Dr. David Unwin - 'Why black swans matter: The difference N=1 and noticing success can make'

so I'm I'm David Unwin a GP from Southport and I wrote this speech specially for all the N equals one people who've made such a difference because I became upset that they were being ignored and told they weren't relevant to science and I hope I'm going to show you in the next half an hour exactly how important you are and the difference that you can make and we should just rush through the disclosures so what should I disclose so I said before nobody pays me for anything I am actually the senior medical advisor to diabetes co uk but they don't pay me anything at all so it's important you know that so let's get on with the talk and it's entitled why black swans matter because I'm here in Australia so I wanted to give it an Australian kind of a thing black swans black swans right so you've got a you've got a prologue and the prologue really is a repeat but the point is that one patient one single patient who impressed me has in the end possibly affected maybe a million people that one Haitian what a difference she made certainly through the the low-carb program we've now done four hundred and fifty thousand people and I wouldn't have done it if that very first patient hadn't come to me and shown me that remission of type two diabetes was completely possible so this is the pro the the prologue which we can do very rapidly so basically if you have type 2 diabetes glucose can be thought of as a sort of poison we need to get table sugar out of the diet but then again what if you've already done that what if you've already done that and your diabetes is still a problem and if that lady taught me that starch is sugar and I needed a patient her to tell me that and again its revision but a starch molecule is lots of glucose molecules holding hands and digestion turns it into absolutely lots of glucose once again and I've shown this so many times but this was my interpretation to help people understand the consequences of dietary choices so that based on the glycemic index a small bowl of rice is the same as 10 teaspoons of sugar a slice of healthy boundary is the same as 3 teaspoons of sugar so not necessarily very good dietary choices for people with type 2 diabetes and once I understood that I was able to start within my own practice in Southport and by implementing a low carbohydrate diet this slide is is already out of date we've now got 71 cases of type 2 diabetes remission these are people who have come off drugs and that summarizes the improvements in lipid profile improvements in liver function in blood pressure and weight and so I started there and then we went on to a local program and as I say that's 450,000 but that's probably not it's still growing all from that one patient so much so we to find an Australian link again so the Legislative Assembly of Western Australia came 9,000 miles to Southport to meet my patients and scrutinize my data and then afterwards they were kind enough to say there is convincing evidence to support the use of dietary interventions such as the very low calorie diet and the low carbohydrate diet and the treatment of people with type 2 diabetes so that one lady that came to see me in 2012 has now affected at least 450,000 people through me and even the government of Western Australia so Wow isn't that amazing what if you could all do something like that wouldn't that be amazing so oh I'm just pointing the Black Swan there so this is kind of supposed to be a black Black Swan so you're probably wondering where they come in but there is one there for you yeah so in a way I think diabetes I think we've done that I think we've solved diabetes is very easy and we've solved it so how about we move on to another subject perhaps you're bored of me talking about type 2 diabetes so why don't I talk about something else and high blood pressure it strikes me as very very important and we know the high blood pressure is the second biggest global risk factor for disease after poor diet it's absolutely huge and yet very interesting very interesting so it was in - a few years ago I was talking amongst the doctors we were at coffee time and I said I wonder what the cause of high blood pressure is and they said don't be don't be silly David that's why we call it essential hypertension because we don't know the cause I'm saying what does that not you know should we not be interested if it's so massive and we're prescribing drugs every single day shouldn't we be interested in why they says and they know it's essential hypertension David you know we're not right so it was interesting earlier this year at the Times gave a thing and it said here right it's simply a result of ageing of the circulation because the heart has to pump harder to maintain flow through those stiffened arteries so will they where we can relax because that's the cause of hypertension because it's in the time this it's in the times and then I thought a bit more about it what if what if essential hypertension maybe it's about weight and there have been people who say that it is about weight and certainly if you look at this case here this is somebody who is losing weight on the low on my low-carb diet and you'll see over time their weight the two graphs