GP before finding her very rewarding role in palliative care.

The wellness approach at Willowbrook Hospice has been holistic and has included a focus on eating real food (minimally-processed food and drink) and a lower carbohydrate intake.

“You will eat the biscuits”

Dr Powell starts her talk with a scene familiar to many people who work in the highly emotional world of palliative care. When someone being looked after gets to an end of life moment, bonding around biscuits and chocolate given by the family is a common experience in palliative care.

Paula shares some of those moments with us and concludes that when these moments happen, “you will eat the biscuits.”

Holistic approach

The hospice has introduced a holistic approach to wellbeing. The strategies helped staff to adopt a lower carbohydrate, real food way of eating, along with other wellbeing strategies.

Behaviour change methods employed by Paula include use of Dr Jen Unwin’s GRIN model and Dr David Unwin’s teaspoons of sugar infographic.

The GRIN model is a template for conversations around lifestyle change with GRIN standing for goals, noticing, increments and noticing. Dr David Unwin’s teaspoons of sugar provides an, at-a-glance, way of helping people to see how much sugar is present within different food types. Note that complex carbohydrate is a string of glucose molecules bonded together which break down into glucose when digested.

Dr Powell tells us how doughnuts, sandwiches and a popular local pie presented challenges for healthy eating.

The strategies employed have helped educate staff on exactly what they are eating and to make informed choices.

To help with this, healthy, real food choices have been made more prominently available in the canteen and containers of water with fruit in have been put in place as a strong alternative to fizzy drinks from the vending machine.

The hospice has its own WhatsApp group to help keep staff motivated. Dr Powell tells us how some extra nudges helped with keeping staff focused on healthy living after the Christmas and Easter periods.

Very positive results

Dr Powell takes us through the results of the behaviour change, including a focus on two of her staff, Karen and Susie, who both experienced a terrific turnaround in health.

The improvements seen across staff included a total 20kg of weight loss, irritable bowel syndrome being vanquished, and lower levels of fatigue.

Dr Powell notes that around a third of staff made a very significant change to their lifestyle, another third of staff dipped in and out of the lifestyle changes and another third decided that the low carb lifestyle changes were not for them.

The lifestyle changes helped with achieving significant weight loss, sharing moral support, sharing of resources including books on lifestyle and helping staff be mindful of how much better they feel when choosing healthier options in place of sweeter foods.

Paula also outlined how the simple changes made by individuals created a ripple effect in benefitting others such as partners, children and the parents of staff members.

Dr Paula Powell presented her talk at the Public Health Collaboration conference in May 2019.

Yesterday, Tom Watson announced he was stepping down as deputy leader. His talk at the PHC foretells of his passion to focus his time towards battling the public health crisis.

In his talk with Dr Aseem Malhotra, Tom talks us through his commitment to understand the scale and influence of food lobbying and his bid to encourage independent research into nutrition.

In the candid interview, he even states how he intends to work for McDonalds as part of figuring out what is going on with the food industry.

A new mission in life: public health

The interview starts off as Dr Malhotra asks Tom about his personal health journey.

In answering the question, Tom reveals he has a “new mission in life”. He tells us how he was able to transform his life, through nutrition and health, at the age of 51.

He talks about how he had been living reactively to situations in his life and how he is now looking at his life ahead:

“I want to live another 51 years but a purposeful life, where the decisions I made would be positive decisions based on really deep values.”

He talks about his hopes for the NHS, that the organisation develops to include a greater emphasis on preventative measures.

Tom states, “The only reason I got well was when I defied the advice of my own government and my own NHS on nutrition. [The NHS] needs to put full and fulfilling lives at the centre of its purpose.”

“Utterly transformational”

Aseem asks Tom about his health journey, which involved following a much lower carbohydrate approach to his diet and Tom answers saying, “I feel emancipated, I feel free.”

He mentions about how many health books, research papers and podcasts he read and listened to, in order to give him the information he needed to choose and have certainty in his approach to lifestyle.

Tom tells us his own diet was to start on a ketogenic way of eating and that he “kicked type 2 diabetes in six weeks flat”. After achieving sufficient improvements for his health, Tom now alternates his diet between keto and Mediterranean/Pioppi diet approach.

“I’ve never felt more determined and strongly about anything”

He states that he waited a year before talking about his health achievements, and that a key guiding reason being that he wanted to be sure that his achievement was a lasting success and not a “weird temporary aberration”.

He mentions how, and feels many others must share this feeling, that when he’d achieved this, he became angry and annoyed that he could have pulled this off 20 years earlier.

“You just want other people to feel as good as you do,” he states.

He empathises with others who have type 2 diabetes and how millions of them could also enjoy the same success as him if they know how to.

He resolutely states: “I’ve never felt more determined and strongly about anything. Every time I have to go into a stupid meeting about Brexit, I feel like I’m missing an opportunity to return to what I think is the remaining big cause I have in politics.

“That’s why I’m going to do it”

Dr Malhotra next asks Tom about the extent of commercial influence on dietary guidelines and the conflicts of interest.

Tom talks about the difference in scale with these huge global companies and lobbies compared with the people who are working towards a balanced, independent review of the guidelines.

“It’s the people in this room versus Coca-Cola,” he states before adding, “The man from Coca-Cola only does it because he’s paid to do it. You do it because you believe in it. And that’s why I’m going to do it.”

Tom goes into the scale of the influence. He tells us how the most powerful lobbies try to influence at every point in the communications chain about diet and health. While Tom doesn’t detail these points, such points include influence of the people doing dietary research, how the media conveys research and how governments respond to it with food policy.

He talks about how busy Parliamentarians are and how it is very difficult for them to map out the communication chains of huge food lobbies

“MPs know there are problems in how much sugar there is in the diet, but they don’t know what the scale and what the game is,” he states.

There is policy work to be done to ensure there is independent work into nutrition.

Cross-party talks

Tom discusses how he would not like to have his involvement in the Labour party “over-politicising” his bid to tackle public health.

He states that he has raised a commission on halting the rise of type 2 diabetes and his future aims to convince Matt Hancock, current Secretary of State for Health, of the need for change to tackle the public health crisis that exists.

In light of the news this week, the interview Tom gives at the PHC conference gives an enlightening insight into where Tom’s future ambitions lie.

The enlightening talk covers many topics, all connected with farming but tied together with the health of humans and the environment.

He starts his talk with the question, “What should I eat that is healthy and sustainable from a farming perspective?”

Patrick Holden, founding director of the Sustainable Food Trust, approaches this question from the farming perspective. Patrick is founding director of the Sustainable Food Trust and has been running his own farm in Wales, as sustainably as he can, since 1973.

Sustainable farming

His farm is set up so that there is a natural cycle of regeneration. Cows graze and provide milk for cheese. The cows provide manure which is a natural and rich fertiliser. Crops and grass then grow on the fertilised soil that can feed the cows.

The right kind of crops, such as legumes, can provide nitrogen back to the soil. Natural gasses from the making of silage is collected and used as a source of energy for the farm.

Patrick Holden: “If the planet is an organism, it’s sick”

Patrick likens farms to “the metabolism of the planet”. His view is firmly based around the idea that if we wish to effectively address climate change, the way we farm and the way we eat needs to change.

In the previous few decades, farming has undergone a lot of changes. Chemicals and artificial fertilisers are being used as short cuts and the extensive use of endocrine-disrupting chemicals has harmed the biodiversity of farmland.

The message Patrick provides is that modern short cut methods of farming are harming the land, “if the planet is an organism, it’s sick”, he intones.

Patrick tells how for many years he grew carrots on his farm. However, streamlining of supermarket logistics has meant the nearest packing station for carrots is now too far away for Patrick’s farm to continue growing carrots.

Agriculture as the primary health service

Patrick talks passionately about the work Sir Albert Howard who studied farming in India and learnt how sustainable farming techniques prevented disease in the crops.

He impresses the importance of the interplay between the soil, plants, animals and people on health. If the soil, animals and plants in our environment are healthy, then we as humans will be healthy.

He notes that Lady Eve Balfour, co-founder of the Soil Association, stated: “we should regard agriculture as the primary health service.”

While the NHS has traditionally treated medical conditions once they have developed, the health of food and our environment represents a much earlier stage at which disease can be prevented.

At what cost?

The vast majority of modern farms are driven towards producing high yields of crops at low cost to the farm businesses. However, what is the true cost of this way of farming?

Patrick draws our attention to the ‘Hidden Cost of UK Food’ report. He states, “for every pound that we spend in the shops on food, there is another hidden pound, split 50/50, between damage to the environment and damage to public health.”

