Friday, 15 June 2018

#FastFixDiabetes - Sounds too good to be true, almost!

Three prime time TV programs in two weeks on my favorite subject of dietary intervention for managing diabetes! 

How exciting that this subject is finally getting the recognition and air-time that it deserves. Interestingly there were several claims that this was new science, and yet I was writing about it four years ago and I feel that I am new to the subject! There were also many bold claims that the diets to be described on these shows could save the NHS billions of pounds; this is also a subject close to my heart.

Programs 1 and 3 took almost the same approach, which rather puts a dampener on their claims to be new. They both put a number of pre-diabetic people on a crash diet limited to 600-800 calories a day from nutritionally balanced shakes and soups. They followed the groups for some time and then measured their HbA1c level. Following the diet was difficult with Professor Gill accepting that it is a really hard diet to stick to and most patients stating how difficult it was, using words like “Brutal” and describing “the pain of being hungry”.  

In #fastfixdiabetes this was done at a beautiful retreat in the hills a mile from my house; it certainly won the prize for the best photography.

At the end of the two shows the patients were given their results; predictably they all did very well, which is great. This should have been the cue for how the diet was to be continued, how the patients could then go on to lead healthy lives free of diabetes and save the NHS a fortune. Unfortunately this did not happen. The Big Crash Diet program ended with a minute or two of bemused faces as Susan Jebb (the chief advisor on obesity to the government) showed the patients how to cook a few “healthy balanced meals”. The program's website does point you to a page of healthy low calorie recipes but there was no description of how well or badly the patients might have got on with this when they got home and so their prognosis could only be described as being “better than it was before”; hardly cause for jubilation in the NHS accounts department.

#fastfixdiabetes was worse; there was no discussion about long term diet at all with the patients, just a quick statement at the end that read “After the experiment the patients were  reintroduced to a healthy diet, under supervision”. As well as contemplating the cost of this supervision I was left thinking what does “a healthy diet” mean? A question I and millions of others have been wondering about for many years.  And I have come to the conclusion that the answer to this question is 
Trust me, I’m a dietitian.”

I feel I need to call out one of the amazing claims made in #fastfixdiabetes. At one point Professor Jason tells Doctor Zoe “What we are hoping to achieve is something that we simply do not see in routine diabetes care; we do not see people getting diabetes into remission, and we are trying to do it without any drugs.” This statement amazed me as I have been writing blog posts on the subject for a long time now. Surely the professor would be aware that there are several successful dietary intervention programs in the UK already, both inside and outside the NHS including a huge program hosted by  Dr Zoe would also be well aware of this; since like me she recently attended a conference where several speakers gave detailed descriptions of doing exactly this. This bold claim certainly made the TV program sound very impressive but it was not true.

Both of these programs were based upon the results of a trial by Dr Roy Taylor at Newcastle University and Professor Mike Lean at the University of Glasgow. A description of their trial on explains how it works and it is truly impressive, in the short term. It also explains that:
       “This is no quick fix, and we’re not recommending you try it alone. Some of the people in the study are finding the diet incredibly challenging and this programme is about more than just the low-calorie diet. After this phase, people may need to work hard to keep to a healthy weight and stay in remission.” 
And that's the thing; we all have to work hard to keep to a healthy weight; this ever-present fact and the poor quality of dietary advice from the NHS is very likely to be why we have such a huge problem in the first place .

There was another howler from the professor, who after giving the great results to Dan said; “Just keep your weight the same and make sure it doesn’t go up” with no indication as to how Dan might do this. This is just like reiterating the tired “Eat less and move more” advice that doctors with very little training in or knowledge of nutrition have been giving the population for the last 30 years. 

Perhaps Dan will manage this as he now appears to be launching a company to provide the #fastfixdiabetes plan with its intensive retreats to “professional people”, so his motivation to achieve this goal will presumably be higher than most. I hope he succeeds on both of these aims but I fail to see how this will help the NHS in any great way.

