First published Autumn 2018


 

A spoonful of sugar might help the medicine go down for Mary Poppins, but type 2 diabetes is crippling our health service. Louise Wates finds out about the NHS staff who are fighting back

This August, the British Heart Foundation warned that by 2035, England could see a 29 per cent rise in the number of heart attacks and strokes — directly because of an increase in the number of people suffering from type 2 diabetes.

Lifestyle diseases, particularly type 2 diabetes, are currently putting the most pressure on the NHS; with the situation so critical that the future of our health service, which celebrated its 70th birthday this July, looks uncertain.

But within the NHS, there are growing efforts to fight back. Significantly, on 5 July — 70 years after Clement Atlee’s post-war government ushered in free healthcare for the nation — one hospital decided to do something most of us would never do for a birthday celebration.

It gave up sugar.

A sugar-free challenge

Tameside Hospital in Greater Manchester has not only removed sugary, unhealthy foods and snacks from its premises. To mark the NHS’ three score and 10, it also invited its staff and the people of Tameside to go sugar-free for 70 days.

Susan Osborne, spokesperson for the initiative, says: “Radical thinking led to [the NHS’] creation and its founding principle of free, high-quality health care for all. Now, that same radical thinking approach has to be directed at one of the biggest challenges it now faces — the growing health-related consequences of obesity.”

The estimated annual cost of obesity to the NHS, she says, is approximately £5 billion; a figure that is expected to rise.

The Tameside challenge, however, follows a staff weight-loss programme. Prompted by concerns about the health of the hospital’s workforce, 100 members of staff — consultants, midwives, community nurses and medical support secretaries — took part in a 12-week Slimpod trial. During this time, not only did participants all report health improvements and benefits, but one participant lost 13.1 kg (2 st) over the 12 weeks, and one who had been chronically diabetic now has the condition under control.

The hospital has also become the first within the NHS to ditch sugary snacks and drinks from its restaurant. The plan, now, is to extend the initiative by improving patient meals and getting rid of sugary snacks and drinks from its on-site shops and vending machines.

But the initiative doesn’t stop there. Osborne says it is hoped to get a bigger conversation going and to encourage schools, colleges, and Tameside council to take up the challenge.

“We opened a debate,” she says, “but made it clear we were not endorsing any one idea or diet.

The hospital has also become the first within the NHS to ditch sugary snacks and drinks from its restaurant

“Tameside Hospital has ditched sugar from its canteen. It no longer serves puddings, and the chef and his team are constantly looking at ways of offering healthy options in the restaurant, which is used by both staff and visitors. We understand the nutritional needs of patients can often be complex, but we are currently reviewing our menus and the choices on offer.”

Whilst the Tameside challenge aims to inspire others through leading by example, elsewhere within the NHS there are other professionals who have already been doing this for several years.

Nice guidelines

Dr David Unwin, a softly-spoken GP based in Southport, Merseyside, has become a formidable voice on the treatment of type 2 diabetes. His surgery spends an average of £38,000 less each year on diabetes medication compared with other surgeries in his area, and many of his patients are now symptom-free and off medication. The secret of Unwin’s success is quite simple: a low-carbohydrate diet — less sugar and fewer starchy carbs such as bread or potatoes that break down into sugar.

In 2016, when Unwin received the National NHS Innovator of the Year Award for his “outstanding” work, he described diabetes as a “national emergency”. Now, following NHS approval of a low-carbohydrate plan from diabetes.co.uk — one that Unwin played a leading role in developing — it is hoped that the rise of type 2 diabetes might not just be halted, but reversed.

Historically, type 2 diabetes has been treated as an irreversible, life-long condition. Unwin says that until 2012, in 25 years of practice, he had never seen a patient reverse their diabetes. But six years ago, one of his patients did.

“I wondered how she had done it,” he says. “It turned out she’d been part of an online society and to my utter amazement there were 40,000 people online, helping each other.”

The patient had been following a low-carbohydrate diet and told Unwin he ought to know that starch — found in carbohydrates such as bread, pasta, potatoes and rice, and which are recommended by Public Health England as the basis of a healthy diet — break down into sugar, which then has an impact on blood sugars and insulin production.

