Non-alcoholic fatty liver disease. Is diet the culprit? by Dr David Unwin | PHC Conference 2018

[Music] and now it gives me great pleasure to introduce one of the heroes David Allen well well hello can you hear me marvelous marvelous I'm just interested to know how many of you have heard me speak before put your hand up if you oh dear that's terrible that's awful because the the first third of this is a kind of recap so all of you are going to be very bored in the first beginning but anyway well we'll we'll have a go we'll have a go so I'm going to do a little little recap that will bore many of you and but then I'm going to move on to stuff that I hope is more interesting to do with the liver and triglyceride and then we'll finish up with a few last-minute things that have happened recently I ought to tell you who I am though I think a lot of you know so I'm a GP from the north of England I come from the Norwood surgery north of Liverpool and we've been using the low-carb approach for about five years now in our practice and it's made some of the changes I'm going to to share with you disclosures are supposed to disclose things well where shall I disclose I don't earn any money at all from this we don't have private patients if I do earn anything I actually donate it to the pH C array that's something somebody said to me yesterday afternoon they said that I am biased so I suppose I ought to disclose the fact I'm bias so this person said that I was biased and I thought about it and it may be true I think I am biased in I really believe that a low-carb diet can make a difference and the funny thing is I think my patients are becoming biased as well because do you know they seem to believe that the low-carb diet makes a difference and then it's weird because they're not using drugs anymore and they're losing weight and so this bias thing is very interesting is it I may be biased that may be a good thing to accuse me of but I'm certainly enthusiastic and I hope I'm going to to share that with you so we'll have a go now see what comes next oh yes right so many of you know that I had that's an old guy like me in the wilderness and I was in the wilderness for 20-25 years of diabetes as a progressive deteriorating condition i prescribed drugs I did my best it didn't go very well it was very disappointing and I came to a point where I was ready to live to leave medicine you could see he looks rather a depressed old guy there in the wilderness and that was that was me that was me and then moving on if we look at this slide this is very interesting so hemoglobin a1c as you all know is how sugary is this patient been in the preceding three months and more sugary is worse and less sugary is better and so the the point is at that point in time that patient I told him he had diabetes and look what happened in 38 days he'd reversed his diabetes put his diabetes into remission and that is an amazing thing to see in 38 days that's not something I'd seen anything the equivalent of in 25 years and law what happened to his waist look at that dropping this guy's proud he's wearing jeans he looks amazing I saw him only a week ago amazing somehow we've gone from the confused old GP stumbling into retirement into seeing cases like this and you know Simon Tobin's here from my practice sitting right there hello Simon we are we're seeing every week people whose diabetes is improving in this way every week in fact every day for me so moving on so one of the things people say is well yes you know it's a few cases and no wonder because I give them loads of time and they do very well so these are some later figures latest figures of what happened to our surgery overall so thinking about Norwood Avenue here we were about 2013 these these are we're looking at quality so going up is better and down is bad and there we are losing their Norwood Avenue was we were worse at the time than NHS England north of England commissioning whoever they are Cheshire South bottom for me is our local CCG and there we were at the bottom and we've really tried very hard in the five years it isn't just the patients on the reef down the research cohort it's a practice wide approach and you'll see that gradually over the years there we are and oh look hooray we're winning there look at that there we are so we're the top of NHS England or that our hooray so it is a practice wide thing isn't just the few patients that I'm seeing it's all of them thinking about my practice it's just interesting I know I've told you before but we think about what has happened to our communities so when I when I joined Norwood Avenue in 1986 there were 57 people with type 2 diabetes 57 and now 550 550 so in my professional life I've seen a tenfold increase the waiting room was completely different the people look different and much heavier much heavy and the point is I simply do not accept I do not accept that this epidemic should be allowed it it's obviously reversible these people cannot have changed genetically in one generation something has changed we mustn't accept it we must fight it people don't have to become fatter and become diabetes absolutely not necessary I believe it's diet that's made the