Are we blaming salt for what the sugar did? by Dr David Unwin | PHC Conference 2019

[Music] so it's my great pleasure now to introduce our next speaker David Unwin who is a fellow of this Royal College and I met David in Liverpool and we had a very brief conversation about three minutes by chance but you know it David is a great example of a very common phrase and leadership which is conversations with the great purpose so every conversation has a purpose whether we know it or not and David asked me I had to think about a couple of things and I was so taken with that because I know I'm frustrated with some I'm a real doctor I practice medicine I'll be doing that on Monday I'm frustrated by the results I'm getting you know and I I feel we need a different approach and David described to me his work around a more holistic approach to the practice of medicine and some changes he'd made so I invited him to Leicester which is where I work and he gave I talk to the Leicester Medical Society and we had the highest number of people attending ever and we are a 200 year Society 200 years old Society and he transformed the thinking he's created a movement and I think the way he's done that is very very significant and he's showing through data because a data collection and evaluation is important about the reduction the prescribing for example where this is appropriate I think prescribing does have a role in in many clinical circumstances but he's shown a big difference and you know I cannot listen to him again and again and again and I shall do so now David welcome you [Music] [Applause] [Music] well here I am again Here I am again so we we've we've dealt with things globally with Robert so amazing imagine following Robert Oh crikey so he's global and and I'm tiny and I'm at the coalface so this is a message more from me from the coalface and I thought be interesting to do it as an old-fashioned detective story so you heard the music that went with that unfortunately you'll have to put up with a prologue first so you understand the detective story but before we get onto that I should talk about disclosures I really haven't got any I never take money from anybody and if I do get money I donate it to the pH C because the pH C is a charity and if we don't support the charity it won't exist so that's my my disclosure so here's the here's the here's the prologue which is kind of how I got to be the detective so you've all heard a lot of this before so we'll do it fairly rapidly so our practice and Simon is from the practice as well Norwood Avenue we'd suffered an Eightfold increase in type 2 diabetes in 30 years in the same population so couldn't be genetic could it really and then I told you before one single patient changed my life and then a lot of other lives one patient one day and she had put her type 2 diabetes into remission a thing I hadn't seen in 25 years and she helped teach me how she'd done it and that's the part of the prologue really and she'd done it by giving up starchy carbs because for her it was bread and it was cornflakes things like that so in a way that's if we look here so if you have type 2 diabetes be teased glucose becomes perhaps is difficult to metabolize it's kind of a poison really and that's exactly why our nice guidelines tell us to advise a low glycemic index source of carbohydrate I agree absolutely with Robert the very first priority is to cut out table sugar the problem was I had a lot of patients who had told me they cut out table sugar and they didn't understand why their diabetic control was so poor I had somebody only three weeks ago and when we drilled down into it he was having a packet of cornflakes every morning and you know he said well I haven't had any sugar but when he drilled out he'd had some other things it had some other things he sorted out now he's sorted out now yes so how do we help people so here's just a reminder and this is what the patient said to me she's her doctor I mean didn't you learn they say at OU level that starch is really sugar that bread do I have to explain everything to you and in a way she did in a way she did so and then we cut straight to the I discovered that it says nice says yes advised low glycemic index source of carbohydrate but hardly any doctors really know what a low glycemic index source of carbohydrate is I've asked them and they will often say brown bread oh dear no no no or a banana particularly not he's not the bananas so the other part of the story is and Simon knows this is true I became a glycemic index boy I went on and on and on about it and it wasn't Simon one of the other partners said please David why don't you go away for maybe a year and come back when you can explain the glycemic index to us but also to your patients so I went away and it did take a year and I'm very lucky because Jeff dr. Jeffrey leaves he who was one of the very first initiators of the glycemic index helped me reinterpret actually it's the glycemic load in terms of teaspoons of sugar so that if we look at the chart there somebody could easily understand that a bowl of rice is the same as 10 teaspoons of sugar or potato all the the banana there is about six teaspoons and actually it's very interesting now because with the the rise in continuous glucose monitoring many patients are able to check whether I'm right or not I know for myself I had a freestyle Libre on I have type-2 diabetes a single banana will double my blood glucose on a bowl of muesli I got two by eleven again a doubling so we use this information in the practice of the coalface and hundreds of our patients have had advice on this and as mayor was so kind to point out you know we should all collect data general practice we think we're nobody that is not true because now data is power and it's amazing isn't it we have power be we have data and we have data going back for years researchers can't get that we're getting it for free