Unwin says that from that first patient, he was determined to learn more and began to question whether starchy carbohydrates were good foods for people with type 2 diabetes.

“It could be said they have almost a ‘carbohydrate intolerance’ so their bodies can’t deal with it,” he says. Eventually, he asked some patients with pre-diabetes if they would like to try a low-carbohydrate diet, going on the diet himself, even though he did not have the condition. “Personally, I was surprised that I wasn’t hungry,” he says. “At the same time, the results that were coming in for the patients were really good.”

Unwin also signed up to diabetes.co.uk — the online community his patient had been using — to find out more. The site, he says, “was being rubbished by the medical profession”. So when he offered his help in his professional capacity, he was immediately suspended as a troll.

“I didn’t know what a troll was,” he laughs. Until then he had no experience of social media, and his children had to explain what it meant.

Since then, Unwin has joined Twitter as @lowcarbGP and can be found on YouTube. More recently, he and his wife were interviewed on the BBC documentary The Truth About Carbs. He was welcomed back by diabetes.co.uk some time ago and is now the community’s senior medical advisor.

... he asked some patients with pre-diabetes if they would like to try a low-carbohydrate diet, going on the diet himself, even though he did not have the condition

Low-carbohydrate diets have long been controversial, however, and some doctors have faced criticism for recommending them while the carbs versus fat debate rumbles on.

However, Unwin explains that his recommendations were, in fact, in line with guidelines then and now.

“I’m very clear that the NICE guidelines for type 2 diabetes specifically mentions that we should recommend low-glycaemic index sources of carbohydrate,” he says. “And for me that really describes a low-carb diet because there are no low-glycaemic breads that I’m aware of, no low-glycaemic index breakfast cereals, and no low-glycaemic potatoes.”

Yet Unwin’s patients do have a choice. “What I would say is really important — another thing that NICE guidelines enshrine is individual choice.

It’s essential that people enjoy the food that they eat; I don’t force patients. It’s an option, and it’s an exciting option if you want to come off medication. I’ve discovered that patients are very interested — and are prepared to make dietary changes to avoid going on lifelong medication. That really surprised and pleased me.

“Patients are far more sophisticated than they are given credit for in terms of their wish to be well and ability to make positive lifestyle choices.”

It’s possible some GPs may remain reluctant to support lifestyle changes over medication. In such a situation, Unwin advises polite compromise.

“The NICE guidelines are helpful here because they enshrine individual choice,” he says. He suggests if a person finds their GP is reluctant to put off medication, that patients propose trying lifestyle changes just for a couple of months, perhaps with the agreement to go on medication afterwards, should it fail to make a difference to diabetic control.

But, says Unwin, there is a growing interest among British doctors in lifestyle medicine — particularly young ones coming into the profession. Conferences on the subject are selling out with long waiting lists. And if the NHS is to be with us for another 70 years and beyond, he thinks that lifestyle medicine is the way forward. “Surely this is a more cheerful, patient-centred and yet cost-effective way to go,” he says.

Keeping it simple

Another NHS doctor whose practice spends less than the national average on type 2 diabetes — despite having around twice the national average of type 2 patients — is Dr Kesar Sadhra.

Based in Slough, Berkshire, Sadhra has looked after the practice’s type 2 diabetic patients for 29 years; most of whom are South Asian and so have a higher risk of developing the condition. Among his patients aged over 65, around 45 per cent are diabetic. Including pre-diabetics, that shoots up to around 60 per cent.

Like Unwin, Sadhra offers his patients a choice between medication or trying lifestyle changes including diet and gentle exercise. He says that with type 2 diabetes, he had always felt that insulin and similar medications did nothing to treat the underlying problem. “You’re almost aggravating it, because of the [side-effect of] weight-gain,” he says. “Right from the early days I have been an anti-insulin initiator, but I got criticised because it didn’t go with the flow and the recommendations.”

In the early 2000s, Sadhra started looking at the glycaemic index of foods that were typically eaten in the South Asian diet and began experimenting with alternatives. Being Punjabi, he not only understood South Asian tastes and culture but was also in a position to lead by example, changing his own diet even though he was not diabetic.

He says whilst the food patterns followed by his patients were not dissimilar to those of the general population, he needed to make his message culturally relevant. “I started looking at what the alternative could be that was not going to shock them — what they were going to find acceptable.”