are contemporaneous and if you look the weight comes down and the blood pressure goes down so maybe it is about weight but here's my first Black Swan here's my first Black Swan a different lady a different lady taught me something here's a Black Swan and so she fifty year old lady only weighed eight stone twelve pounds and she had a very high blood pressure as you see she wasn't at all overweight so that challenges the idea that weight is to do with hypertension because there's quite a small person and quite an unfortunate book pressure there so some more stuff started happening some more things started happening I wonder if you can guess what that is perhaps it's lucozade you know that yellow thing this has made my wife Jen very cross because that's actually her measuring jug out of the kitchen and I mean I'm sorry to tell you that it is urine it is urine and but what what I noticed what I noticed was when I went low-carb I started weighing loads perhaps some of you in the room have noticed that you just we loves you can't believe I'm up again and again and after a bit I started measuring it because I'm so fascinated how much how much urine was there pints and pies I had one patient and he lost five kilos in a week when he first went low KUB and the only way that you can lose five kilos in one week is fluid so my patients were weeing loads and when they went low carb isn't that interesting those that's something to notice and think about because it's odd and the next thing I noticed was many of the patients were certainly they benefited from salt in the diet they seemed to need more salt and I did and if they I gave them salt they felt better and they they didn't get that sort of keto flow at the beginning so salt seemed to be important and right across the world people were noticing that you you need salt and that's kind of odd because I thought salt was supposed to kill us all certain death certain death is salt stuff so I was became unhappy because I thought am i advocating something to my patients that's really bad for them and so the reason that the way that salt is supposed to be certain death is it's supposed to put your blood pressure up isn't it but here was another really weird thing I'd had high blood pressure for years so my blood pressure used to be around or not not very high but just slightly high like 160 over 90 160 over 95 something like that cuz I never went to a doctor or told anybody because that's a terrible idea but I just quietly worried away and then then I noticed another thing was if I stood up too quickly I felt faint I had to hang on to the desk this was really new for me because this was actually low blood pressure so I was 55 and I did my blood pressure BP 130 over 70 what on earth was going on this new thing so I was having more salt and my blood pressure went down completely mad completely mad so what was what was going on I was noticing things and so here we are I've introduced the the Black Swan lady the Black Swan lady and she when she went low-carb now she went low-carb because she had fatty liver which was another really weird thing given that she was so small and a completely unexpected thing was her blood pressure dropped so much she felt dizzy and if you look at some of those levels were so low I was forced to stop her Parinda prill her drugs for hypertension so that was one of the very first cases where I was forced to deep prescribe and it really fascinated me because I couldn't understand what was going on but it started happening in lots and lots of patients not just one not just two and then there were 18 who I wrote up and then there was 30 and now there are 252 in in the total cohort here's another one here's another one so this this patient had been on medication for his blood pressure for years and you'll see there came off am Lada peeing a big dose he came off her besought an another who came off to drugs for his high blood pressure and even so his blood pressure as you can see the graph there on your left his blood pressure is still really good despite the fact I've stocked all these drugs he's there as a Black Swan because some other interesting stuff happened to him the most important was he had been on Prozac which is our major antidepressant for 11 years really after 11 years nobody comes off Prozac that's a one-way thing in the old days after a while I'd start adding in a second antidepressant so you'd increase the dose of the first one and then when that didn't work tight I'd add in another one is to add in venlafaxine a second one but this guy kinda cheered up weird he kind of cheered up and went lively and actually I thought is slightly manic I thought you're a little bit worrying now a little bit too cheerful so we reduced the Prozac and then he came off it he couldn't believe it he said it was so wonderful because he said actually on Prozac he didn't feel like happy he just felt vaguely dulled the pain the misery was sort of dulled and he said I feel normal now that made him a really significant Black Swan for me because I hadn't seen that before not after 11 years his case shows you something else can you see the triple dipping there the triple dipping so what is happening is his weight goes down but then for some reason it goes up again then it goes down