Defeat Diabetes

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Dr Unwin is a UK family doctor (GP) and researcher widely credited with transforming the treatment of type 2 diabetes through a low carb approach. In the decade since finding success with using low carb as a medical intervention, Dr Unwin has improved the health outcomes for nearly 10,000 patients.

Why I started low carb 

In 2012, I was thinking of retiring. I was disappointed in myself because it didn’t feel like I was making a difference. We would tell people that they had pre-diabetes, but we didn’t do much about it. My wife (psychologist Jen Unwin) happened to be reading ‘Escape the Diet Trap’ by John Briffa, and we decided to give low carb a go. We then took 20 patients initially, gave them the book and started weekly sessions. The results were amazing: weight loss, increased energy, and they were taking control of their health – and doing better than they thought possible. 

How I implemented low carb in clinic

1. At the first appointment:

a. Explore possible benefits/risks of a lower carb approach to type 2 diabetes (eg medications, risk of hypo) and make a start on patient motivation.

b. Visit the basic physiology of sugar, starting with the fact that ‘your HbA1c shows how sugary your diet has been in the last few months’, and explain sugar can almost be seen as a metabolic poison to someone with type 2 diabetes.

c. Establish baseline data: Weight, waist, height, TBC, HbA1c, renal, and fasting lipids.

d. Addressed the need to alter medications:

i. Insulin, gliclazide: Reduce dose/stop but monitor

ii. SGL2 Inhibitors: Stop, but monitor blood glucose

iii. Hypotension: Explain that with weight loss, BP may well improve, and medications for this may be reduced

2. 2-4 week review: Weigh, measure waist, BP. Ask follow-up questions:

a.Do medications need to be changed? 

b. How is it going?

c.Ask about hunger: do they need to drop their carbs a little more so they can burn fat? Another possibility to help with hunger is to increase the dietary protein. 

3. Educational resources were produced to support patients and staff.

4. Inform the primary care team (physiologist, pharmacist, dentist, optometrist, podiatrist, etc.) that the patient is following a low carb education plan (DD as the source) and align treatments.

Results of implementing TCR

  • By the end of the 8-year period (March 2013–April 2021), my surgery had a type 2 diabetes disease register of 473 people, of whom 186 (39%) chose the low carbohydrate approach.
  • Median weight loss for those following low carb was 10 kg
  • Median HbA1c dropped from 7.9% to 6.4%
  • The median systolic blood pressure dropped from 140 (134–150) to 132 (122–138) mm Hg
  • In the first year after diagnosis, 77% of those given low carbohydrate advice achieved type 2 diabetes remission, with a HbA1c of <48 mmol/mol (6.5%) while not taking any diabetes medication. 
  • There were major prescribing savings; my average surgery spend was £4.94 per patient per year on drugs for diabetes compared with £11.30 for other local practices. In the year ending January 2022, my surgery spent £68,353 per year less than the area average.

Key learnings 

1. For clinicians considering advising a TCR approach for patients who are already on anti-diabetic medications, there are three important considerations:

a. Whether the drug/diet combination poses a risk of hypoglycaemia.

b. SGLT2 inhibitor drugs, combined with a low carbohydrate diet, have the potential to lead to diabetic ketoacidosis that may be masked by relative normoglycaemia.

c. As demonstrated in our service evaluation data, lowering carbohydrates in the diet is associated with a lowering of BP, so medications need to be considered.

2. Three worrying patterns regarding HbA1c and weight were noticed:

a. Weight and HbA1c are climbing: The most common reason is ‘carb creep’, NOT failure of the diet needing medication. So check for this by rechecking dietary intakes.

b. Weight loss alongside a climbing HbA1c is worrying. Consider type 1 diabetes.

c. HbA1c ‘too good,’ e.g. 28mmol/mol (4.7%) could the patient be anaemic?

3. Over time, many patients drift. It’s better to see this as a learning opportunity. We all learn from our mistakes!

4. Genuinely inquire into the personal health goals of the patients and what they are hoping for. Playing with their kids or grandkids? Being able to travel and walk everywhere on holidays?

5. When patients are diagnosed, use the powerful placebo effect of hope:

a. “The good news is you could change this.”

b. “You don’t have to have this progressive deteriorating condition.”

c. “If you’re prepared to change your behaviour, things could be even better; you could have better health than you have now.”

6. Compliment patients when they achieve something. A sincere compliment increases resilience.

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