Farmers may save money by using cheap fertilising methods and pesticides, but the cost is borne out in other ways; on the environment and human health.

Patrick touches on the recent EAT Lancet report that puts across the case for plant-based diets. He states that, “the authors were well-meaning but none of them understood agriculture”.

Patrick believes that meat farming is very much sustainable, provides natural fertiliser and that the ‘methane cycle’ has been working perfectly well in the environment for millennia. The real danger for climate change, Patrick warns, is the continued widespread use of fossil fuels.

Harmony

Nature works in balance and Patrick illustrates this with a series of slides showing how patterns in nature are repeated in small creatures up to the structure of galaxies.

Patrick uses this to illustrate the importance of working in harmony with, rather than against nature.

He ends his talk saying, “We have plundered the resources of the planet in a couple of lifetimes, and now it’s time to do something about it.”

You probably know Beyoncé as the US pop singer, wife of Jay-Z and all-round feminist and musical icon. But in recent weeks her star has shone within the dietary community, and it’s been met with cloudy resistance by nutritionists, fans and journalists.

A backlash has met her launch of Beyoncé’s Kitche, the dietary plan she followed in preparation for a gig at the 2018 Coachella festival, her comeback appearance having had twins in 2017.

In a video posted to YouTube last month the singer revealed she embraced a plant-based diet comprising “no bread, no carbs, no sugar, no dairy, no meat, no fish, no alcohol”. Her plan, which she followed for 44 days (she completed a 22-day plan twice in a row), also involved many hours of physical training per day.

Beyoncé’s trainer Marco Borges, a New York bestselling author, is the founder of 22 Days Nutrition. Following criticism of the so-called ‘crash diet’, Borges spoke out and said Beyoncé was “mindful of the importance of proper nutrition and exercise”.

You don’t have to peruse the internet for long to uncover a number of dietitians who have spoken out against the diet, concerned about the low calorie intake and elimination of so many food groups.

On Thursday 8 August Daniel O’Shaughnessy, a nutritionist for Nutrition and Lifestyle Medicine told the BBC’s Victoria Derbyshire Programme that the diet is “dangerous” and could lead to “nutritional deficiencies”.

But is the furore over the diet justified? Is this actually just a typical vegan diet? There are lots of important questions that the majority of media publications haven’t explored, and while it’s easy to slam Beyoncé for embracing a perceived extreme diet, it’s far more significant to analyse the diet in greater detail.

Tara Kelly, a Specialist Dietitia, has sought to answer these questions and elucidate whether the diet is indeed something to be feared or whether there may actually be some benefit to it.

What can you eat?

One of the first questions about the diet worth exploring is: what exactly can you eat?

The 22 Days Nutrition diet is plant-based, which means focusing extensively on vegetables, grains and legumes – replacing meat or animal products as the core of your meals.

A cursory look through the meal plans reveals that – contrary to Beyoncé’s ‘no carbs claim’ – carbohydrates are permitted, including grains, beans and squash. This is one such meal plan:

• Breakfast: sunflower seed butter and strawberry toast, almond spiced pear crisp
• Lunch: jalapeno pumpkin soup, black bean and butternut squash millet bowl
• Dinner: red lentil dal with crispy toast, Indonesian tempeh with brown rice
• Snacks: cashews, unsalted pistachios.

Let’s focus firstly on the positives. There is a lot of plant-based fat and protein in this meal plan – which is ultimately comparable to a vegan diet – and the benefits of plant-based diets have been explored in a variety of studies.

In some studies, plant-based diets have been associated with a 23% reduced risk of type 2 diabetes; emphasised as a means of type 2 diabetes prevention; linked with improved insulin sensitivity in adults without diabetes; and could improve diabetes-related complications such as atherosclerosis.

However, there are standout negatives from this meal plan. Firstly, the high carbohydrate content from the bread and rice means that blood glucose levels will raise higher compared with eating more healthy fat or protein instead (this is because carbohydrate is digested faster in glucose in the body than fat or protein) and for this reason may not be a great option for people with type 2 diabetes. Secondly, the void of nutrients that derives from eschewing so many food groups. And thirdly, there is no guidance on servings or how many meals or snacks can or should be eaten during the day.

When you exclude all animal products – as the 22-day diet does – this means that vital nutrients derived from foods such as vitamin B12, iron or protein have to be replaced. While the 22-day diet offers a range of protein powders and energy bars to compensate for energy levels, no supplements are advocated on the 22 Days Nutrition website.

Tara says: “If people wish to follow a plant-based or vegan diet they would need to ensure they are getting a variety of plant-based foods in the diet – which is certainly achievable.  Some supplements such as B12 are recommended as this is not found in a plant-based diet. A variety of plant-based protein sources such as tempeh, tofun, legumes, nuts and seeds would need to be included to ensure complete amino acid profiles are being met.”

But Tara questions the point in adopting a diet that leaves you hungry. Instead, she says, it makes more sense to follow a diet which satiates you and keeps you full. “Aiming for a certain weight via a semi-starvation diet which leaves you hungry is unlikely to be sustainable and likely to result in weight regain in the long term.”

Essentially, the food content of the 22-day diet is similar to what vegans eat. And while vega, plant-based diet can lead to health improvements, ensuring vitamin supplementation is important.

Significantly, for people with diabetes, eating higher-carb foods within the construct of a plant-based diet can lead to blood glucose swings. Given the lack of portion sizes and lack of supplementation recommended within the 22-day diet meal plans, there is a lack of balance that makes this incompatible as a diet for people with diabetes.

Why follow a diet that leaves you hungry?

One of the criticisms aimed towards Beyoncé was her admission in the YouTube video that she was “hungry” on the diet.

This criticism can be analysed two-fold: firstly, the debate over whether it’s suitable to follow a diet that leaves you hungry. And secondly, for Beyoncé advocating going hungry in order to achieve weight loss goals. She says in the video that weight is “every woman’s worst nightmare”, promoting a negative relationship with food and essentially recommending starving yourself to look good.

It should be stressed that the diet is intended for 22 days only. Yes, Beyoncé did it 44 days, but this is not a diet that is sustainable in the long-term. It may serve as a placeholder diet before transitioning onto another diet or lifestyle.

But Tara questions the point in adopting a diet that leaves you hungry. Instead, she says, it makes more sense to follow a diet which satiates you and keeps you full. “Aiming for a certain weight via a semi-starvation diet which leaves you hungry is unlikely to be sustainable and likely to result in weight regain in the long term.”

The 22-day diet bares resemblance to intermittent fasting (IF), in some ways. Also known as time-restricted eating (TRE), IF typically involves eating little to no calories over a specific time period, ranging from nine hours to seven days. Fasting has been reported to help men at risk of type 2 diabetes improve their blood glucose control and reduce the risk of type 2 diabetes by preventing pancreatic fat build-up.

A 22-day fast is not sustainable, but this very low-calorie plant-based strategy could be used for fasting days if you practice IF or TRE. For example, if you’re trying to eat less than 500 calories one or two days per week, then eating lots of low calorie vegetables might be helpful, Tara says.

With regards to the criticism of Beyoncé for her comment on weight, Tara notes that not only does this project a negative image, but it also simplifies the drive for weight loss as being more important than holistic health improvements.

Tara says: “For a prominent female role model to say a certain weight is every woman’s nightmare is very unhelpful. I would urge women, and men for that matter, not to focus only on weight but to focus on overall health, energy levels, how they feel.”

Is the criticism of the diet justified?

“I think there are some points which can be taken – i.e. focusing on real foods, plant-based diet – as long as there is a variety of protein foods and healthy plant-based fats such as avocado, nuts and seeds,” Tara adds.

“Cutting out processed foods and alcohol will more than likely have positive health benefits – however, a diet which leaves you hungry is a diet which should be avoided.”

What’s the take-home message?

There are plenty of diets out there and people should find a diet which works for them in the long term. Many diets such as low carb, ketogenic, plant-based diets have one thing in common – they generally promote real food and a reduction in ultra-processed foods.

Diabetes Digital Media’s Low Carb Program has shown that through eating a real-food diet containing healthy fats leads to one in four people putting type 2 diabetes into remissio, with many more reducing their medication dependency [1].

It is possible to eat a healthy diet, plant-based or not, and achieve health benefits. But maintaining muscle mass and not feeling consistently hungry is important. The 22-day diet may have worked for Beyoncé, but she is an international star with swarms of nutritionists, physical trainers and health experts at her beckoned call to provide her with advice.