difference I think that is what has changed moving on so what are we doing about it so I mentioned we have a research cohort and these are some of the latest figures because it's changing it's being updated every day so this is 93 patients with type 2 diabetes and this is what has happened they've been on the diet for an hour average of 20 months you see most of the studies are quite short term what Norwood Avenue represents is we've been doing it for a bit longer so the studies are longer-lasting so this is an average of twenty point nine months let's look at the people when they began again we're looking at hemoglobin a1c so up the page is bad because it means you've been more sugary and down the page is good when these people start this is the the research cohort they have an average hemoglobin a1c of 63 that is actually poor control so these are not average diabetics they're actually they're some of the worst ones 63 is poor control and then look what happens on an average of twenty point nine months so those those people the average has come down to 47 from 63 what that actually means is the average person the average patient at 47 looking at the way Roy Taylor classifies remission of diabetes the average patient here is in remission of their diabetes without using drugs so we're actually getting 50% of those people 50% of them are have remission of their diabetes that's amazing I never thought I'd live to see such a thing when we started looking at the statistics it was a very great surprise a great surprise Oh we've gone blank oh there we are so you've seen this slide before but this is an updated one January 18 so year after year Norwood Avenue there we are we are the cheapest in our area for drugs for diabetes were simply not needing the drugs for diabetes we are the cheapest so we're not using drugs we're obviously doing something else and the point is that when when you look there so we spend at the moment 38,000 pounds less being here on drugs for diabetes than his average for our area that's a recurring saving that could be spent on on patient care sadly we don't get to keep that money but we should because we're actually saving the government money so we're not using drugs I'm really falling out of love with drugs steadily because I just so they can help but so often they don't and we should try lifestyle first and we should particularly give patients the choice first before we start using medication if we can moving on oh yes so here's a thing here's a thing so talking about how we did this at Norwood Avenue this is a starch molecule and it's actually made up of glucose molecules and this is very interesting in that so often I'm told oh well I've given up my sugar and I don't know why I'm so heavy or why my diabetes is a problem because I've given up sugar and I think what so often happens is people don't realize that starch is actually concentrated glucose and is made up of glucose it's interesting I I was talking to thirty thirty young doctors teaching them there about AD reject when t ate in Manchester three weeks ago and I asked the question I said what is the building block of starch 30 young doctors only one knew it was glucose only one um OMG OMG only one so we have a very long way we have a very long way to go if we have that sort of level of knowledge I mean they they all of them when I pointed out all that I I gave a house point you are an Olympic genius you know that starch is made up of glucose and then they all remembered it so it only needs a little reminder but it does make the point about education and here we are here we are in the core here of the establishment in the Royal College and I do hope we can do something about education I do hope when I think of my own education and nutrition I don't remember whether I learned anything at all possibly hard ten minutes I don't remember that 10 minutes but we had days and weeks of pharmacology and so of course my paradigm was that drugs were very important because I spent so long learning about them and the basis of my knowledge was was pharmacological anyway moving on moving on oh yes right so you've seen this before so again in the practice we we know the guidelines that the nice guidelines say that we should encourage low glycemic index sources of carbohydrate trouble is none of us really understood the glycemic index and one of my partners said go away David and when you can come back with something I can understand you know I'll teach the patients so I came up with the idea of the teaspoons of sugar equivalent so if you look at foods that contain carbohydrates you can actually rework that glycemic load from glucose into teaspoons of sugar and this gives you an idea of what is happening to your blood glucose when you consume these foods and what's interesting how often have we been told that brown bread is a excellent thing for people with diabetes but you know that's only a small slice and it's going to affect your blood glucose to the same extent as three teaspoons of sugar and actually look it's hardly any better than white bread I think we've been sold and nonsense with this brown bread thing but actually none of the breads are particularly good so I