all the time from our computer systems at the beginning of this the low-carb approach was very unpopular I have been at events where I've been booed yes and so because I was frightened and scared I collected lots of data because I was told the lipid profile all died of heart attacks and lipid profiles a deteriorate etc etc and so here's some of my data so this is 155 patients so we're not talking about hundreds of thousands or millions of patients these are just our own patients it's just a cohort in a little practice in the north of England but to these people it matters actually and if you look there the weight goes down by about 10 kilos the hemoglobin a1c is how sugary of they been in the preceding 2 to 3 months and the improvements in diabetic control were amazing amazing we're now getting at Norwood if people choose to go low-carb about 46% of them will go into remission of type 2 diabetes and come off their drugs that's amazing as just as good as the direct study and to those individuals it means a great deal a great deal on top of that we're delighting the Treasury because we spend 40,000 pounds every year less on drugs for type 2 diabetes so the patient's happy I'm happy and the Treasury are delighted so there we are and just by the way look there the cholesterol doesn't actually go up it comes down and that's significantly isn't that odd because they're all having eggs more than 10 perhaps they're having eggs and they're having dairy and they're having steaks and all the rest of it and the cholesterol is coming down the HDL is the protective cholesterol that's going up but look at the triglyceride isn't that interesting drops by about a third and that's on average and it's over 2 you won't find many researchers who can fund research over two years on a dietary thing but in general practice we can do that without any funding we've had seven thousand pounds to fund something we've done for six years seven thousand pounds in total is our funding and we can come up with this and then also notice the significant improvements in blood pressure so it's been amazing absolutely amazing and in the six year so we've been doing this for six years now in the six years the whole world has changed I am NOT being I haven't been booed recently and I think the sugar debate is getting through we're making we're making real progress and recently this is so amazing the government of Western Australia sent a scientific delegation to Southport in the north of England 9,000 miles to beat us and my patients because they'd heard we were doing something differently they also came to see a lot of other people including the wonderful Roy Taylor and in the end there's their conclusion look there is convincing evidence to support the use of dietary interventions such as the very low calorie diet and the low carbohydrate diet in the treatments of people type 2 diabetes that's the first time I've seen that from a government thing like that hooray hooray hooray but there's more but there's more there we are so here we have only weeks ago in nutritional therapy for adults with diabetes Priya a consensus report by the American Diabetes Association this is huge absolutely huge and look reducing overall carbohydrate intake for individuals diabetes has demonstrated the most evidence for improving I see Mia thank God no more talk of fat and meat what's that got to do with diabetes I have no idea absolutely not but there you have it amazing amazing and that's coming from the very top so in a way I'm bored with diabetes now because it's sorted the rest lets you know the let's let the american diabetes are so this they're ready now off you go with one there we are that's good so let's find something else to be interested in so that was the prologue there we are let's be interesting something else so what have we got here now then there's that's Jen's here somewhere oh there she is Jen that's her kitchen jug now who thinks that put your hand up if you think that's lucozade in the jug is it lucozade no it isn't Luca soda I'm so sorry Joan it's urine right and what else have we got there's some salt and there's some sugar so some obviously we're going to do a sort of detective story here a detective story and what do Det detectives do I think they notice things Poirot always did didn't he he sort of noticed things and I noticed the first patient who'd reversed her diabetes but she kind of punched me in the face with that so it wasn't a very subtle noticing anyway let's let's develop this a little yeah high blood pressure so it's the second biggest known global risk factor for disease after poor diet high blood pressure really really serious it's killing millions and millions of people and you know I spent nearly all mine life doing blood pressures how much time so it's up always say oh no oh god poor patient they're scared or what would we do well we know what we'll do we'll put Mon drugs every time won't we every time I've spent 30 years putting people just giving them a little bit of this drug and that drug anyway so it's hypertension we all agree it's worrying is important yeah but what causes hypertension about five years ago we have coffee the doctors we have morning coffee together in the morning and I said in the doctor's common room essential hypertension I wonder what causes it and it wasn't Simon but there were two or three young doctors in the room and they said don't be don't be ridiculous it's called essential hypertension because we don't know what the cause is so we have this thing killing millions of people and we have no idea what the cause is isn't that kind of worrying and it's even more worrying that we're using drugs we're spending millions and billions of pounds treating this thing that we don't even know what the causes it's kind of worrying that you're using a treatment how can you be sure of a treatment if you don't know what the causes anyway never mind this is