If you don’t have a health entourage, staying away from hard-to-follow diets that don’t offer portion sizes, advice on nutrient supplementation is probably the safest call.

References:

[1] JMIR Diabetes. 2018. JD – Outcomes of a Digitally Delivered Low-Carbohydrate Type 2 Diabetes Self-Management Program: 1-Year Results of a Single-Arm Longitudinal Study | Saslow | JMIR Diabetes. [ONLINE] Available at: https://diabetes.jmir.org/2018/3/e12/. [Accessed 12 August 2019].

For everyone, pregnancy and child birth bring with them the opportunity for joy and, of course, many challenges. For mothers-to-be with type 1 diabetes there are additional demands including blood glucose testing and insulin dosing to think about.

However, with preparation and management, people with type 1 diabetes – both mothers and fathers – can  help to make a healthier pregnancy more likely.

Planning ahead

A healthy pregnancy starts before you actually become pregnant. If you can prepare yourself, and optimise your blood glucose control and health before you become pregnant, it could lower the risk of complications. Eating a healthy diet that is lower in sugar and ultraprocessed foods, and higher in ‘real’ unprocessed foods will typically help to maintain more stable blood glucose levels, and support a healthy body for mother and baby.

Additionally, being physically active, stopping smoking and excluding alcohol are recommended for everyone prior to and during pregnancy [1].  In addition, folic acid should be taken from before pregnancy and up until 12 weeks. For people with diabetes, a higher dose of 5 mg a day is recommended to prevent neural tube defects such as spina bifida. This should be started at least 3 months before becoming pregnant [2].

Managing blood glucose levels

There are many factors that play into the path a pregnancy might take. For many of these factors we have no control, as the human body is often complex and unpredictable. Also, any form of diabetes can increase the risk of complications in pregnancy [3].

Giving birth to a large baby is a possibility for mothers with type 1 diabetes, and this is linked to increased HbA1c and excessive weight gain during pregnancy [4] [5]. This may not sound like an obvious cause for concer, however, larger babies can complicate birth, often requiring a Cesarean or ‘C-section’. Large babies are also at an increased risk of metabolic issues in later life [5].

Aiming for good health and blood glucose control prior to and during pregnancy is something that we can have a degree of control over. Optimal management of type 1 diabetes can help to support a healthier pregnancy and baby [6].

Testing blood glucose regularly is fundamentally important in helping to manage type 1 diabetes for anyone. During pregnancy, with all the changes that are happening to the body, regular testing may need even more attention. Some people find a continuous glucose monitor (CGM) a useful addition. People may find keeping track of how blood glucose levels change throughout the day, and how various foods affect the blood glucose levels, can help inform dietary and lifestyle choices [7].

During your pregnancy, you will be in close contact with your healthcare team. If you are unsure about what your blood glucose targets are, or are struggling to meet them, exploring this with your healthcare team is very important.

What’s the take-home message?

Having type 1 diabetes brings with it some important additional considerations for pregnant women. As with many things in life, planning and preparation is important. Where possible, speak to your healthcare team if you are planning to become pregnant. Taking steps prior to becoming pregnant in order to optimise the management of your type 1 diabetes and health is important. Staying in touch with your healthcare team throughout your pregnancy will help you to ride the highs and lows of pregnancy, maintain optimal diabetes control, monitor your growing baby and prepare for birth… and beyond.

https://www.facebook.com/Diabetes.co.uk/photos/a.327303571995/10156894785636996/

References

[1] NICE. (2010). Public health guideline [PH26]: Smoking: stopping in pregnancy and after childbirth. Available: https://www.nice.org.uk/guidance/ph26. Last accessed 12/06//2019.

[2] NICE. (2016). Quality standard [QS109]: Diabetes in pregnancy: Quality statement 1: High‑dose folic acid. Available: https://www.nice.org.uk/guidance/qs109/chapter/Quality-statement-1-Highdose-folic-acid. Last accessed 12/06/2019.

[3] NICE. (2015). NICE guideline [NG3]: Diabetes in pregnancy: management from preconception to the postnatal period. Available: https://www.nice.org.uk/guidance/ng3. Last accessed 12/06/2019.

[4] Ladfors, L., Shaat, N., Wiberg, N., Katasarou, A., Berntorp, K. and Kristense, K., 2017. Fetal overgrowth in women with type 1 and type 2 diabetes mellitus. PloS one, 12(11), p.e0187917.

[5] Cyganek, K., Skupie, J., Katra, B., Hebda-Szydlo, A., Janas, I., Trznadel-Morawska, I., Witek, P., Kozek, E. and Malecki, M.T., 2017. Risk of macrosomia remains glucose-dependent in a cohort of women with pregestational type 1 diabetes and good glycemic control. Endocrine, 55(2), pp.447-455.

[6] Mago, N. and Chauha, M., 2012. Pregnancy in type 1 diabetes mellitus: how special are special issues?. North American journal of medical sciences, 4(6), p.250.

[7] Feig, D.S., Donova, L.E., Corcoy, R., Murphy, K.E., Amiel, S.A., Hunt, K.F., Asztalos, E., Barrett, J.F., Sanchez, J.J., de Leiva, A., Hod, M., Jovanovic L., Keely E., McManus R., Hutton E.K., Meek C.L., Stewart Z.A., Wysocki T., O’Brien R., Ruedy K., Kollman C., Tomlinson G. and Murphy H.R. on behalf of the CONCEPTT Collaborative Group., 2017. Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. The Lancet, 390(10110), pp.2347-2359.

This Diabetes Week (10-16 June), of which the theme is redefining diabetes, Diabetes Digital Media’s Low Carb Program spoke to Mr Watson about his diagnosis, motivation, advice for others with the condition and what changes are required to reshape the way type 2 diabetes is viewed.

Mr Watso, 52, was diagnosed with type 2 diabetes in 2017. “When I was first diagnosed I was utterly crestfalle,” he said. “I felt like something inside me had broken. At the point where I was diagnosed, I’d probably had type 2 diabetes a while. My blood glucose had probably been high for months, if not years.”

He was prescribed medication and feared that due to his past disappointing experiences with dieting he was stuck with this condition. “Before I changed my nutrition – after 30 years of putting on weight and doing yo-yo dieting – I just got to the point of thinking I was a lazy, greedy person. I’d embedded that notion in myself because I just couldn’t lose weight.”

The diagnosis served as a wake-up call though, and Mr Watson learned more about the role of diet with regards to beating type 2 diabetes. He cut out sugar, processed foods in plastic trays and almost all starchy carbohydrates.

“What I now know is that for 30 years I was getting sugar cravings, every three hours, and as soon as I dealt with that I stopped being hungry. I used to wake up and think ‘which part of me aches the most?’ and then I’d probably think ‘is there any pizza left in the fridge? Let’s drink coke out of the bottle’. I never want to go back to that. As soon as I came off sugar, the weight started to come off and the brain fog lifted from my body, and I just started feeling better and better every day.”

It was a rapid turnaround. By June 2018, he had lost six stone, crediting ‘bulletproof coffee’ as being pivotal in his new diet, as well as swapping beer and curries for avocado salads. He also began walking 10,000 steps a day which contributed to the weight loss, eventually moving on to jogging and cycling.

In September 2018, Mr Watson announced that he had put his type 2 diabetes into remission. This meant that his blood glucose levels had stabilised and he no longer required medication. A significant step indeed, but far from the last, because Mr Watson’s work to spread the low sugar message is only just beginning.

Seeing diabetes differently

“A low carb diet changed my life,” said Mr Watso, who hopes his story will inspire others to embrace a low carb lifestyle and experience similarly transformative health benefits.

“The thing I feel so passionately about is that there are millions of people who could do what I’ve done. And I want them to feel as good as I feel. I know the UK guidelines say don’t do it, but talk to your GP and tell them you’re going to give it a go. It’s more likely than not that you’ll feel great at the end of it.”

Mr Watson has since campaigned for a number of health changes. Earlier this year he called for cartoon characters to be removed from all high-sugar foods to help drive down childhood obesity rates, and he is working with an independent group of experts looking into what measures could be introduced to combat the rise of new type 2 diagnoses within five years.

“The rise of childhood obesity should be a concern for all of us. Nearly a third of kids are leaving primary school either overweight or obese and that’s a serious health problem 10 years down the line, for all of us as a society. We have some schools giving kids breakfast now, which isn’t particularly regulated – a lot of it is charity donations, a lot of it is high, starchy carbohydrates.”