again but notice the second time it goes down it goes down deeper then the third time it went lower still I wonder what that reflects that jumping up and down now I actually think it may well reflect addiction to carbohydrate he's struggling to give something up he knows he should he feels better when he gives it up and yet and yet he does the very thing he doesn't want to do the thing that makes him ill and back he goes I would just say in clinical practice that is not failure you know when when when his weight went up I didn't see that as failure I saw it as a chance for him to learn how would you do Christmas better because some of those were Christmas next Christmas don't beat yourself up how would you do Christmas better and look how every time he did it he learned something have a little a number of these triple dippers each one better and that's called learning that's called getting older and learning stuff so he's a Black Swan in lots of ways just another case this now this guy yeah he's remission number 66 remission number 66 and he also makes the point that it wasn't just his diabetes but he would came off his medication in about three weeks and also his lipid profiles improved let's just talk about this Black Swan thing this Black Swan thing so if you took schoolchildren if you took my grandchildren so I I if I was to ask Lucy my adorable grandchild who is 7 in the UK what colour are swans in the UK she's gonna say swans are they're black papa she calls me papa they're black sorry she'd say they're white she's they named them she's in England swans are white in England ok but and I'd say so Lucy are all the Swans white and she'd say absolute they're all white don't be silly Peppa they're all white how interesting I come to Australia and I say to a child so what color are swans you're swans they're weird because they're black so you know are there white swans no in England are the black swans no but you know if I show Lucy one Black Swan my hypothesis my hypothesis that swans are white is finished because if I show her one Black Swan the hypothesis is dead ok if I have a hypothesis that type 2 diabetes' remission is not possible I see that first lady I know it's possible black swans are so so important and we should look for them in good science we should be fascinated by black swans we shouldn't discount them and I see across the scientific world people with interesting histories being rubbished as you're only an N equals one like you're a story you're just a story and yet if you've shown it once it's possible the next thing okay you've done it once can it be replicated can it be replicated is just one black swan or other have you got more than one black swan in Australia I wonder I have seen I've seen to a three there may be more than three I don't know but we're seeing more black swans okay my type 2 diabetes' remission I'm up to 71 so this is looking like a bit of a thing now there's 71 and here's another really important point about black swans is is there a reasonable body of physiology to explain type 2 diabetes remission have we got a theory that it kind of and then you think well if diabetes is broadly about sugar and you give up sugar and then you diabetes seems a lot better that kind of makes sense so that we should look to physiology for our our black swans reasonably and I think I have an idea that's far too much epidemiology is my personal feeling and not enough physiology because that's kind of better science and a good way to look at these fascinating black swans and then my final thing if you are collecting black swans think about data and that's what I did so I had one Black Swan type 2 diabetes remission and it fascinated me and then I got a few more so why don't ordinary clinicians start collecting data because I also adds real value to these things that win noticing collecting data so now we come so I got all these as regards blood pressure I think I ended up with I think about a hundred and fifty you know in a separate kind of blood pressure box in my head worrying about why was this happening and why you know and yet I was giving them salt and I'm searching and searching as to why should this be and that this is a rather boring slide but what you've got there is some references and who knew who knew that the physiology of this has been sorted out for years and I I love going around cardiologists now to say have you what are your thoughts on salt and the kidney and and and you know something is there anything at all about insulin and they no no there's nothing nothing that's not true so the actual physiology underlying this is that if you have type 2 diabetes you would tend to have a high insulin level and many of you in Australia can measure that insulin for people with type 2 diabetes causes you to hoard salt you're not weighing out the salt you're hoarding it and with the salt you're hoarding comes fluid more fluid in your system is increasing pressure that's really simplistic but there is perfectly good science has been around for years to say that insulin causes you to retain sodium of salt and that sort of fits in with all these other things I had noticed I'm weighing loads because a go low-carb main stealing levels drop suddenly my kidneys are releasing all that sodium I'd hoarded