the times again not long ago and they apparently do know the cause of hypertension here we are in more than 90 percent of cases it is simply a result of ageing of the circulation because that part has to pump harder to maintain flow through the stiffened arteries so it's hopeless from the times it's aging so I wonder if the tablets help aging because it hasn't had my hair I don't know I don't know and actually I did have high blood pressure so it's kind of important to me so it's just aging so there's nothing we can do with really or just drugs it's kind of sad really whatever way we look at it isn't it so that's the times right so perhaps and this is coming back to Robbie perhaps it's all about wait that's a popular idea and we're we're always being told - that's right it's your fault cause you fat no wonder what can you expect and in fact the patients it's so tragic because they come in and they say I know it's kind of all my fault because I'm heavy and that's why I got my knee pain and my blood pressure and it's all my fault that's terrible really that's terrible and then we caught we sort of collude with that by agreeing with them yes yes because you're heavy you should do something about that but meanwhile I'll give you the drugs it's not kind of right somehow no it's not right anyway is it about weight and in some patients it really seems to be so because I'm keeping loads of data so I thought well well let's look into this and I couldn't to pace cases our new computer systems that the GP computer systems are amazing at printing graphs and I I use the graphs as as feedback because patients love to know how they're doing and they're so proud and you can imagine this patient how proud would you be if that was your graph and it I can't got my glasses on but that goes back years yes so that graph is just dropping like that but look the blood pressures doing the same so you could so easily say there you go lose blood pressure BP improves it was the weight perhaps it is perhaps it is and in fact there is research on this where one millimeter of mercury drop for every kilogram you lose so this was quite a big thing in 2008 and they absolutely looked at people who lose weight and what happens to their blood pressure and they concluded they go lose weight and your blood pressure will improve so they were you would think kind of saying right just lose weight yeah here's another patient again this person this wonderful person is the lightest I think it's yes a lady the lightest she's been since 1992 I've got loads of these I think I've got now how many of I got I'm still got about 50 patients lighter now than in the year 2000 that he's amazing absolutely amazing and the weight stays off and it stays off for years because I'm monitoring for years so this patient there we are another one she loses loads of weight her waist circumference comes right down and look at the blood pressure there was high and there is low and actually it was high there and I mean I wasn't neglecting her so I did use the drugs of course I used the drugs but she was actually able to come off them so blood pressure perhaps it's all about weight but what interests me you know science is all about questions asking questions and I think in in for all of us a lot of you are in this room cuz you're asking questions and you're thinking don't quite add up a lot of this so what's the outward losing weight cause your blood pressure to go down I'm not sure I understand how that would be so it's worth thinking about so what is the physiology I think physiology I didn't used to think it was important but physiology helps explain what happens at a cellular level or in within your body so how does being heavy cause your blood pressure to go up this is very interesting when I actually initially I was writing a paper and I took that this is the same publication as before and I have to admit I was a bit sloppy I just looked at the abstract because I thought it'll do it'll do but recently I read through the whole paper and later on it it says their weight loss might not be an independent influence on blood pressure it is possible as some aspect of diet when altered are the true determinants of blood pressure reduction so there was a clue even then they were beginning to wonder whether this was association we keep talking about Association instead of causation this is just to show you as a statistician looked at the data that Salman and I have produced and that shows the improvements for you and how significant they are the significance in blood pressure of 150 people so there's average improvements their systolic came down by ten point eight millimeters of mercury and diastolic six point two but here's the thing when I went back and looked really carefully at those 150 cases we'd managed to reduce their prescribing by 21 percent so we'd cut out 21 percent of the drugs for hypertension that's again amazing really imagine if you could do that day all of the world how much would we spend if we could cut out 20% of a drug budget would be what could I do with the money I could run low-carb clinics can i that would be good and so yeah that's amazing the drugs weren't needed and that's the drugs I got out but it actually meant of course that at the beginning of the study the patients were on all these drugs so the blood pressure eat and they weren't on those same drugs at the end so the blood pressure at the beginning was falsely low in a way because they were on drugs they weren't on at the end there was a variable in there so I went back on 150 patients and thought well what was the blood pressure why would they put on the how high was it when they were put on the drug in the beginning and if you do that the results are even better where you're getting an adjusted BP lowering of 14.8 against 8 it's really sick I wonder what the p-value of that is be very very tiny very significant right here's another thing