The name of the program suggested that the patients “fixed” their diabetes, and this suggestion was repeated several times. To be clear the patients did not fix their disease, they significantly but temporarily lowered the risk of developing type 2 diabetes. This is a great thing but it is not a fix. A fixed pipe does not need constant monitoring to ensure that it does not burst again. 
Job Done?
To claim that you might save the NHS a fortune you clearly have to provide a solution that describes the long term treatment of patients, not just for a few weeks. If your plan requires expert help in the short term and referral to a dietician in the longer term then I fail to see where these millions will be saved. I certainly don’t see Jeremy Hunt forking out for all pre-diabetics to spend a couple of weeks at a retreat in the Sussex countryside, no matter how lovely the views or what longer term savings might come of it.

Luckily there is a long term solution, and it was described in The Truth About Carbs. This program introduced a number of subjects relating to carbohydrates but the main one was a similar two-week dietary intervention performed on a group of eight patients with pre-diabetes. They were placed on a low carb higher fat (LCHF) diet, essentially this involved cutting down on refined carbohydrates and foods containing sugar; this was described not as a short term fix but a long term lifestyle change.

The patients all agreed that the diet was relatively easy to adopt (although it should be said that the motivation related to being on a TV show must play some part here – don’t these TV trials always succeed?); they attended weekly group sessions but did not require constant motivation to keep going. They all lost weight and improved their diabetes markers in a very similar way to the patients on the other two programs. But this is where the similarities end; because all these patients had to do at the end of the show and for the rest of their lives was continue using a diet that they enjoyed; they reported that the food tasted great and they didn’t report being hungry all the time.  Continuation of the diet requires little in the way of further costs and intervention as the patients already know how the diet works.

To be fair the LCHF diet is not suited to everyone but the results show positive outcomes for most people. This TV show was based on the successful dietary intervention trial performed by Dr David Unwin and his team at the Southport Surgery on Merseyside. David has recently published the results from four years of offering this intervention as a choice to diabetes patients; there has been great success and there has been a clear saving of about £30,000 per year in costs to the NHS. Extrapolate this to every surgery in the country and we are talking about the possibility of saving many millions of pounds.

It is great that this subject is getting more air time. More and more doctors and health professional are taking a serious look at the possibilities for controlling obesity and diabetes with diet rather than drugs. It is up to these people to educate the public as to the choices available to them and the louder the debate the more likely that people will start to realise just how much of their health depends upon what they chose to put in their mouths.

Friday, 25 May 2018

The Public Health Collaboration Annual Conference

I spent last weekend at the annual conference of the Public HealthCollaboration, a charity I’ve been a patron of along with my wife Jane for the last 3 years. The conference was at the Royal College of General Practitioners in Euston Square and was attended by over 300 doctors, scientists, health professionals, journalists and professors. There was even at least one IT consultant, and I have to say that he was feeling somewhat out of place on Saturday morning surrounded by such eminent and dedicated people.

There was a packed schedule of 8 talks on each of the 2 days with subjects ranging from the history of fueling for endurance sports to curing epilepsy with a LCHF diet. 

The whole weekend was televised and will be available shortly on the PHC website. I’d like to highlight a small sample of the content that had the most impact on me.

Tom Williams and Simon Tobin gave a great talk on parkrun. Tom is the COO of parkrun which now has weekly 5k runs in over 530 locations worldwide. We had dinner with Tom on Friday night and it turns out that he is a low-carb advocate as well as a passionate believer in sport for all; there are even parkruns in prisons now and Tom likes to ensure that the focus of each event is not on the first finishers (we don’t call them winners!) but on the slower runners; the ones for whom 5k is a huge achievement. One of the things that Tom is most proud of is that the average parkrun time is getting slower!

Tom is pictured on the right here with Dr Ian Lake, a type 1 diabetic and marathon runner enjoying a very tasty LCHF dinner at Caffe Caldesi

Simon Tobin is a doctor from Southport and a previous correspondent of mine on this blog; he and the other doctors in his practice have been offering the LCHF diet as an intervention for patients with type 2 diabetes for several years now; the results are amazing with most patients managing to reduce or remove their dependence on drugs for managing the disease.  Remember that the best that a patient can hope for on drugs is that their condition might not get worse.