taking with it lots of fluid at the same time within days I'm feeling faint if I stand up so there you have a Black Swan something I'd noticed a clinically interesting thing and some physiology to underpin it so the next thing is to write a paper on it the next thing is to write a paper and this is what I'd say to clinicians is I always used to think that the likelihood of a GP or just an ordinary clinician contributing anything to science was really small was really small and in a way it's a bit like patients who feel the likelihood of them contributing anything to science is really small and yet that lady contributed something and I'd say clinicians if you notice things and then you collect data and you can underpin it with physiology well maybe you could write a paper because so often I find that academics don't think I have anything useful to contribute because they say you know you just do the clinical stuff David and and we will sort out the guidelines and you know the proper science and all the rest of it and yet I think clinicians I think we're very important just as patients are important I think clinicians are important so this is a paper I published a few a few months ago and of course I'm going to show off again because I like showing off but it it makes a point that this paper now there have been I think 1,400,000 papers published ever and this potat particular paper they they measure the popularity of papers with an ultra metric thing and this paper came as 9500 so it puts it into the top one percent of all papers ever published which is mad and bonkers completely bonkers because it started off with a woman and then you know she this that and the other she wasn't fat that sword and me wiing into a jug and it's like really weird because it's done done rather well it's done rather well and here's that one of the things that has caught the imagination of people if you look at the the circle actually I ended up taking away 21 percent of all the drugs the 150 people were on 154 patients and I was taking out all those drugs on the right hand side there are the drugs that I ended up taking out and was also the reference for anybody that wants to look at the paper which is open access and here's the thing so I'm taking out all those drugs but look at the blood pressures so even despite taking away drugs the those improvements in blood pressure are highly significant as you see from the p-values on the box and whisker so the box and whisker a way of showing distribution and that the mean and the median and the percentiles are all changed significantly here was a thing that was very surprising this went wild on Twitter when I popped it on that this was the improvements in lipid profile so that they'd gone low-carb the blood pressure had improved and again people think well probably the cholesterol get worse because they're on full fat everything and and yet look at the p-values the the lipid profiles improved really significantly and if you can improve lipid profiles and you can prove blood pressure that's a really great clinical thing to do now there may be some risks in what I do but if your weight is better and if your blood pressure is better and if your lipid profile is better I just wonder where the risk would come from you know just a question there just a question so back to the the consensus report this is a wonderful wonderful thing published this April the consensus report from the American Diabetes Association commenting on the low carbohydrate diet and the very low carbohydrate diet and they actually tell you so this is in the consensus report a massive thing they point out that blood pressure lowers their they point it out I don't think we talked enough about the blood pressure improvement that so many of us notice so many of us notice in clinical practice how about some of the black swans how about some of the black swans heart failure so a story story I had an 87 year old gentleman come to see me with his wife and I'd looked after them for 30 years he was a great re still is a really great guy very macho he'd make a good Australian he's very very macho and don't mess with him don't mess with him but actually was very sad because he was sick he had heart failure and I'd used every single drug I could think of on him and when you get to that point in heart failure those people usually don't have long to live and his wife understood that and she said there's one thing though the tablets I was giving him were causing him to we all the time because I was trying to get the fluid out of him and he was needing the toilet the whole time and that was very embarrassing because he had what you see for older people which she's a fast bladder and slow legs if you get that and so as I've said this is really embarrassing is there anything you can do dr. Amin because I know he's sick but that is it it's his dignity it's taking so I said Jim said are you up for something could we do a weird thing and try this this low-carb diet try this low-carb diet and he was a big fellow he wasn't a big fellow well a month we did this now within a month that guy was gardening and his wife said I can't stop him is he in danger because he's moving about so much and I can't you know he's cleaning the car and he hadn't mowed the lawn in