The rise in obesity and type 2 diabetes, particularly among children, can be traced back to the 1980s where guidelines based on dubious evidence were released in the UK claiming a high carb, low fat diet will ward off heart disease. This was then introduced as dietary policy for diabetes. But these guidelines have since been debunked, and low carb, low sugar eating is now becoming more accepted by prominent healthcare professionals as a means of not just improving blood glucose and losing weight, but also putting type 2 diabetes into remission.

Sign up to the Low Carb Program for much more on cutting carbs, including recipes, meal plans, and the full video interview with Tom Watson. Plus, annual members are currently receiving a beautifully designed 7-day Kickstarter guide in the post for Free! Get your subscription »

Still though, doctors and pharmaceutical companies remain keen to ensure people with type 2 diabetes don’t fear medication, and this is something Mr Watson believes should be challenged. Rather than making prescription drugs the first-line treatment, he says social prescribing (referral to services designed to holistically improve health) should be prioritised by government and the NHS.

“Now, social prescribing is the thing we need to look at, and how we deepen and broaden the reach of social prescribing. It requires good partnerships [between surgeries and the NHS] and best practice to be scaled, but this could be a really important way forward.”

Diabetes Digital Media’s award-winning Low Carb Program is among the services that has demonstrated outstanding benefits, namely one in four people with type 2 diabetes putting the condition into remission at the one-year mark; the Low Carb Program app received NHS Digital approval earlier this year. Elsewhere, more than 200,000 people have been referred onto the NHS Diabetes Prevention Programme since its launch in 2016.

When Mr Watson reflects on his diagnosis and the changes he made to reform his health, he acknowledges that he required urgent medical treatment – his health had deteriorated. But moving forward, he hopes that nutritional advances and a growing evidence base will lead to less people automatically being shifted onto medication.

“Do not panic”

“The first message we should give people when they’re diagnosed is ‘do not panic, you can sort this out.’ There are things you can do to get your life back.”

Mr Watson was in the midst of changing GPs during his diagnosis, and believes prior consultations could have led him on a different path far earlier. “In hindsight, I can recognise intervention points where if there had been a conversation about the suite of sugar-related illnesses, I could have avoided medication.”

The benefits of coming off medication and going low carb became immediately clear. “I now realise I’ve expended so much mental energy thinking about where the next sugar rush would come from. What [coming off sugar] gave me was more energy and more mental clarity to spend on doing more positive things rather than thinking about eating and drinking all the time. That then frees you to embed other habits which make life more meaningful and fun.”

If you’ve been recently diagnosed with type 2 diabetes then visit our Diabetes Forum for support and experiences from over 300,000 members. The Forum also has success stories from people who’ve achieved significant health improvements, recipes, meal plans and provides an open platform for those looking to share their stories.

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The question is: “Is there any research on whether even with good control, glucose tolerance will still worsen?”

To answer this questio, it’s worth looking back at how type 2 diabetes has been previously viewed, then comparing this with the significant health changes it’s now known that people with type 2 diabetes can achieve.

How was type 2 diabetes viewed in the past?

It is often said that prevention is better than cure, and so much effort is put into preventing prediabetes and type 2 diabetes from developing in the first place. Despite a long-running trend of increasing diabetes rates, there has recently been a drop in new type 2 diabetes diagnoses, which is very positive news. But, what about those who have already been diagnosed with type 2 diabetes?

Historically, type 2 diabetes was thought to be a one-way street: a chronic, progressive and irreversible disease that required increasing amounts of medication to control, as the years went by. In a typical case, someone might have failed to control their blood glucose levels with diet and lifestyle alone and been started on metformin. As the years went by, the person may have seen a progression of their diabetes and been placed on additional anti-diabetic medications, such as gliclazide, as the diabetes worsened. If good control was still not achieved, then the person may have then been placed on insulin therapy. In essence, after diagnosis, a slowing of the disease progression was usually the best that was hoped for.

Type 2 diabetes brings with it a range of complications including retinopathy (damaged eyesight), neuropathy (damaged nerves) and nephropathy (damaged kidneys). It also increases the risk of heart disease. The notion that there is not much one can do about these issues is not one that offers much hope. Fortunately, thinking around the ‘progressive’ nature of type 2 diabetes is changing rapidly.

Hope offered by type 2 diabetes remission

The idea of type 2 diabetes remission has recently gained much traction, as many people diagnosed with type 2 diabetes have been able to achieve and maintain normal blood sugar levels, without use of medication. Research has shown that remission is achievable through at least three different methods: Bariatric surgery, a very low calorie diet or a low carb lifestyle [1] [2] [3]. In addition, the practice of intermittent fasting, as part of a healthy lifestyle, shows similar promise [4].

While a healthy diet and lifestyle has always been recommended as part of standard care for type 2 diabetes, complete remission was very rarely achieved and not considered an attainable goal. In fact, one study suggested that complete remission was achieved in just 0.14% of people on standard care [5]. In contrast, remission rates at one year are many times higher, at over 25% each, for bariatric surgery, very low calorie diets and low carb and ketogenic diets [1] [2] [3] [6]. These methods could therefore make remission a realistic goal for many people.

These strategies can bring about remission and weight loss in similar ways; they all essentially allow a reduction in calorie intake. However, importantly, these strategies may allow us to avoid overeating by changing how our bodies work, perhaps making things easier than they might be if we were simply trying to cut down on calories through sheer will. For example, carbohydrate restriction can greatly improve insulin sensitivity, and bariatric surgery can result in changes to a range of hunger hormones [6] [7].

Visceral fat and liver fat are thought to play a key role in the development of the insulin resistance seen in type 2 diabetes, and low carb diets, very low calorie diets and bariatric surgery have all been shown to effectively reduce these types of fat [8] [9] [10] [11].

The power of these interventions to address the underlying causes of type 2 diabetes, as well as the symptoms, could explain why they allow remission rates that are much higher than what is seen with standard care.

What’s the take-home message?

As type 2 diabetes remission is still a relatively new concept, more research is needed to further investigate the ways in which different strategies make remission possible. However, the literature so far offers much hope to people with type 2 diabetes, showing that the condition does not need to get worse and can be effectively managed or put into remission with lifestyle changes or surgery. Moreover, the power of lifestyle changes specifically in bringing about remission can give people with type 2 diabetes the opportunity to once again be in control of their own health.

References

[1] Sjöström, L., Peltone, M., Jacobso, P., Ahli, S., Andersson-Assarsso, J., Anvede, Å., Bouchard, C., Carlsso, B., Karaso, K., Lönroth, H. and Näslund, I., 2014. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. Jama, 311(22), pp.2297-2304.

[2] Lea, M.E., Leslie, W.S., Barnes, A.C., Brosnaha, N., Thom, G., McCombie, L., Peters, C., Zhyzhneuskaya, S., Al-Mrabeh, A., Hollingsworth, K.G. and Rodrigues, A.M., 2019. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. The Lancet Diabetes & Endocrinology.

[3] Saslow, L.R., Summers, C., Aikens, J.E. and Unwin, D.J., 2018. Outcomes of a Digitally Delivered Low-Carbohydrate Type 2 Diabetes Self-Management Program: 1-Year Results of a Single-Arm Longitudinal Study. JMIR diabetes, 3(3), p.e12.

[4] Furmli, S., Elmasry, R., Ramos, M. and Fung, J., 2018. Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin. Case Reports, 2018, pp.bcr-2017.

[5] Karter, A.J., Nundy, S., Parker, M.M., Moffet, H.H. and Huang, E.S., 2014. Incidence of remission in adults with type 2 diabetes: the diabetes & aging study. Diabetes Care, 37(12), pp.3188-3195.

[6] Hallberg, S.J., McKenzie, A.L., Williams, P.T., Bhanpuri, N.H., Peters, A.L., Campbell, W.W., Hazbu, T.L., Volk, B.M., McCarter, J.P., Phinney, S.D. and Volek, J.S., 2018. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an open-label, non-randomized, controlled study. Diabetes Therapy, 9(2), pp.583-612.

[7] Dimitriadis, G.K., Randeva, M.S. and Miras, A.D., 2017. Potential hormone mechanisms of bariatric surgery. Current obesity reports, 6(3), pp.253-265.

[8] Sasakabe, T., Haimoto, H., Umegaki, H. and Wakai, K., 2015. Association of decrease in carbohydrate intake with reduction in abdominal fat during 3-month moderate low-carbohydrate diet among non-obese Japanese patients with type 2 diabetes. Metabolism, 64(5), pp.618-625.