Simon often prescribes parkrun to his patients as a lifestyle intervention! This makes a lot of sense when you consider that over half of the diseases we suffer from are the result of lifestyle choices. Drugs are not the only answer and in many cases they are clearly the wrong answer.

Over the last 6 years Aseem Malhotra has become the poster-boy of the UK Real Food movement. He is regularly seen on TV debating with the likes of Susan Jebb the UK Government's advisor on obesity who is part if the team that advice the government on advice for healthy eating, or Professor Roy Collins who advises the NHS that just about everyone should be taking statins, although his own research suggests quite the opposite to anyone who doesn’t have a vested interest in the sales of Statins!  

When I first met Aseem 5 years ago he offered to share this slide with me but I forgot to follow up on his promise. 

One of his first major causes was to try to stop the sale of unhealthy and sugary foods in hospitals. When he had a heart attack patient wake up after an operation to be fed a burger and chips in bed he knew that something had to be done. His local hospital has now become the first in Britain to ban the sale of junk foods on site.

Aseem has published a number of contentious papers in the British Medical Journal, and he has developed a particularly tough skin having made a number of high profile enemies along the way. He is highly critical of the role of the food and drugs industry in influencing research and advice on matters of health; and equally critical of the eminent scientists who profit from this support whilst ignoring the latest scientific data on issues such as what causes heart disease.  

The best example of this is how the NHS still tells us that saturated fat and it's co-conspirator cholesterol are bad for us and will increase our risk of CVD despite the overwhelming evidence that they will not. There is so much at stake here in terms of NHS money and people’s lives, but it appears that what matters most is the imminence and incomes of those learned men and women who, by working so closely with the food and drugs lords have found themselves in the position of advising Her Majesty’s Government on what is best for her subjects. 

The phrase “eminence trumps evidence” is true at the highest level but it is good to see that increasingly, doctors are refusing to allow transparency and objectivity to be trumped by eminence and vested interests. A survey in Pulse, a publication for GPs, in October revealed that two-thirds of GPs were rejecting the Nice advice to offer statins to those at low risk.

Aseem received a well-deserved standing ovation at the end of his presentation. Interestingly this was attacked on twitter as evidence of cultist behaviour in the PHC movement. Anyone who was there would assure you that it was nothing of the kind. Just a spontaneous outpouring of gratitude for someone who has given so much. Exactly the same could be said of the next speaker.

Aseem and Tim
Tim Noakes – was just marvelous. He gave a self-deprecating account of his career, explaining how as a result of his research into nutrition for endurance sports he became the first producer of energy gels and the author of the bible of distance running (Lore of Running). He then tore this illustrious career apart by describing the faults in his methods and how they had been avoiding the importance of fat all along “because we didn’t understand the pathways by which the body uses fat for energy”.  Years later after reading the work of others he was not too proud or eminent to admit that his interpretation of his clinical data was wrong.

His favorite anecdote seems to be the one where back in the 80's the great Zimbabwean triathlete Paula Newby-Fraser accidentally miss-heard his advice and adopted a low-carb rather than a low-fat diet.  She then proceeded to win more Ironman races than anyone else in the history of the sport.

Tim has been involved in a high-profile court case for the last few years in which the Health Professionals Council of South Africa (HFCSA) have clearly tried to ruin his career because they take his recent research and publications on LCHF as a direct attack on their profession. Four years ago Tim gave some generic advice to a woman asking a simple question on Twitter and they have accused him of bringing their profession into disrepute.

You can find out all the details online if you wish but suffice it to say that I have never heard a sadder tale of the lengths that an eminent group of learned people will go to in order to protect their power and influence; ignoring simple evidence and attacking a kind and caring man in such a profound and prolonged manner. They are a disgrace to their profession and prove John Cleese (and more recently Assem Malhotra) correct when they said that 
One should never forget the first principle of the old KGB. Always accuse your enemy of exactly what you are doing.”

The abuse that Tim has received as been awful, but the support he has gained is incredible and the whole fiasco has brought so much attention to the diet that he now feels that perhaps the human cost was worth paying.