years in years and this fellow is still alive now and I did that years ago he weed and weed and he went low-carb he weed and weed and weed which for a few days was really bad but then he stopped retaining the fluid and I was able to stop the frozen ID so the drug that I got him on was called frozen ID which forces your kidneys it's a mallet on the kidneys it forces the kidneys to put out the fluid but he suddenly could regulate his fluid normally now this is only one case but surely I've done it a second time so that's two black swans with heart failure cause it's borderline stuff this so folks don't go home and take please don't stop all your heart failure tablets just because don't do that but you know I'm a doctor I did it with my patients I consented them each of them felt they'd nothing much to lose because they knew how sick they were and that's - I've done so that's a that's a Black Swamp this is this is liver function this is a graph of it's actually the patient who's had his diabetes in remission longest of all my patients is at least nine years now some of you will remember that I said I started in 2012 so how come this is nine years well there's an interesting story behind this guy he did it all by himself but never told me because he knew I'd rubbish him okay so he did it years ago 2008 he was my patient in 2008 but he was very careful like so many people in those days not to tell his doctor but then he was really annoyed because on Twitter he found that I was celebrating my longest patient was six years six years and he came in saying no I am your longest patient and he said go on send me for a blood test now but you got to put me on Twitter and I want to go around the world and I owe this guy I owe this guy because look we did the blood test now in this case for the purposes of this slide I'm demonstrating his liver function so I thought his liver if you look was terrible this is liver function bad up is bad down is good so I thought his I didn't know why his liver function improved I never asked him okay I never asked it I just always got better that's good I wonder why that's happened probably no reason these things just happen you know they just happen and if you look at the graph I got bored of doing his blood tests so he hadn't had a blood test for years cuz I just thought always fine now never asked so we did the blood test again just for the purposes of bringing it up to date so years go by I hadn't done a blood test since 2015 but there we are 2019 his liver function he's absolutely spot-on and hemoglobin a1c of 34 is really good okay I know you don't work in millimoles per mole but that's really good so there was a Black Swan I missed there was a Black Swan I missed I could have been helping people back in 2008 he would have loved to have told me he would have loved but he actually he tried with one of my partners he did try he went to see one of my partners to say I'd like to come off my drugs for diabetes because I I've cured it and my partner who we won't name just rubbished him and said no don't be silly you know and had a massive argument because the guy wanted to be recoded on the computer system as non-diabetic which would have helped his insurance and there was a massive fight and he just went away for a while but he did come back to me eventually so that's interesting isn't it I missed that Black Swan I missed that one here's a more recent one so this is a lady who very fond of this lady and I'd had her on this fruit imide you know the drug froze amide that squeezes the kidneys I'd had her on froze amide because her ankles used to get massive massive and then there was her skin used to be like a tomato that's gonna split now used to worry that she's gonna get a leg also so she was on freezer might because that that will sort that out so I'd really cured her you see without any thought at all in my head as to why this lady had big ankles and you know was it through some ID deficiency perhaps it was because I gave them I gave the frozen ID and it and it worked but there's a little there's an unfortunate thing about froze right over time it actually weakens renal function and over time it can make it one of the side effects it can be diabetes so it's a bit of a sticking-plaster rather than actually a wonderful solution I can't remember now how I came across I think it was another one of these shall we have I love this idea shall we have a go shall we try this so she came to see me about something else and oh no it was diabetes that's right she was sent by one of the other partners diabetes but again after a she she came in and said look at my ankles dr. Amin and that happened within weeks and and she said there was so good I came off the frozen ID I hope that's okay because I haven't taken it for a while and and I'm just like and those are that lady's ankles so I'm it you know she's say just go on put them on Twitter go on do it I went on Twitter a great woman and no wonder she's proud so the world has seen her ankles right so we've we more or less come to the end there but just some some reflections so this is about celebrating N equals one it's about noticing them and asking and saying isn't that interesting maybe I can learn from anybody maybe we can learn from people maybe your story has