[9] Mardinoglu, A., Wu, H., Bjornso, E., Zhang, C., Hakkaraine, A., Räsäne, S.M., Lee, S., Mancina, R.M., Bergentall, M., Pietiläine, K.H. and Söderlund, S., 2018. An integrated understanding of the rapid metabolic benefits of a carbohydrate-restricted diet on hepatic steatosis in humans. Cell metabolism, 27(3), pp.559-571.

[10] Taylor, R., Al-Mrabeh, A., Zhyzhneuskaya, S., Peters, C., Barnes, A.C., Aribisala, B.S., Hollingsworth, K.G., Mathers, J.C., Sattar, N. and Lea, M.E., 2018. Remission of human type 2 diabetes requires decrease in liver and pancreas fat content but is dependent upon capacity for β cell recovery. Cell metabolism, 28(4), pp.547-556.

[11] Meyer-Gerspach, A.C., Peterli, R., Moor, M., Madöri, P., Schötzau, A., Nabers, D., Borgwardt, S., Beglinger, C., Bieri, O. and Wölnerhansse, B.K., 2019. Quantification of Liver, Subcutaneous, and Visceral Adipose Tissues by MRI Before and After Bariatric Surgery. Obesity surgery, pp.1-11.

This Diabetes Week (10-16 June), of which the theme is redefining diabetes, Diabetes Digital Media spoke to Christopher about his diagnosis, motivation, advice for others with the condition and why a diagnosis of type 2 diabetes is far from a death knell, it is an opportunity to make lasting healthy changes.

A new outlook

Christopher is notably optimistic when discussing his type 2 diabetes. But that isn’t to say his journey has been easy. His diagnosis was a life-changing moment, and he cancelled a performance at the Edinburgh festival soon afterwards to take stock and reevaluate his health. In hindsight, he says this is a decision he didn’t need to make, but adds that when you are first diagnosed it’s easy for panic to set in. However, Christopher has one salient piece of advice for someone newly diagnosed with type 2 diabetes:

“If I knew someone who’d just been diagnosed with type 2 and the fear of doom was put on them I would say ‘don’t panic’. As long as you’re aware of what you eat, things can only get can better.”

Last year the 70-year-old visited a medically supervised health spa in Germany and ditched sugar, losing a stone in the process. He has since made beneficial changes to restrict his sugar intake further and hasn’t looked back once.

“When you’re diagnosed you of course don’t realise that sugar is everywhere. I used to drink fresh orange juice in the morning, which is like drinking two pounds of sugar. Now I drink coconut water, and I don’t get cravings.”

He added, “Now I pick items up in the supermarket and I look how much sugar the food contains. If it contains 54% sugar, for example, then I put it back. On a daily basis I do this now, whereas before I didn’t.”

Redefining diabetes

A misconception within diabetes circles is that type 2 diabetes is a chronic, progressive disease, but modern research is disproving this theory. Eating a healthy, real-food diet and getting regular exercise can help people lose weight, improve their blood glucose levels and, most impressively, even come off medication and put the condition into remission.

For Christopher, staying positive regarding his health goals is paramount. He admits to sometimes having challenging days regarding his diet, but says that the ability for people with type 2 diabetes to transform their health isn’t as commonly discussed as it should be.

“I don’t think people are aware that you can make substantial changes if you have type 2 diabetes,” he said. “Obesity and type 2 diabetes are crucial areas that [the NHS] should make people more aware of.”

Christopher has struggled with knee problems in recent years, but this has only strengthened his weight loss motivation further. “Having type 2 diabetes makes you aware of all the pitfalls, and the problem is that being overweight involves pushing down on that knee, so I’ve had quite a few problems and I’ve seen a lot of doctors, chiropractors and specialists. My local GP is very pleased with my weight loss progress.”

Towards the end of our interview, Christopher candidly mentions a friend who pays minimal attention to the foods he eats. His friend’s reason for rejecting dietary changes is because his motivation isn’t there. For Christopher, the difference is crucial: he has motivation. “I personally don’t want to die,” he said. “So I want to help my body.”

If you’ve been recently diagnosed with type 2 diabetes then visit our Diabetes Forum for support and experiences from over 300,000 members. The Forum also has success stories from people who’ve achieved significant health improvements, recipes, meal plans and provides an open platform for those looking to share their stories.

Visit our Facebook, and Twitter pages for more content throughout Diabetes Week.

This approach is now widely accepted across healthcare and is known as “person-centred care” or “personalised care”.

In treating type 2 diabetes there are a number of important roles for a GP to undertake; a person-centred approach is centre to this.

My approach as a GP

Type 2 diabetes is no longer defined as being a ‘chronic progressive disease’, despite what medical school textbooks and lectures taught me 20 years ago!

How we frame a disease, and our core beliefs are important. They will influence our goals and decisions. I now hold the core belief that improvement in type 2 diabetes is possible for everyone, to a greater or lesser degree. Also, many people with type 2 diabetes are achieving significant health improvement, including placing the condition into remission.

The range of options for type 2 diabetes management means it is important to take a person-centred approach and enable a person to choose the management option(s) that are best for them. As a GP the approach I will take with different people will of course vary. Every person and every consultation is different. However, there is a common pathway I follow which is described below. In this article, I’ll offer some thoughts on how a low carbohydrate approach, if that is the patient’s chosen management option, can be shoe-horned into a 10-minute appointment. Besides, we’ll consider the wider resources and opportunities that are available to GPs and patients outside of the standard short GP appointment.

Throughout consultation with a patient I’ll be aligning my thinking and approach with four key areas to help ensure the person-centred goals are achieved:

• Needs and goals
• Physiology
• Preferences, options and choices (options includes drawing on the best clinical evidence)
• The journey

The consultation

Before the patient coming into the consultation room, I will review their medical record (in under 15 seconds!). This comprises:

1. Review of most recent consultations
2. Current and past medical history, and any significant recent events. Including other diagnoses suggestive of poor metabolic health such as; obesity, hypertension, NAFLD, dyspepsia, cardiovascular disease, gout.
3. Blood tests (recent and historical, and trends). Particularly looking at HbA1c and for other blood tests that signify poor metabolic health (e.g. high triglycerides, low HDL-C, raised liver function tests, raised uric acid)
4. Current medications

I will then welcome the patient to the room and discover the reason for their visit. If the consultation is specifically to address their type 2 diabetes I’ll ask if they were aware that type 2 diabetes is no longer just a disease that can only get worse, and that most people are able to significantly improve the condition, and some are able to achieve a normal blood sugar whilst come off drugs.

We’ll review the evidence based management options for type 2 diabetes [albeit briefly due to the 10 minute appointment limit], and we will utilise this decision aid:

We will briefly [due to time constraints] discuss the various options, their pros and cons and their appropriateness for the person. The majority of patients chose “aim to improve/place into remission”.

We will then review current lifestyle including food preferences, physical activity and wider life interests/needs/demands such as work or family life)

Next, we explore “what matters” or “what’s important” to the person. Uncovering this can be very helpful to assist with behaviour change. An example might be “wishing to improve health to be around for the grandkids in years to come”. These life aspirations are often more motivating for many people than the more clinical focus of seeing an improvement in my HbA1c”.

Many people choose a low carbohydrate approach to improve their type 2 diabetes because of it:

1. Sounds enjoyable to most people (once explained and understood)
2. Is easiest to implement as it does not need any additional medical referral or medical resources

With the low carbohydrate approach chose, the clinical tasks for GPs are then:

1. Perform a more detailed review of relevant blood tests, blood pressure, pulse and weight (are they up to date? Within the last 8 weeks is reasonable). More recent tests would be required if there had been a recent significant recent health issue. If necessary arrange for tests to be performed.
2. Review medication; particularly diabetes drugs that may need to be adapted when their carbohydrate intake is reduced [link to table] and anti-hypertensives (On top of lowering blood glucose, a low carbohydrate diet can cause an improvement in blood pressure. Anti-hypertensive doses may need to be reduced if someone’s blood pressure is already at the lower end of the range).
3. Provide the patient with resources (or signpost them to appropriate resources) that offer the necessary information and support required to move towards a low carbohydrate diet.
4. Provide detail of the common side effects of a low carbohydrate diet. These side effects, if they occur, are typically seen in the first 1-2 weeks. [Side effects handout]. Also highlight the commonly reported positive effects (including loss of constant hunger, weight loss – especially centrally, and often better mood and clearer mind). Behaviour change can be hard, so it is important to assist people in becoming motivated to change.