here's a thing I noticed here's a patient - 50 year old lady she weighed 8 stone in 12 pounds and her blood pressure was high so that's odd it doesn't quite fit in does it because she's not fat just as Robert was telling us here is a lady with Noah bisa T at all she has high blood pressure so and she wasn't old I don't think 50 I hope 50 is an old cuz I'm I'm 60 so she's not old and she's not fat so that's hard and it doesn't fit him and it's quite interesting to look for things that don't fit in cause sometimes that's a clue as to where to put your attention so I just leave you with that lady and we started of course Parinda prill which is the drug of choice or I thought so at the time and there we are so and lately that's the first little thing detective style B Todd doesn't fit in she's not old not fat now then here we are sorry not Lucas age is urine Jeff when we did when we started on that on the low carb groups they all started noticing something and many of you in this room will have noticed but when you go low-carb you whe like crazy you do now we'll come on to this later but I had patients with quite significant ankle edema and I was able to take them off the drugs for swollen ankles because their ankles were so much better on a low carb diet permanently for years odd I had two patients with heart failure one of these patients was 87 years old and his wife was distraught he was on every drug including very high doses of water tablets but that is really difficult because if you're 87 what you actually have is a fast bladder and slow legs so his wife said his wife said so can we do something about this does he are these tablets really and I said well we could take a risk we could do this thing you know and he went low-carb and came off all the water tablets and he's doing very well years later and people with heart failure aged 87 don't usually go on for years he was on everything that I could think of and there was a there were two people with heart failure so this is getting a bit interesting really so what what has that you're in you know and the blood pressure improving and the loss of fluid and the edema again just interesting and I just watched it thinking this is interesting I don't understand it another clue came along but you know I don't know what the next slide is we better just have a look to see if it's wrong oh yes this is the this is the next clue so many of you going low-carb will know that you start after a bit particularly I was a a runner and you start with muscle cramps what happened to me and I discovered that if I took more salt I felt stronger and it helped with the muscle cramp so I just felt better and we know now when we go low-carb at the beginning you call it keto flu you take more salt you feel better and that was sort of worrying this more salt thing because we all know that salt is certain death certain death like a banana really certain death so it was very worrying for me to tell patients to be taking more salt because that would create totting amongst the healthcare professionals yeah so salt that's that that was kind of Ori and yeah so next slide here we have here we have so I had all this I I had all this these worries and I can't remember now how I found out but these are the references now I put them there it's a very dull slide it's a very very dull slide but what it's telling you what it is telling you is that insulin has an effect on salt who knew we have known this Robert knew because he is an international expert you see but nobody else in the room and so this is really fascinating so what's the link between insulin and salt and we have known it for a very long time and how funny it never gets talked about just odd so we're all told cut salt cut salt cut salt and until recently sugar was kind of fine very odd and this is where I worry that this is the title of the talk isn't it are we blaming salt for what the sugar did because it turns out that if you have type 2 diabetes there's a particularly strong effect where your kidneys will hold on to salt because of insulin so if higher insulin and insulin resistance that causes your kidneys to hold on to that sodium and then I agree sodium does bad stuff but why and this question why we must ask it again and again why so he holding on to the salt nature actually this thing called homeostasis is brilliant and it's there to keep us in balance so we were designed if you're on a salty diet because you live by the sea did you die because you can cope with a salt no you didn't die because we're adapted to get rid of salt but if you become diabetic you can't get rid of the salt as easily then when you go low-carb goodness me I mean how many pints of urine do you produce it's so surprising and actually I'll admit I did measure it with jokes sorry Jen because he's just so fascinating you just can't believe how much urine comes away wet you know I mean look so slim - it's it's great cuz you you know you're going I've lost so much weight and was so much weight so and there are studies to support it this salt this days kind of depends on sugar I think quite often and that we don't need to worry perhaps I should say perhaps we don't need to fret too much about the salt that we put on our food if the diet if we're not diabetic and if we're not taking loads of sugar because it's the sugar that starts the problem is the sugar that starts the problem but isn't that weird and it's been known for ages and I just use drugs and I never thought about it ever so fascinating this idea watching that the ice to think like we knew all the science and I was a modern doctor and so I knew everything and we hardly know anything at all and and you can still as an observant person notice things that make a difference so the very first patient the people whose ankles went down I found I felt dizzy so what happened to me the thing I noticed was I had reasonably high blood pressure and but