some relevance and then if we find several of you start collecting data and then revisit physiology I'll try and think how might this fit in and in a kind of way isn't this science isn't this science or a diff or a different kind of science and then the other thing I'd like you to think about I also wrote this speech for the N equals one but I also wrote it for clinicians I wrote it for clinicians I wrote it for clinicians because we matter and we care and I have been rubbished so much and the things we notice the things we do should also form part of science and there's a there's a wonderful idea that my wife taught me recently she said there's two things about validity so you want your science to be valid there is a study would have internal validity this is the old-fashioned studies would have internal validity if you got rid of all of the variables so this is the RCT where we're looking at blood pressure but you don't allow patients on that who've got depression or arthritis or on drugs for anything else so you only have one variable then you know the drug treats the variable but I had a problem with that because all my patients they're kind of older and they have obesity and they're depressed and there are a verse in the UK over 70 S on for drugs so the studies don't well they don't represent my patients very well there's a other kind of study the opposite of the ones with internal validity are the ones with external validity and that's kind of what clinicians see these are my cohorts of ordinary people so in them my work is a mess it's a mess because it's just a cohort of people and they're ill in different ways and all sorts of different drugs and people say yes but what is the diet they're eating and can imagine oh are we testing them every day no they kind of just living life and then stuff happens but this kind of research has external validity and it rolls out well because nearly everybody in this audience has done that I know it's worked for you as well so stuff that rolls out and has external validity is also important so in the balance of science what we need what we need is a value of internal validity we need those studies but we also need people like us with external validity to check it works so let the clever guys do the internal stuff but the external stuff wheats been in neglected neglected and we haven't I think being belittled a little as not important and I want the clinicians get braver so I want the public to get braver if your case is unusual that then ask why and are there others but I want the clinicians to look for these black swans collect data and publish because if I can do it as mr. nobody from nowhere who's heard of Southport in Lancashire nobody's heard of that just the GP that well surely lots of other people can do it and here's another thing we seem to have started valuing massive studies so I found in 2012 all I ever did was say well how many was in the study because I had an idea that the bigger the study the more value of the study so if I saw a meta-analysis and was three and a half million people in the meta-analysis well that's definitely a good study and then I'd see a study with 50 people in and that you see that's a rubbish study do you see cuz size always matters always and I'd kind of missed out the quality thing and I think people all over the world where were more impressed than we should be by very big studies because we should be thinking about the the two things the quality of that study and how he would measure that quality but here's another thing if you had a study if you had a study with 50 people in and those 50 people were really like you that study could be highly relevant to your case he'd be far better to look at that study and what they did then a study of let's say an international study of three and a half million people taken across the world well are those people like you or you I have no idea so you see that there's a place for the small things and a place for the big things and we need to become discerning and and think about it I'm sure I've used up my time just one last N equals one to two Vinit Dez Chris there's Chris a really important N equals one I think actually he was probably the first patient Chris was he was he was I think on I wrote his case up in the British Medical Journal because I was so amazed to stop his Parinda Perl which is his drug for high blood pressure so he's the first one that's been very exciting thank you so much thank you very very much [Applause]

Channel: Low Carb Down Under

Views: 42,741

Rating: 4.9673848 out of 5

Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, Low Carb Gold Coast 2019, #LowCarbGC, Type 2 Diabetes, Blood Pressure, LCHF, Low Carbohydrate Diet, @LowCarbGP, Ketogenic Diet, HbA1c, N=1

Id: AoCzm9-J_Ok

Length: 40min 5sec (2405 seconds)

Published: Sat Feb 08 2020

Reddit Comments

[u/tomsgal85]

Excellent talk! ⭐️⭐️⭐️⭐️⭐️

[u/mahlernameless]

This was great. Whereas my metabolic syndrome came on via hypertension and not diabetes, it was nice to hear a little of myself and history in one of these talks. I totally agree with his thrust about finding black-swans. There were a lot of little paradoxes over the years that suddenly clicked together for me the more I learned about this whole low-carb thing.