And in many ways this story reflects the problem that we at the PHC were all gathered to discuss; the way that government advice is dictated by a small group of eminent men and women who seem intent on protecting their own dated research and opinions and incapable of changing their minds in the face of new evidence.

Professor Tim Noakes amazed the scientific world by tearing up the chapter on nutrition in his famous book and declaring that he got it wrong. Perhaps it’s now time for UK government health advisors like Professor Rory Collins and Doctor Susan Jebb to do the same thing.

Tim also mentioned the work of Virta Health, an American company providing structured programs for dietary intervention for the treatment of type 2 diabetes. There were not many plugs to commercial enterprises during the conference but this one deserved it’s airtime.

There is not much data on the longer-term impact of the diet on important health markers such as blood pressure, cholesterol and blood sugar, and this is what allows many of the diet’s detractors to state that the diet may work well in the short term but they have concerns about its longer-term efficacy and adherence. Well the data from Virta and Southport  (see below) is filling that void with overwhelmingly good news. Virta already have a very large study group and the papers that they are producing make fantastic reading. All of the important health markers being measured on their patients continue to improve in the two years that the data has been collected for. Comparing this data to the alternative of a life on Metformin and the likelihood of a painful early death I know what I would recommend to my loved ones.

When you consider that the huge majority of health issues relate to lifestyle choices it is a wonder that so little NHS time and investment is put into dietary interventions like this.

Which brings us on neatly to my final hero of the PHC conference Dr David Unwin. Four years ago a GP friend send me a link to a report written by Dr David Unwin and his wife Dr Jen Unwin from the Norwood surgery in Southport. The report described the early results of a trial that they had been performing with their diabetic patient in which they provided dietary advice as an option to patients. Patients who opted into the trial were given regular advice and assistance with adopting the LCHF diet. The results were very impressive and I wrote about them in this blog post

David's talk provided a fascinating insight into the subject of fatty-liver disease, a precursor to diabetes and something that is entirely influenced by lifestyle factors such as diet and exercise.

For me the best bit of the talk was the way he dealt a huge blow to the detractors of the LCHF diet. If you research “LCHF diet” you will find lots of influential dietitians and health advisors whose principle criticism reads like this:

The diet may have positive benefits in the short term but we have concerns about its long term use”.

These concerns arises from the lack of long term studies of the diet. This is despite the fact that of all the studies comparing the health effects of low-fat verses low carb diets there is an overwhelming majority in favour of low-carb. 

Much like the work by Virta Health but clearly in the impartial, public NHS domain, the Northwood trial has now been running for several years and they have been meticulously collecting data from all of the participants; they have now published data that shows the following:

And that’s not all that was achieved in the Northwood group. The risk of heart disease has dropped significantly according to the JBS3 score used to judge this risk

And so now we have the data. Of course it is open to scrutiny but I for one will be passing these last to graphics to anyone who continues to suggest that they have concerns about the long term use of the diet.

There were lots of other great talks at the conference; Peter Brukner (the Doctor on the Australia Ashes winning team) provided a very humorous introduction and update on the latest worldwide news. Zoe Harcombe was on fire as usual, destroying the ridiculous notion that “calories in = calories out” with a perfect explanation of the laws of thermodynamics and how they do not apply to weight or food. 

Zoe Williams (of Trust Me I’m A Doctor fame) gave an interesting talk about the importance of physical activity; her rather famous co-presenter Micheal Mosely was in the audience. Jen Unwin and Charlotte Summers made us think hard about whether we are addicted to sugar. Trudy Deakin, David Cavan and Professor Ian Broom gave us loads of fascinating insights into the practicalities of reversing type 2 diabetes for large patient groups. And Dr Scott Murray gave a great talk on factors influencing heart disease.   There were more talks but I had to take a few walks to stretch my limbs and give my brain time to digest everything!

Lastly, thanks to Sam Feltham the Director of the PHC charity. 