do wonder when we advise patients to have whole grain healthy when we advise patients with two died type-2 diabetes I do wonder which bread we would advise I do wonder that because I I struggled to find one that would be a good idea for my patients now then what's next oh yes I've done something special for you the the teaspoon of sugar equivalent things go crazy on the internet they're very very popular so I've done one just for you and you are the first people in the world to see this daddy now then oh go on clap go on yes now then you know when we're told about fruit and veg is great every time I hear that a piece of me dies a piece of is in anguish because you know if we if we let's just take veg let's take veg it's as if all veg is the same well it's obviously not the same how is cabbage like a potato and yet we tell patients to have veg it's nonsense it's absolute nonsense for somebody with type 2 diabetes they are not the same and my teaspoons of sugar show this there we are boiled potato 150 gram serving isn't a huge serving but look at the equivalent in terms of teaspoons of sugar and then compare that with cabbage now you all know this really and yet in the guidelines we keep trotting out this veg nonsense and yet it could be so good if we said green veg that would be a good idea if we just said a little bit more and based it on science fruit yeah honestly I come across quite a few patients who think that raisins are fruit well I suppose they are but just look serving size of 60 grams isn't enormous the amount of sugar in there look at the amount so when we're advising healthy fruit well I wouldn't know you know how often is is is fruit such a good idea certainly the berries I'm quite happy with those they're not a very high glycemic load but lots of fruits now my particular hatred is the banana I met that's obviously another bias because bananas make me angry they just and every now and then I hear you know there's only one only one form of banana apparently it's the Cavendish and they're all genetically identical and any day now a virus is going to knock out the whole lot I can't wait for that virus to sweep through the world because bananas almost without exception I find that very heavy people love bananas and the number of times I'm told her I have three because they're healthy more is more you know and bananas they very very sugary so a single banana a single banana they're about the same as five and a half teaspoons of sugar it does depend how right they are and how big the banana is but really is that good food for somebody with type 2 diabetes I'm really not sure next slide now on the 7th 7th of November last year I wonder what happened on the 7th of November last year I can't remember part for one thing I did a dangerous thing and I did it for you okay so here's what I did oh yes so low carb GP ate a ripe banana right there it was Tuesday the 7th of November now this I was wearing at the time freestyle Libre which measures your blood glucose continually so what I was doing really was I you know I say there's the theory of blood glucose with my teaspoons of sugar maybe it's a little rubbish who knows so I thought I'll prove it so I was actually the there are several days represented here and you can watch my blood glucose so there was there was one day going along there and there's another day those are two days and look hardly anything happened to my blood during those days I was doing the usual things and eating but you can hardly tell yes a little bit of a thing there the Apple meant I ate something that actually I know what it was it was a three-egg omelet there was a three-egg omelet can't remember what that was but not much happened with the blood glucose but this day on Tuesday the 7th of November I ate a single ripe banana and it doubled my blood glucose went up to ten point four I think this makes the point that for somebody with type 2 diabetes can we stop advising blandly all fruit and all vegetables it depends and all of you have got meters can check with your own meter what happens to your blood glucose and I know many of you know that's the truth really so that's my little crusade down with bananas I hate them moving on yeah moving on so we're always being asked aren't we oh my goodness you don't eat bread what do you eat like there's nothing left to eat because we don't eat bread it's like that you see I there are such a thing as a carb addict I'm convinced of it there's a lot of people addicted to bread I know a lot of them and they do they actually you see fear in their eyes when you suggest that they stop eating bread and and yet here we are we really tasty stuff don't we it's delicious what is the problem is that so that was just to show it's lovely now they're much coming next oh yes but now we've got a problem now we got a problem so that's the end of the happy bit now we got slightly sadder day so some great things have happened and particularly the the November 2017 the sign guidelines from Scotland hooray are actually mentioning that a low-carb diet down to 50 grams per day a PS safe yay that was such good news it made me very very happy very happy oh what's this for up to six month what's