The follow-up

To conclude the appointment we will agree on a follow-up visit. This will typically be at 12 weeks (if no further medication adjustments are needed). Blood tests will be arranged for within a few days before the follow-up appointment (typically HbA1c and lipids, plus any patient-specific tests).

The review could be sooner if diabetes drug doses, or anti-hypertensives, will likely require further adjustment within the initial 12 weeks (review could be face-to-face or via telephone consultation)

At a follow-up appointment, we will review what has worked well, any challenges and solutions (I like to hear about a “top tip” that the person would like to share with others). Blood test results will be reviewed, as well as weight and blood pressure. Then we will decide if the approach is appropriate for them (physiology and life preferences), and if any adjustments are required. Celebrate successes, and agree on next steps, possibilities may include:

1. Return to annual review
2. Further 12 week review
3. Change in management plan.
4. Referral on to wider primary care team for support (e.g. health coach or social prescriber)

Making the most of the consultation

A typical 10-minute GP appointment is not designed for addressing conditions such as type 2 diabetes. Although it is possible within this very short consultation to undertake a person-centred consultation, complete the clinical duties, and to build a management plan (that could include behaviour change plans). It is certainly a challenge, so to best meet patient’s needs it can help to consider how care could be better delivered. This can include:

• Making use of the primary care team
  • Practice nurse – who may already be the lead clinician for diabetes care in the practice
  • Pharmacist – who could assist in adjusting medications
  • Health coach / Social prescriber – to support the patient with behaviour change
• Group education/consultations – these are becoming an increasingly popular and effective way of supporting people to manage and improve their type 2 diabetes. They allow more time for discussion, and patients can learn from and support each other.
• Digital solutions – many of the tasks relating to a low carbohydrate diet for improving type 2 diabetes are non-clinical. A digital solution to educate, empower and support a person with type 2 diabetes can remove many of the tasks from a clinical appointment. The Low Carb Program has been designed for this purpose. It can be “prescribed” during a short consultation, just like a clinician would prescribe a medication. The Low Carb Program could also be used alongside group consultations.

In the general practice setting patients with type 2 diabetes who choose a low carbohydrate approach will be able to improve their health. At least 25% of people will likely be able to place their type 2 diabetes into remission. Supporting patients to better manage their type 2 diabetes can transform health, reduce medication, reduce clinical workload and likely reduce the rate of future complications. It is also a very rewarding part of GP daily work.

Learn more about how low carb can help reduce medication and visit DDM’s award-winning Low Carb Program. One in four users of the program put their type 2 diabetes into remission within one-year, and other benefits members experience include better mood, increased energy and better quality of life.

Register your interest for healthcare professional training.

What the diet study says

The Global Burden of Disease Study 2017 has been published this week in The Lancet [1], a prestigious medical journal. The authors reviewed the health effects of dietary risks in 195 countries and revealed that 11 million worldwide deaths were attributable to dietary risk factors. This equates to one in five deaths around the world, making it a bigger killer than smoking.

The analysis used estimates of countries’ eating habits to conclude how often diet was shortening lives. Around 10 of the 11 million deaths were due to cardiovascular disease, while cancers and type 2 diabetes accounted for the rest.

The findings are alarming, there can be no doubt of that. But there can be doubt over the causes. The researchers report that the dangerous diets were those containing:

• Too much salt – associated with three million deaths
• Too few whole grains – associated with three million deaths
• Too little fruit – two million deaths

Low levels of nuts, seeds, vegetables, omega-3 from seafood and fibre were also shown to negatively impact our diets.

One important thing to note is that this is an epidemiological study, and so, it cannot prove cause and effect, it can only look for associations between certain dietary factors and disease risk.

Digesting the findings

There are a few notable takeaways regarding the foods highlighted. Nuts and seeds have both been found to have strong health benefits in recent years, aiding weight loss and lowering heart disease risk [2] [3]. Fibre is also beneficial for the body because it helps nurture our gut bacteria and reduce glucose spikes in response to food, though high fibre foods do vary in the amount of digestible carbohydrate they contain.

Whole grains, however, have been shown to be less healthy than we thought in recent years. Referring to things like cereal, wheat, barley and rice, whole grains have a reputation as being useful for reducing heart disease risk, but a 2017 study observed no positive effects on blood cholesterol or blood pressure attributable to whole grain diets [4]. Yes, whole grains are rich in dietary fibre, but they are high in carbohydrate, and it is carbohydrate which has emerged as a primary risk factor for type 2 diabetes and other health complications. Moreover, whole grains are by no means the only source of dietary fibre; nuts and seeds are packed with it.

That leads us on to fruit. Some fruits are incredibly healthy for us. These include berries, avocado, cantaloupe and watermelon, which are all very low in sugar. Bananas, grapes and mangoes however are much higher in sugar. A single medium-sized banana contains 14g of sugar and can have a prominent impact on blood glucose levels. It is consistently high blood glucose levels than can eventually lead to insulin resistance, the hallmark of type 2 diabetes.

The study also found that low omega-3 from seafood was a risk factor. Omega-3 fatty acids are renowned for their health properties, and can be found in oily fish and fish oil. Meanwhile, the study claimed that a diet low in “omega-6 fatty acids from all sources, mainly liquid vegetable oils, including soybean oil, corn oil, and safflower oil” was also a risk factor. This is rather unlikely, as such industrial omega-6 oils have been found to be proinflammatory, which can actually worsen chronic disease [5].

Next, salt. Most of us over the last 15 or 20 years will have likely been told by a GP, nurse or dietitian that too much salt raises blood pressure and raises the risk of heart attacks and stroke. Recent findings have refuted this claim though [6].

The Department of Health recommends we eat no more than 6g of salt a day, which is equivalent to one teaspoon of salt across the day. But this does not mean that we should avoid salt. Japa, which imports and consumes very high amounts of salt, had the lowest rate of all diet-related deaths (which may also be attributable to the high intake of omega-3-rich seafood) in the study review. Later this year renowned GP Dr David Unwin will speak at the Public Health Collaboration on how salt has taken the blame for the impact that sugar has on the heart.

Limitations

One of the unfortunate aspects of the study, and the way it has been reported, is that it lumbers together food groups. By grouping whole grains, fruit and vegetables together, the inference is they possess the same qualities. But there are vast differences in their nutritional properties. Not all of the foods in these groups are born equal. They all have varying properties that could lower the risk of health problems, but also varying properties that could increase the risk.

Furthermore, the researchers’ dismissal of sugar was alarming.

Professor Christopher Murray, director of the Institute for Health Metrics and Evaluation at the University of Washingto, said in an interview with BBC that sugar was a “much smaller issue” compared to the researchers’ standout findings. But sugar has been significantly linked with heart disease and a host of other complications in recent years [7]. The government’s 2018 introduction of the sugar tax is designed to reduce sugary drink consumption linked to obesity and type 2 diabetes rates, conditions which both have strong links to heart disease if not urgently treated. The Global Burden of Disease Study found that too many fizzy drinks were still being drunk worldwide.

The European impact

Where is the UK in all of this? A total of 14% of UK deaths were related to diet. This figure was behind countries like France, Belgium and Denmark.

Success stories were observed in Mediterranean countries. France, Spain and Israel had some of the lowest numbers of diet-related deaths, and it’s not hard to see why. The Mediterranean diet is gaining popularity for its incredible health benefits, including improved brain health, weight loss, lower heart disease risk, treating sexual dysfunction and reduced type 2 diabetes risk.

Ultimately, the findings from the study can be interpreted in a few different ways. But we know that diet is a very personal thing, and studies tend to crossover regarding their recommendations. If, however, you want to learn more about food and its impact on the body, then why not visit our award-winning Low Carb Program? One in four users of the program put their type 2 diabetes into remission within one-year, and other benefits members experience include better mood, increased energy and better quality of life.

References

[1] Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

[2] Liu, G., Guasch-Ferré, M., Hu, Y., Li, Y., Hu, F.B., Rimm, E.B., Manso, J.E., Rexrode, K.M. and Su, Q., 2019. Nut consumption in relation to cardiovascular disease incidence and mortality among patients with diabetes mellitus. Circulation research, 124(6), pp.920-929.