it was odd because when I stood up to go and get a patient I was hanging to having to hang onto the desk because I felt so dizzy it was just my blood pressure was dropping I wasn't used to low blood pressure because I'd never had it and then one day I took it how so delighted because so odd I felt dizzy and then the patients were feeling the same so I started having to cut the medication because I was really worried one of them would hit the head and then a legal case oh everybody's frightened relieve me so there we go I don't know what we're going to do next this is back to that patient so this says is that that first patient and she's a really interesting case all my cases are consented all of them she's actually a lucky woman because normally a 50 year old with a you know you wouldn't suggest a diet just somebody weighing 8 to 10 12 pounds with a normal BMI just so happened she had fatty liver ha ha so I had already noticed that when you put people on with a fatty liver on a low carb diet their liver function improves in a week or two weeks you can mop it out so fast so I thought well obviously I discussed it with her she was concerned about her liver function and her blood pressure I didn't know it was going to do the blood pressure her liver function normalized after years very rapidly but there was a surprise because her blood pressure dropped and you see the second set of stuff I put in there was the fat type she came off Parinda prill years ago so this rare wonderful patient I learned such a lot from that one person we can learn a lot we can learn a lot from these huge meta-analyses we can learn a lot from enormous things but there is still a place for the scientist in all of us there is still a place to observe ourselves and what makes a difference and when you feel better I think a lot of you have done that and once you've done it and it works and if you feel well you kind of brave aren't new cause you don't care what somebody tells you about you know you need to take the drugs you think you know I'm sorry I don't trust you and if the medical profession is not careful we're going to lose trust if we keep suggesting things that are not in keeping with what the patient's beliefs on understandings are and this is what mayor and I are so passionate about which is collaborating working with patients and listening to them and that gives a wonderful future really if patients care if doctors care and we collaborate bearing in mind what patients feel which I wasn't doing before but now I do yes epidemiology I worry about epidemiology quite a lot but the other side use epidemiology so I'm going to use a bit in the ology and this is a wonderful thing it happens to have been done by Geoffrey leaves II the expert on the glycemic index and he's done a meta-analysis there 44% increase in in cardiovascular risk for each additional 65 grams on the glycemic load that's glucose and there's the risk its epidemiology it's a theory but there's some evidence for it that the more the more of the glycemic load you have it relates perhaps to cardiovascular risk and I'm always being battered with with these enormous studies there's a matter analysis I think it's a bit wrong that we always are more impressed by the big studies the more numbers like it's better it's not always better Zoe and I were saying this last night it's not always better just cuz it's a meta-analysis and big numbers it's the quality of it but nevertheless that's a meta-analysis yeah so there's another patient who came off amlodipine and urbis our turn on the low-carb diet now amlodipine I've grown to dislike him Lada being a bit like bananas I find amlodipine causes ankle edema it's a really common side effect I also find that so many doctors use a lot of thing for the blood pressure and then when you get ankle edema instead of thinking why has the patient got an Kadima they put in a water table as well no thought but anyway that patient had ankle edema and was delighted to come off the amlodipine because the ankle edema also gave her headaches as well so we could have done the headaches what could have added to for that Co proximal oh then you've got constipation but don't worry because I'll give you lactulose ankle edema diuretic so it gives you doubt don't worry I've got a drug for gout as well I've got something for everything you know right yeah and here's another thing this particular patient really interesting case it's actually a man he's come off Prozac he'd been on prozac for 11 years and he was it just changed him because he took control over his life at the beginning of the process he couldn't earn a living and one of his problems was was money really now he has two jobs he's off all his medication he's off his antidepressants he's a new man imagine the kind of medicine that that is for me that keeps you behind the desk it's wonderful it's what I became a doctor to do but for 25 years I didn't do any of that I didn't I don't know I was half asleep this is cheerful potentially cheerful medicine working with people like you to get good results what's this oh yeah yeah so you remember the the consensus thing massive consensus thing but if you look carefully they know about the blood pressure because there it is look and again they've not made a big song and dance of it but they are mentioned they know it helps blood pressure so I think maybe that as I say diabetes right but let's think about the other parts of the metabolic syndrome because all of them improve together which is why you it's just win-win-win situation oh yeah what's this about yeah do you remember we've had a lot of discussion really about the fact that individuals get rubbished we're there any course Juan along the lines of yes well you're just another it noisy annoying example of a person that should shut up N equals one can matter N equals one can matter and there's a wonderful analogy that many will have you will know