going on so I'm healthy and now I got to start eating cocoa six months you know get out the banana it's a worry some worry is it's safe why have they said this and then diabetes UK also have come a long way they've come a long way bless them haven't they look so they're now saying well yeah you know low-carb may have a point but apparently look at this concerns have been expressed concerns oh that's a worry and it's interesting this is their dietary guidelines and so I was searching obviously for the references about who is concerned who is concerned and why no reference so I am worried that you could come up with concerns with absolutely no references or what sort of concern that's terrible for patients now because they're now thinking concerns what sort of concern what might happen to me it read on read on potentially adverse effects of these diets oh here we go look especially on cardiovascular risk now I'm scared cardiovascular I thought dr. Amin was giving me good advice and now I've got cardiovascular risk what there remains no evidence of harm over the short-term oh good back to six months long term side effects remain unknown and cardiovascular risk whoa well again so I'll be healthy for six months the end of six months well that was night I felt great I lost weight I can exercise more my mood is better liver function better so many things better six months oh well back to the cornflakes you know it's a worry it's a worry so we perhaps ought to look at that and that's the sort of second half now the bit you haven't heard before see the ones you were asleep and wake up now because we're with some new ground new ground so what are we going to talk about we're worrying about cardiovascular risk and the title of the talk of course was to do with it's not just about diabetes so we're going to move on well here's that the very first pointer I like telling stories so what what I noticed in the really early days the very first few patients that I saw something totally unexpected happened I was finding amazing improvements in liver function and these improvements in liver function were coming about in weeks at the first few I didn't think much about it but then when I seen fifty of them I became very interested what was going on I was measuring a gamma GT it's an enzyme a liver enzyme there are others you can measure but I was interested in gamma GT so these level enzymes had interested in a few years because I'd noticed there was a lot of patients with abnormal liver function and I didn't really know what to say to them I hadn't got a thought in my head because it's abnormal but what you said I didn't have any advice I didn't really I thought maybe they're drinking are you drinking so or is it drugs what is it I didn't really know but then this cohort of patients their liver was cheering up so rapidly I couldn't believe it and in fact I discovered that the liver function predicted what would later happen with the hemoglobin a1c and the diabetes and it predicted weight loss weird and very very interesting so we're going to explore that let's just look at this particular patient this actually is the practice patient who has the longest remission of diabetes so we're up to there he is we're up to about nine years now so again one of the early things I was told was it well yes David very good but it won't last for some people it really does less than this fellow he's up to nine years now but let's look what happened to his liver function dropped like a stone so that is when that is when he started cutting the sugar and starchy carbs right there and that liver function dropped like a stone and I've been following it look how many blood tests he's had over the years isn't he tolerant what it kind fellow every one of those is a blood and then we got bored there we got bored but then bless him he found me on Twitter and he came to see me he said doctor I mean you haven't featured me and you know I hadn't I hadn't and he said I think I am the longest remission doctor of rain and bless him he's right he is the longest remission so he said don't you want another blood test and so there it is for you all ladies and gentlemen that was done thank you yeah that seems to his blood test I'm so grateful to him for suggesting that he volunteer for that and his liver function years on is still normal how very interesting I wonder what I wonder what's going on so let's look at a few more all right this is a this is another patient this patient is again we're looking at Gamma GT down here now this this is a lady who I've looked after actually since at least 1996 and probably before this poor lady had abnormal liver function as you see that's that's her journey for years normal is down there so there's the normal bit and there's where she was for years and and in fact we the graph would go back over here somewhere 1996 so this lady kept worrying me with her abnormal liver function and I didn't know why it was so I tried saying to her you know how much you drink and she'd say wait it's really about two sherry a month and I'd say are you sure just the one just the one sherry you're not having others at all no doctor I mean I I dunno you know really so I sent