[3]  Vuksa, V., Jenkins, A.L., Brissette, C., Choleva, L., Jovanovskin, E., Gibbs, A.L., Bazinet, R.P., Au-Yeung, F., Zurbau, A., Ho, H.V.T. and Duvnjak, L., 2017. Salba-chia (Salvia hispanica L.) in the treatment of overweight and obese patients with type 2 diabetes: A double-blind randomized controlled trial. Nutrition, Metabolism and Cardiovascular Diseases, 27(2), pp.138-146.

[4] Kelly, S.A., Hartley, L., Lovema, E., Colquitt, J.L., Jones, H.M., Al‐Khudairy, L., Clar, C., Germano, R., Lun, H.R., Frost, G. and Rees, K., 2017. Whole grain cereals for the primary or secondary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews, (8).

[5]  Simopoulos, A.P., 2008. The importance of the omega-6/omega-3 fatty acid ratio in cardiovascular disease and other chronic diseases. Experimental biology and medicine, 233(6), pp.674-688.

[6] Mente, A., O’Donnell, M., Rangaraja, S., McQuee, M., Dagenais, G., Wielgosz, A., Lear, S., Ah, S.T.L., Wei, L., Diaz, R. and Avezum, A., 2018. Urinary sodium excretio, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study. The Lancet, 392(10146), pp.496-506.

[7] DiNicolantonio, J.J. and OKeefe, J.H., 2017. Added sugars drive coronary heart disease via insulin resistance and hyperinsulinaemia: a new paradigm.

What are very low energy diets?

Very low energy diets (VLED), also known as very low calorie diets, have been used for many years in the treatment for obesity. VLEDs can be defined typically as a diet containing 600-800 calories per day. Low energy diets typically contain 800-850 calories per day.

My current role as a research associate dietitian on a study using low energy diets has been an eye-opening journey for men, and perhaps challenged my own unconscious bias. The DiRECT team in Newcastle and Glasgow, with very high quality evidence, have shown that type 2 diabetes can be safely and effectively put into remission using a total diet replacement LED. Perhaps most impressively, this has been done in primary care, showing the potential scalability of this approach.

VLEDs are often affectionately known as the ‘soups and shakes diet’. VLED with ongoing support and follow up from appropriately trained healthcare professionals are far more than just ‘soups and shakes’.

The current best evidence on the use of VLEDs show that nutritionally complete total meal replacements can be an effective and safe way of achieving remission of type 2 diabetes. Weight reduction up to 15% is associated with improved clinical health outcomes including type 2 diabetes, obstructive sleep apnea, and osteoarthritis (1). DiRECT has also given us an improved mechanistic understanding of type 2 diabetes, with advanced MR imagining of the liver and pancreas showing reduced fat around these organs in those who achieve remission. Type 2 diabetes is no longer a guaranteed road to total beta cell failure.

What has surprised me most about the use of VLEDs is that patients consistently report that they have more energy, feel well and don’t report much hunger once adapted to the diet. People also report they enjoy the break from food. The constant battle of trying to get home from work, tired, hungry, having to cook “healthy” meals is a relief to many. But what happens when the shakes are finished? A supported stepped food reintroduction is absolutely crucial in this approach.

Many people have in the past tried total diet replacement diets where they have ordered a package online, lost weight, not had any long-term support resulting in them regaining the weight plus more. For this reason, I find many patients (and healthcare professionals) quite hesitant to consider the option of a VLED.

Open conversations, based on newer evidence, with a long-term follow up plan in place is likely to lead to much improved outcomes versus undertaking a VLED without support.  Maintained weight loss is the primary factor for type 2 diabetes remission after a very low energy diet, and supporting the individual to use whichever dietary approach works for them should be expected from healthcare professionals and dietitians to ensure best outcomes.

Further training in primary care is required to ensure safety and efficacy in the long term. I believe VLED should be a recognised option for those with pre-diabetes or recent-onset type 2 diabetes, especially those who are motivated and for the many people where current standard dietary advice has not worked. Appropriate follow up and weight maintenance support which is tailored to the individual is key.

Type 2 diabetes remission – the bottom line

The bottom line is that the best diet is one a person can stick to. For some people, after many years of dieting and failing, surgery may be the best option. Nationally, we have a long way to go before all of these options are openly available and affordable to all, but we can hope and strive towards that. In my eyes, collaboration and patient choice remain key.

To all surgeons, endocrinologists, diabetologists, GPs, diabetes nurses, dietitians, academics, psychologists – rather than fighting over who’s ‘method’ is best, let us join forces, share experience and expertise, and allow for the best chance of remission for our patients.

Register your interest for healthcare professional training.

Tara Kelly

Registered Dietitian & Research Associate

Dietitian at Diabetes Digital Media

References

1. Brow, A. and A.R. Leeds, Very low-energy and low-energy formula diets: Effects on weight loss, obesity co-morbidities and type 2 diabetes remission – an update on the evidence for their use in clinical practice. Nutrition Bulleti, 2019. 44(1): p. 7-24.

Bariatric surgery

The first evidence for type 2 diabetes remission comes from evidence in bariatric surgery. Bariatric or weight loss surgery is considered by many to be underutilised and the most effective treatment in those with severe and complex obesity (1), and is cost-effective (2).

My first clinical experience of type 2 diabetes remission came about during my first rotation as a dietitian in a busy London teaching hospital. I shadowed a colleague in a post-op dietetic bariatric clinic. The lady was four weeks post op, 10kg down, with insulin and gliclazide both stopped day one post-surgery. In clinic, her blood glucose levels were perfect. Excuse me?! I was not taught this in University!

Embarrassingly, I had never heard of remission. I was taught that type 2 diabetes is a chronic, progressive disease and we should ‘manage’ it with the same dietary advice that we advise to the rest of the population.  I remember having lunch with the bariatric registrar that day; he was amused at my excitement of seeing remission for the first time.

As time goes o, I start to learn more about bariatric surgery and start to undertake pre- and post-op clinics. I hear the most wonderful stories. Patients arriving into clinic with 10k medals, old pairs of jeans which they could now fit into one leg of, proudly showing pictures of themselves with grandchildren playing in the park. Something they never could have done before surgery.

It’s not the ‘easy way out’

Bariatric surgery, despite popular belief, is far from the ‘easy way out’. It’s often seen as the ‘final option’ for people with obesity, after years and years of struggling with diets, exercise and weight stigma. I am yet to meet a patient undergoing bariatric surgery who has not tried to lose weight multiple times in the past.

As per national guidelines, patients must attend a specialist service for 1-2 years including many appointments with specialist nurses, dietitians, psychologists, bariatric physician and surgeons. Surgery is not guaranteed for any patient, and often patients are deemed not fit or not right for surgery by the multidisciplinary team. Some think of a bariatric service as some sort of ‘assembly line’ where each and every patient is operated on without much consideration. This is not true, and insulting to the hours of hard work undertaken by patients and healthcare professionals alike.

However, it is not all a walk in the park and as with any surgery, it does carry risk of complications. I had one lady who I used to see every week,  had a feeding tube placed while she waited for revisional surgery, because she was unable to tolerate anything more than just a few sips of water. Many people have undergone surgery and not made the appropriate lifestyle changes alongside, and have regained the weight lost. It takes a dedicated patient and a supportive team.

Bariatric surgery can be a powerful catalyst for change. Guiding the patient, openly and honestly through the expectations and letting them know that bariatric surgery is both a challenging a life-changing experience is critical for best positive outcome.

Bizarrely, we would often have patients show up to bariatric assessment clinic, not realising they had been sent for bariatric surgery assessment, with absolutely no interest in having bariatric surgery. Why? Was the referrer not confident or comfortable to have this discussion with the patient? I urge primary care doctors and other healthcare professionals to engage with bariatric services and understand the criteria and evidence behind bariatric surgery. HCPs must be confident in being able to open these conversations to patients. This surgery is life saving for many people.

In part three of this series I explore the impact of very low energy diets in regards to type 2 diabetes remission.

Register your interest for healthcare professional training.

Tara Kelly

Registered Dietitian & Research Associate

Dietitian at Diabetes Digital Media

References

1. Rubino, F., et al., Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care, 2016. 39(6): p. 861-77.
2. Keating C, Neovius M, Sjoholm K, Peltonen M, Narbro K, Eriksson JK, et al. Health-care costs over 15 years after bariatric surgery for patients with different baseline glucose status: results from the Swedish Obese Subjects study. Lancet Diabetes Endocrinol 2015;3: 855-865.