Sadhra tells his patients to focus on cutting out chapattis, breads, rice, pastas, potatoes and cereals; and if they can’t cut them out completely, to cut them down to a minimum. “The first thing they ask is what can they eat.” The majority of his patients, he says, tend to base their meals around chapattis, bread, rice and potatoes — all starchy carbs.

He shows his patients A4 images of traditional foods in which rice, potatoes and chapattis have been replaced by large, finely-chopped mixed salads and vegetables. “I say choose whatever salad you like, it doesn’t matter.” He asks his patients if they think the images look good, and if they think such a meal would fill them up. “The general reaction is ‘yes, probably a bit too much’.”

Visual examples, he says, are important because many of his patients — particularly the elderly who might not be so literate — will not want to be over-loaded with information. Consultations are kept to 10 minutes, and the patient is given a little bit of digestible information to take away.

Many patients go by folklore or what their peers say, he explains. “If you start telling them about carbohydrate content, percentages and GIs [glycaemic index it goes above them. If you give them the right message supported by the right pictorial messages, and approach them with sensible alternatives that they can relate to, then you can succeed.”

“...with my patients if I am seeing them regularly they will be doing very well. If I take the pedal off the gas and don’t see them for a long time, six months or more, you know the vast majority of them are going to slip up”

He also uses charts and diagrams to show how blood glucose spikes after eating foods such as bread, or how combining fat and protein with carbs (so eating a keema naan as opposed to a plain naan) can reduce such spikes. He also uses charts depicting improvements in individuals, showing patients that they can get better — “it gives them confidence”. He always emphasises that his evidence is experienced or observational and makes it clear that he has not carried out clinical trials.

“The results have been immense,” he says. “They’re incredible on the people who cooperate.” But the message needs to be reinforced. “I’ve noticed with my patients if I am seeing them regularly they will be doing very well. If I take the pedal off the gas and don’t see them for a long time, six months or more, you know the vast majority of them are going to slip up.”

The difficulty in keeping patients on track is because of mixed messages: from the community, the environment (we discuss a sign for a “desi breakfast” near to his practice — £5.99 for a selection of high-carb foods), or from current dietary guidelines that are at odds with a low-carb diet, even though the latter has been approved by the NHS for type 2 diabetes.

“They [read or hear] the opposite to what I have been saying. They talk to other people with diabetes who say that’s not what their dietician tells them. Or they go to a dietetic talk with the diabetic clinic and are told they should have some carbohydrates.

“The low-carbohydrate approach is gaining a lot more force but it’s still being criticised and not being allowed to flourish as it should.”

Recently, a report in The Lancet Public Health prompted headlines stating that low-carb diets could shorten life. But the study, he says, “has got a lot of flaws” and lacks consistency.

“Common sense tells us that type 2 diabetes particularly is related to carbohydrate intolerance — it is the body not being able to manage because of the insulin resistance.”

Sadhra says that when he publicly spoke about the programme several years ago, he was criticised by dieticians for not following guidelines as set down in what was the Eatwell Plate and is now the Eatwell Guide. He says after that he didn’t talk about it and just “persisted quietly in the background”.

Even a consultant radiologist who recently came to him as a patient didn’t know about the impact of diet. “I told him the choice was his; either go with the standard spiel and start on medication, or did he want to try and put it in remission? He said obviously he would like to sort himself out. Now his HbA1c [average blood glucose levels] are at the sub pre-diabetic range. And he’s stayed off medicine.”

This patient, says Sadhra, was “a knowledgeable, educated person” but had not known that starchy carbohydrates could be impacting his health.

Sadhra’s approach has resulted in yearly drug budget savings in diabetic medications equivalent to 10 per cent of the practice’s total drug budget for several years in succession, whilst achieving one of the best HbA1c control targets for a practice in the clinical commissioning group/locality. He hopes that now a low-carbohydrate diet has been approved for type 2 diabetes, a change in guidelines will follow.

And if it can help to turn the tide on this particular disease epidemic, that might be the best birthday present our NHS could get.

Visit: www.diabetes.co.uk/in-depth/kesar-sadhra-type-2-diabetes-south-asians-diet/ 

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