her of course I didn't know what's going on so I I sent it to somebody Claire rather than me I found a specialist so she went she went to see a gastroenterologist and the gastroenterologist was surrounded with her entourage because he was very clever so a lot of young people he had his you know the training doctors are all there and the great man said to the poor lady are you sure it's only one sheriff are you really sure because do you know I'm really wondering and she felt humiliated and angry and distressed because dr. Amit had already asked her a great many times and here she's been doubted and he didn't have a single thing to suggest apart from possibly possibly a liver biopsy and she rightly turned it down because she's oh I don't feel like ill really but I kept worrying because I thought well if something goes wrong with this patient I am to blame because I know this thing and I don't know the answer so I sent her I sent it to a hepatologist we you know a herpetologist and you know what's going to happen don't you know what it's going to happen to this poor lady is it just the one sherry are you sure and she became angry and she said I'm never seeing another specialist again I am humiliated this is not helping me they don't believe I'm telling the truth and that's kind of a bit sad isn't it really and but then it's particularly interesting because I wonder you know there we go what's happening down here and you know what's happening the same as is happening there so she now has for several years that's her weight is nice and steady but look at that graph look at that graph as a typical person going on a low-carb graph you've seen them on Twitter I try and send you out one a week so her weight she looks superb she's so proud she looks amazing and she's so happy cashing wear fashionable clothes and she feels great yes and but here's the thing everybody worries don't they all but what about all that you know the cardiovascular risk what about her what about her cholesterol profile cause she's having very dangerous full fat yogurt hoo that's dangerous dangerous stuff but here's a thing she starts having dangerous full-fat yogurt there and the HDL which you know is the protective cholesterol jumped up and here's an interesting thing she starts having dangerous full fat yogurt and butter there and her triglyceride drops like a stone so triglyceride is another one of the lipids that we measure it's a little bit more inconvenient cuz you have to have a fasting sample for patients are a bit reluctant but triglyceride and HDL well you're going to meet Scott tomorrow he is a very senior cardiologist and he is the the president of the British society of preventative cardiology and I expect he's going to talk to you about this kind of thing but Scott would tell you that looking at HDL cholesterol and triglyceride is very important if you're worried about cardiovascular risk and from what I told you earlier we are a bit worried about cardiovascular risk so it's kind of relevant really any wait for this lady done so well that my point there liver has improved and we often talk about these sort of anecdotes so I again I'm told I'm very anecdotal but when you see you know somebody that's gone on for years and years and years and then suddenly improves you've got to be interested as to why that has happened but I accept it's only one one case but I don't accept it for long haha because this is more than one case so what we've got here what have we got here so why don't we look at the liver function of all of those 90 patients I just told you about they're in a research cohort we're doing Bloods why don't we look at the liver function so here somebody's done this wonderful thing for me and there they all are now what is happening is the average liver function is improving by 39% that's the average improvement a couple yes have gone up but crikey come on you know what's the p-value of this happening this is not random and we've also heard that the verted data is almost identical to mine we're beginning to reproduce right across the world very the findings so this is about liver function it's improving and it improves rapidly in very many people this is so interesting and I think very important now here's a thing he is a thing so in general by the way how many of us are GPS could you put your hand up if you're a GP great that's so wonderful that loads of you marvelous do you know we're very powerful people very powerful and I you know I used to sort of think all the specialists there so we are not worthy they are so great actually we have real value we know stuff and we have data that they don't have I have data of my practice population goes back decades they don't have that data is power in the modern world only very few of you know how to interrogate your marvelous computer systems and anyway when in the early days this this gamma GT thing got me interested so I thought yeah this seems rather common you seen a lot of I don't remember all this liver function before so I obviously I wasn't able to do the interrogation but I've got somebody who can and so we were looking at within our practice how many people have had blood tests 4750 three