about black swans so if we ask my grandchildren what color is a swan they'll say it's white are all swans white yes swans are white but it only needs you to spot one black swan to know that that hypothesis is wrong and that hypothesis can never stand again because I've just shown you a black swan and that the N equals one people are potentially black swans and if on top of that it can be replicated and it isn't N equals one anymore but it's N equals 150 or n equals whatever then the people who tell us the hypothesis is sound they have a problem a hypothesis is disproved by a case straight away doesn't stand anymore there must be some other explanation you have to look again for another hypothesis that includes the back Swan and the other thing if you if you're looking at cases if we if we're looking at research there's this thing about looking at the meta-analysis but does do the people in the meta-analysis represent 60 year-old GPS that live in Southport am I like them I have no idea but if I could find let's say 50 60 year-old GPS in Southport the evidence from those 50 may be a lot more important to me as an individual than hundreds of thousands of people who are not like me anyway and so that's another thing about the size of studies it doesn't mean they're great just because it's a meta-analysis in it's big and as GPS we don't need to be frightened unbossed about by enormous studies because I used to feel I wasn't a scientist as nothing I can do my research doesn't matter why even collect data why even begin and we do get rubbished I have been rubbished many times but actually you can make a difference and have a better life so it's worth doing black swans you can only you can't actually prove a hypothesis you know you can only disprove it and while it disproves while you can't disprove it it stands but once you found a black swan it's dead and you need to think again we're coming to the end I've just got to celebrate some of my patients I absolutely love this guy this is Chris years ago Simon and I published his case in the BMJ and he's a very good example of what you can do his life is changed and remains changed so he had high blood pressure we sorted that our diabetes we sorted that he was on the statins whose doctor he wasn't in control of his life he now is he's fate he's health is about how you live your life he has a great life that was really really worth it and it's not a life that drugs could give him it didn't matter what drugs I gave that man on the left it did not make a difference to him he was still in pain he was still depressed and in fact the side effects of the metformin were quite difficult for him because the communist side effect of metformin his diarrhea and he drove for a living so quite difficult it doesn't matter how many drugs we add and add and add you will not end up with a well patient that's the thing that lifestyle can give you though that's the thing the lifestyle can do it's unlikely that spending millions and billions on drugs is going to sort all the problems that we have in my very humble opinion surely this is the end oh yes I'm just showing off finally showing off we're seeing this is the second time we've seen Matt Hancock isn't it and look he's holding my teaspoon of sugar equivalents how kind how very very kind of him and there he is and yes he believes in it but there's more there's oh no there's more there's more we're going to we're going to crescendo you'll see yes so this is the big that big thing healthcare professionals are terrified of nice and guidelines they all the young doctors are bored to death because they have to memorize guidelines and if it's not in the guidelines they won't do it because that's dangerous they are not guidelines you know that you don't have to do it sorry they are guidelines they're not tramlines and that's what David Haslam says who is the chair X patient hopes an experience and doctors expertise are just as important as nice guidelines but the college this is where the college comes in thank you thank you the college put my work through to nice and to my amazement they put it through for a prize I didn't win the prize but that doesn't matter because the judges in Nice thought the work was so interesting that the 7 teaspoon of sugar equivalent things you see there have now been linked to the nice guidelines on to on type-2 diabetes and that means that any of you can now quite safely talk about those teaspoons of sugar equivalents with patients and no tutting from anybody because it's now an endorsed resource from nice [Applause] I really I really am coming to the end and now I'm bringing it relevant to the PHC the charity we have set up so we've got something useful there and we really need to bring this to the attention of health care professionals who maybe are not aware of the deadly potential of the banana so what we are doing and this is for the ambassadors we've produced an a4 envelope for you of nice endorsed resources that it's perfectly reasonable that any of you can take to a GP dietitian practice nurse just to say I have these nice endorsed resources I think it may be relevant and the more we do that the more we get this out there the faster we will deal with these problems so I think we've got some of the packs here have we we've got some of the pack what I've got away my con cool yeah if you want to get these digitally so that you can just print them off whenever you like if you go to the website pH cuk dot org forward slash nice and then that you'll be able to download all of those as well as the link to the nice website where these are endorsed thank you so that's me from the bottom of my heart thank you [Applause]

Channel: Public Health Collaboration

Views: 109,414

Rating: 4.8506808 out of 5

Keywords: diabetes, diet, nutrition, health, public health, low carb, obesity

Id: gyZVTsHyLU0

Length: 43min 48sec (2628 seconds)

Published: Thu Oct 17 2019