What is type 2 diabetes remission (T2DM)? Good question. The experts are actively trying to come to a consensus agreement on this. In 2009, the American Diabetes Association suggested two definitions of remission: partial remission or complete remission. More recently, the joint statement from the Association of British Clinical Diabetologists (ABCD) and Primary Care Diabetes Society (PCDS) (2019) suggested a single definition of type 2 diabetes remission being: HbA1c under the threshold of diagnosis (48 mmol/mol) with a fasting plasma glucose level <7 mmol/L at two separate occasions over six months, off all diabetes medication (a mouthful!).

Whatever your thoughts on the exact definitions of T2DM remissio, we can all agree that patients who achieve remissio, by any method, should and must continue with regular surveillance and management of other risk factors and yearly screening.

In this three-part series I will be examining three ways in which type 2 diabetes remission can be achieved: low carb, bariatric surgery and very low energy diets (VELD).

There are some clinicians who wonder whether we should be focusing on remission at all. I once attended a meeting with bariatric surgeons and endocrinologists, some of whom said the term “remission” may make many people with type 2 diabetes feel “a failure” should they be unable to achieve remission. This may be a fair consideration; recent studies tell us that remission is much more likely in those with shorter duration of type 2 diabetes (up to 6 years).

Remission will not be possible for all with T2DM, but this does not mean that best possible management for that individual should not be explored and encouraged, with all options on the table. As the diet “wars” and research continues, I will focus on the common ground among clinicians, researchers, dietitians and doctors – namely, that we all want what is best for our patients.

My experience using low carb diets

Obesity is a disease. Not everyone with type 2 diabetes is obese, but there are strong links. Robert Lustig (Professor of Neuroendocrinology and obesity expert) describes obesity as a combination of several factors: ‘physics, biochemistry, endocrinology, neuroscience, psychology, sociology and environmental heath all rolled up into one problem’.

There is often a stigma attached to type 2 diabetes. The idea that people with obesity or type 2 diabetes are ‘lazy and eat too much’ or that they should ‘eat less and move more’ are extremely unhelpful. Weight stigma among the general population, and among healthcare professionals (often an unconscious bias) are additional challenges we face when treating people with obesity and or type 2 diabetes.

I have worked in a busy London bariatric centre, and also in weight management and diabetes. Having seen patients from all walks of life, within the NHS and privately who have undertaken different treatments options for type 2 diabetes: pharmacological, bariatric surgery, very low energy diets and low carbohydrate diets, one thing is glaringly clear to me – one option does NOT fit all.

Low carbohydrate diets

Low carbohydrate diets, I believe, are an exciting and important new tool in the type 2 diabetes remission toolbox.

There has been some controversy over the use of low carbohydrate diets in recent years, so first of all, let’s clarify a few things. Low carbohydrate diets are not a “fad diet”, certainly not in the context of type 2 diabetes management anyway. Versions of low carbohydrate, high fat diets for treatment of diabetes have been described since the work of Alle, Stillman and Fitx in 1919 (2). Low carb diets are a safe and effective way of managing blood glucose levels and weight.

Perhaps some of this controversy lies in one’s understanding of what a low carbohydrate diet is. This graph has been adapted from Fienman et al (3)

 “The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate protein and fat are consumed.” (Institute of Medicine, 2005).

This means that carbohydrates are not technically an essential macronutrient. Initial reaction from some people, including healthcare professionals upon hearing the words ‘low carbohydrate diet’ is that we need carbohydrates to “fuel the brain”. This is factually untrue.

Luckily, for many people switching to a diet of less than 130g of carbohydrate is enough to see huge health benefits. The results from the Low Carb Program (which is now available in the NHS Digital app library) show that one in four people can put their type 2 diabetes into remissio, with many more reducing medication dependency

The British Dietetic Association in 2017 (4) acknowledged that low carbohydrate diets are safe and effective in the short term in managing weight, improving glycemic control and cardiovascular risk in people with type 2 diabetes (however, the first line dietary advice remains that people consume a diet high in carbohydrate (50-55% of energy). This advice has been widely criticised in the context of type 2 diabetes management.

Meta-analyses (studies of studies) consistently show that low carbohydrate diets perform at least the same if not better in comparison to low fat diets in the shorter term. So, should it not at least be offered as a choice? Of course it should. It is true that the longer-term data on remission of type 2 diabetes via a low carbohydrate diet does not yet exist. Anecdotally, and certainly within my clinical practice, remission of type 2 diabetes can be sustainable for many years. I believe this diet is particularly valuable in the long term as many people report  they are completely satisfied after food.

In my past experiences of dishing out Eatwell Guide advice in weight management clinics, it was downright depressing. Low fat, high carb diets, with an emphasis on calorie counting (eating less and moving more), simply do not work for many people.

How to use the low carb approach

So, how do we use a low carbohydrate diet safely in clinical practice? As always, discussing pros, cons and side effects should be done before starting any diets or lifestyle changes. Liaising with GPs or medical teams regarding the de-prescription of medication is also very important, especially for those on insulin and sulfonylureas.

Implementing a low carb approach need not be complex. Empowering patients with some very basic physiology can be useful. The British Dietetic Association recognises that: “All types of carbohydrate will increase your blood glucose level. Some people find it helpful to reduce the quantity of carbohydrate in their diet to help control blood glucose levels”.

Sugars and starches (including those recommended with each meal for people with type 2 diabetes) break down into surprisingly large amounts of glucose in the body – which in turn, can raise blood glucose levels. Explain these basic facts to your patient, it is their absolute right to know this – and it is then their own choice as to what they do with this information.

First steps:

• Cut out highly processed foods (sweets, cakes, biscuits etc.), and focus on eating real food as much as possible.

Next steps:

• Significantly reduce starchy carbohydrates and replace with non-starchy vegetables where possible.
• Eat moderate amounts of protein and do not fear fat from whole food sources eg: dairy, eggs, avocados, nuts, seeds, oily fish.
• Learn to love food again!

In 1989, Bernhard Naunyn described fat as the “chief food for the diabetic”.

Most of us will agree that dietary fat has been wrongly demonised for many years. Most patients tell me when they eat fats (from whole, unprocessed foods) they feel more full, more satisfied and clearly have less of a postprandial (after meal) blood glucose response. This is life changing for many people, having been a slave to hunger and cravings for much of their lives. Eating nuts, cheese and other foods which they may have been told to avoid for a long time is a real delight for many of my patients.

A really memorable patient for me was one who had been referred by a diabetes specialist nurse, something along the lines of, “please make sure she is eating enough carbs, as we need to start her on insulin”. She was hostile initially, saying she was fed up of seeing “judgey dietitians”. We discussed her options, as she desperately wanted to avoid insulin. The option of low carb had never been discussed with her before, in fact it had been dismissed by her other healthcare professionals. I feel this is wrong in so many ways.

We had a really enjoyable discussion about different options, and she wanted to try low carb. She was lucky enough to be able to self-fund a CGM (continuous glucose monitor) and started to check her response to carbs after meals.  During her next appointment, she was rather annoyed, and asked why on earth she had been told to have porridge and banana for breakfast for many years, when it consistently increased her blood glucose level into the high teens. Good question! A few weeks later, her diet had changed dramatically to a lower carb, healthy fat diet, guided by her own blood glucose levels. She was over the moo, having stopped her gliclazide and proudly doing a dance around the clinic room. She narrowly avoided a lifelong journey of insulin, and instead was on the road to type 2 diabetes remission.

As with many people who follow a low carbohydrate lifestyle, she could not believe how much energy she had, and how she no longer felt constantly hungry. It’s moments like this that make being a dietitian enjoyable for me.

We can argue that the long-term randomized evidence is not yet there, however it seems to meet that supporting people to choose a diet of lifestyle which suits them clearly shows benefit.

In part two of this series later I will be detailing how bariatric surgery is being utilized to help achieve type 2 diabetes remissio, and in part 3 I will look at very low energy diets.

Want to learn more and become confident with the low carbohydrate approach for the management of prediabetes and type 2 diabetes? Register your interest for healthcare professional training here.

Tara Kelly

Registered Dietitian & Research Associate

Dietitian at Diabetes Digital Media

References

1. Remission of Type 2 Diabetes: A Position Statement from the Association of British Clinical Diabetologists (ABCD) and the Primary Care Diabetes Society (PCDS)
2. Alle, FM. Stillma, E, Fitz, R. 1919. Total Dietary Regulation in The Treatment of Diabetes. The Rockefeller institute for Medical Research.
3. Feinma, D. et al (2015) Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base. Nutrition.
4. British Dietetic Association (2018) Policy Statement – Low Carbohydrate Diets for the management of Type 2 Diabetes