people had had liver function test on in the preceding three years and here's an interesting fact 24% of those people had abnormal liver function what is going on that you think diabetes is bad that's what 10% liver function doubly bad what is going on and I haven't noticed it sneaking up on me like this but it's there it's there something's going on so what's going oh yeah that's me a stirring so actually what it is it's non-alcoholic fatty liver disease so non-alcoholic fatty liver disease now represents 20% of the developed world and we're not really talking about it now that's in I wonder why we're not talking about it's really serious these people are coming to harm and prof Taylor gives the most wonderful quote he says there is a long silent scream from the liver before you become diabetic and that long silence screen goes on for about 10 years so non-alcoholic fatty liver disease predicts a lot of other things and one of the things it predicts very well is type 2 diabetes and we know the hepatologists know about this there are marvelous papers in the British Medical Journal it is about 20% and in our practice I found 24% so we know we're not far wrong are we um not everybody's had blood test because I've got 9,000 patients they haven't all had blood tests were probably taking blood from the more at-risk people maybe it's worse than 24% here's a concern now there's so many doctors in the room you'll all have heard of the Framingham study and that the Framingham study this wonderful long-term thing about cardiovascular risk and so much debate over cholesterol so much debate over cholesterol but hidden in the Framingham hidden there is this thing about gamma G T let's just look at this the Framingham Heart Study has provided evidence highlighting the impact of a raised gamma GT liver blood test individuals in the highest gamma GT quartile in the top 25 percent have a 67 percent increase in cardiovascular risk Oh crikey so if we're going to worry about cardiovascular risk looking at liver function is a good place to begin this is the Framingham study it is huge this is talked about in medical schools but this little bit of it is never mentioned but it is there it is there so liver function is interesting and maybe it's slightly reassuring to people who are concerned about cardiovascular risk on the long term these improvements in liver function perhaps that's perhaps that's reassuring moving on bit of physiology I've become fascinated by physiology instead of pharmacology and I think talking about insulin what an interesting hormone insulin is how very interesting what does it do do you know hardly any doctors really know what it doesn't I don't completely but at least I'm very interested so one of the major things that insulin does is push glucose his insulin pushing glucose into cells now if it's a muscle cell and you use the the glucose for energy marvelous but actually many of the times there's excess glucose and it's pushed into abdominal fat or liver and this is the mechanism for the fatty liver that I'm talking about this is the what is going on and in fact the fat it gets turned into his triglyceride and you saw the lady whose triglyceride dropped so here's a fascinating link between glucose insulin and triglyceride it's completely understood nobody is disagreeing this is not groundbreaking nobody's going to it's not contentious this at all now insulin to some other really interesting things that I didn't know about insulin does a funny thing at the kidney insulin holds on to sodium holds on to salt so that's very interesting and it fits in with other things I've noticed the drop in blood pressure so when when you go low carb you go low insulin and you'll start weighing a lot that's the diaeresis as you lose the sodium that you've built up because insulin holds on to sodium and as you drop the sodium sorry drop the carbs the insulin drops and your blood pressure drops very very interesting and nobody talks much about it but it's there and I have of course godly references for that and that's gaining traction now this insulin what else does it do it does a lot of other things certainly has it it's a building up so it tends to make you fat but it also has this effect on the kidneys and sodium moving on oh that's just to show you that's my clever thing that's a cell you see that see that that's a cell right right the counterpoint Siddis so there he is Roy Taylor he is a true hero I am so grateful to Roy he was one that got me published right at the beginning he believed in me he even did my stats for the beginning who do you how many professors would offer to do the stats for a nobody GP from Southport and nobody's ever heard of he did that for me I'm very very grateful but he's done some much more important things he has really looked into what is the journey to diabetes what is the journey to diabetes and he believes that type-2 diabetes results from accumulation of fat in the liver and the pancreas that's what he believes is happening so I'm going to try now oh look there's the cell right but look what's happening in the liver it's filling with fat right before your eyes isn't that amazing look at that so the liver is filling