Jane and I have known Sam for several years and he is a great leader and motivator. He has the greatest respect of the many partners, patrons and members of the organization and he did a brilliant job of organizing a fascinating weekend. Sam puts his heart and soul (and his career) into everything he does.  Commitment like this is contagious, and the impact of the PHC is growing as a direct result of his work. 
 Well done Sam!


Tuesday, 17 April 2018

It's All In The Taper

I was fit and excited and the Brighton Marathon was only 3 weeks away. I’d done every training run but one. Almost everything had gone to plan. I hoped to run under 3:20 and get a good for age place in next year’s London Marathon.

But here’s the thing. I was in exactly this place last year; and the year before that. Both times at the last minute I picked up an injury and I’d had to pull out. It’s now been three years since I last ran a road race!

And right on cue disaster struck! The day before my last long training run, just walking down stairs at home something went wrong in my left calf. I’d say I strained it but I was only walking down the stairs. I call myself a marathon runner and here I was again on the sidelines. I put it down to my sedentary job; I sit at my desk all day and my legs and back stiffen up. This is not healthy!

Out of necessity I’ve learned to be more prudent with my planning and my running. If a run is going well I back off; if I am getting ahead of the plan I take a day off or do a Bulletproof  strength session instead. My weekly average milage is still in the 20s; but then I am getting older and things have to change.  The bulletproof sessions have made me feel stronger, and perhaps been the key to where I was 3 weeks ago, fit and ready to run long. There have been no Strava records this year, instead I have a new mantra – “Less is more, slow down!”.

I’d slowed down now, that’s for sure. On the Saturday I couldn’t run and I baled from my last long training run. On the Sunday I could walk comfortably but not run.  On the Monday I could walk comfortably but not run. But then I figured something out: the damage couldn’t be that bad as it was so innocuous. What if it’s just another nerve spasm? I have a 6-year history of compressed nerves kicking off referred pain in my legs.  There was a small knot in my calf sometimes but it went away in a hot bath. Why not try to warm it up some more and see how it behaves. So off I went to the gym and spent 10 minutes on a cross trainer which doesn’t apply any eccentric force on the calf but warmed it up nicely. That went well so I tried a light jog on the treadmill, and it worked! 30 minutes and 3 light jog sessions later it was still going. My mood went from miserable to very excited in those 30 minutes. There were nearly 3 weeks to go and I could still do it. No more speed work, just one long run, some light recuperation over the next 2 weeks and 1 target paced run 4 days out and I could still be in with a good chance.

So 5 days later I ran a last long run. 18 easy miles. And sure as eggs are eggs my right calf did the same thing just as I got home. Time to brew a cup of tea and think things through!

We then spent a week skiing. Luckily there was a gym at the sports center in Tignes and I visited twice. Each time I could feel the problem but with care and a long warm-up I was able to knock out a few miles. It started to become clear that the problem had to be with my back.

High altitude training camp
So after we got home I booked a session with my physio who found the problem right away, gave me some treatment, reminded me what to do to help it recover and sent me packing.

The next 3 days were horrible. 3 times a day I’d ice my back, do some spine twisting and then some "nerve flossing" and then some heat treatment. At first I could run well, then the problem got worse and included a light pain in my hamstring, and then last Friday I was able to run pain free again.  Just 2 days to go! 

Do I run, or not run? Is it too risky? How would I feel if I didn’t try? It was Jane asking that last question that tipped the balance.

I’d more-or-less given up on my target time. Normally it’s the last 2 weeks when I focus on running at marathon target pace for several runs to get used to it.  I decided to just focus on enjoying it as much as I could; not to worry if I had to pull out, after all I was fit and I’d be running again soon. There are lots of great events to aim for over the summer.

I had a target of 3:20. That’s exactly the time I got 3 years ago; I didn’t train very hard that year but I hadn’t been injured either. Back in December I’d I figured that if I could just train for four months and not get injured then my natural speed and experience should get me to the finish line on time. Now what? Do I abandon that plan, and with it my hopes of a "good for age" entry into next year’s London Marathon? Common sense said "yes; don’t risk it, just enjoy the run".  So that’s what I set out to do on Sunday morning.

Before the start my left hamstring was hurting a little. This is the site of the original referred pain injury that put me out of the Brighton Marathon 6 years ago. I was gunning for a sub-3 marathon after training very hard for six months; all the signs were positive and then it all feel apart. I was a complete mess for some time after that. 

If you saw me at the start on Sunday you would have seen a pretty despondent chap, moping about and ready to give up and walk home. My warm-up had no effect on my leg and I’d have rather been at home tucked up in bed. Not exactly “loving it”.

Then I bumped into an old running club mate and he cheered me up a bit; Mark is a 3-hour runner but said he was aiming for 3:30 and I thought I’ll try to keep him in sight. And I remembered that there were plenty of folks having a much rougher time than me that morning so it was time for me to man-up and get on with it.

For the first 3 miles the hamstring continued to ache, but it didn’t get worse. Then in the center of the city it started to fade away and soon it was gone; to be replaced by…. nothing! No pain anywhere. And that’s how things remained for the next 3 hours.  I couldn’t believe my luck after the problems I’ve had over the last year.  Brighton suddenly seemed full of happy people calling out my name (it was on my shirt for the first time) and the support I received from friends and strangers lifted my hugely.  

For the first time in over a year I remembered my great love of running. After a slowish start I felt great, I began to think about my target time and gradually increased my pace until I was about 10 seconds per mile under that target. By mile 7 I knew that I could keep that pace going and I stayed there for the next 13 miles.  Mile after mile of controlled running, passing runners steadily with very few people overtaking me. 

Those middle miles!
That’s just how I love to run.  So long as no injury came I knew I could do it.  There was no wall, just the likelihood of some pain in the last few miles as normal. My strength training did wonders and I could feel my form holding on for longer. Perhaps I could have pushed harder and gone a few minutes quicker, but perhaps not; I had planned to run at exactly this pace and there was no reason to go any faster, I just had to beat my target.

As for the LCHF diet, I was running high(ish) after training low. Just a few slices of bread and some potatoes the day before and energy drinks before and during the race. This strategy worked well for 15 hours back in October and I wanted to try it in a marathon. I probably only had about a quarter of  a liter of energy drink and a half of water during the race.  I was sure that this last minute glucose-fest would not interfere with my long-term adaptation to running on fat.   My energy levels were still high at the end although there were signs of oncoming cramps in the last 2 miles.

I was unnerved at 22 miles when the mile markers were not agreeing with the beeping of my watch; they came about 90 seconds later. That 90 seconds was my cushion and I thought I’d lost it. Should I speed up? That would be courting disaster, so I trusted the watch, it couldn’t be that far wrong.  

Hove seafront has seldom looked so long! I focused on form and looked out for obstacles; smooth running with no sudden changes to trigger a cramp that could set me back a few seconds. Then we hit the 40K timing mats and I had just over 10 minutes to go. Perfect.  I passed Jane and our friends and they were screaming; they knew I was close. “Just keep going” always sounds like such a stupid thing to say but that is all I needed to do now.

I enjoyed the last quarter-mile immensely. It takes 2 minutes to get to the finish from the Palace Pier and I had 3. Several folks from my running club were marshaling the finish straight and there were smiles and high-fives with no need to race for the line. I finished in 3:18:40, inside the London marathon V50 Good For Age target time of 3:20.  My pacing had gone perfectly and my times for both halves of the race were exactly the same.
Happy marshals from Arena 80 AC
Beating that time was a huge relief to me. Despite a taper of troubles I’d finished my first road race for 3 years and I’d achieved what I’d set out to achieve. I was a half-decent marathon runner again! Certainly not my fastest time but after a year of not racing I was back up where I belonged.

The next day they lowered the good for age entry time for the London Marathon down from 3:20 to 3:15.

At first I felt cheated. Gutted is a great description of how you feel when something you have worked so hard for is taken away. But after 24 hour’s reflection it doesn’t seem so bad now. I hit my target and that’s a big deal for me; the fact that the goalposts were moved while I was running is not something I can control. Far worse things have happened to people very close to me recently and I should be proud of what I have done, not upset about the future.