with fat and as that happens Roy Taylor tells us that that leads to insulin resistance so the insulin doesn't work as well but once the liver is as the liver fills with fat so does the pancreas and as the pancreas fills with fat that interferes with beta cell function in the pancreas which is where your insulin comes from what Roy has shown is that if you can reduce insulin levels then this can be reversed and this is the whole basis of diabetes put into reversal as as Roy Taylor has shown it by actually scanning the pancreas of people before and after his dietary intervention so that's it in a schematic way and I've got 10 minutes left hurry David hurry right hurry so that's it in a schematic way and and basically cut the car cut insulin the liver and the pancreas recover reversing diabetes hooray good moving on oh and there's the fat cell again yeah here's an interesting thing I did a paper with with Richard Feinman very famous and slightly scary professor in New York and he he again a great man took all my data and I was so excited because I wanted to show a correlation between the gamma GT and what was happening with the patients and he rang me up and he said David there is no correlation there is no correlation disaster I'm a failure no correlation no David you idiot no there is no correlation because the liver and weight loss you actually xi cheers up first this is highly relevant everybody says weight loss everybody says cure diabetes with weight loss everybody says cure non-alcoholic fatty liver with weight loss well how interesting because I have some patients who cure the diabetes without weight loss so that's odd isn't it maybe weight loss and improving liver function and improving blood pressure are all downstream of something else what if they're all downstream and everybody's is castigating lose weight and he doesn't matter how you lose weight it does not matter well I wonder I wonder and Richard Fineman was way ahead of me there and he wonders too and that's why he was so pleased to see no correlation hurrying on oh gosh these the results yes this right it's not just about diabetes now these so the long term we're worrying about the long term the long term is risky dr. Amin is doing a thing is risky long term so we thought why don't we look at the people that have been on the low-carb diet in the practice for the longest so this is a smaller cohort and it's 66 patients because they've been on the low-carb diet for an average of over two years 26 months perhaps they're coming to harm should I worry about them let's think about cardiovascular risk that's what we're told to look at cardiovascular risk on longer-term cardiovascular let's just start off with of course diabetes that's that's a risk now of the sixty-six cases 33 50 percent are in remission up 26 months it isn't short term they can do it for longer I mean depends on the patients and it's their life they make choices but if we support those choices maybe the remission can go on longer but really this is about things other than diabetes so let's move on total cholesterol that is a significant improvement in total cholesterol in Canada HDL the reason that's a negative figure as it went up I was looking for a drop but it went up so it's a negative figure and that is statistically significant cholesterol ratio improved significantly triglyceride improved by about a third as now that's really significant to drop triglyceride by a third in 66 patients you know weight loss the average weight loss was nine point seven kilos the blood pressure which I already mentioned and these people I forget now I think they think 15 came off drugs for high blood pressure something like 15 of the patients came off drugs and I'm still getting a significant improvement in both systolic and diastolic blood pressure I am not using drugs and the gamma GT there is improving by a third so again if we are concerned about cardiovascular risk you know maybe there's something I haven't measured maybe there's something going to happen but it's certainly looking encouraging isn't it after two years and I just wonder what the mechanism I'm fascinated by mechanisms you know what is the risky mechanism by eating real food and you know I I just don't get the thing I've been low cup as you see for five years I still seem okay so interesting moving on rapidly because we're down to five minutes yes so I asked I you know go to a clever guy so I asked Scott I said cardiovascular risk what should i how you know for if I'm worried about cardiovascular risk for my patients what should I do and he said the joint British society for the prevention of cardiovascular disease in his opinion have provided a very good risk calculator to have a look at what happens to our patients now the average person on on my research cohort he's actually a male weighing 65 sorry age 65 in weighing 96 kilos quite heavy people these and this is just illustrative you know I'm not saying this is exactly right but it's somewhere near right we're looking at so the average patient that's kind of them you know and he's 65 years old weighs quite a lot and his blood pressure was 142 this risk calculated as systolic not diastolic just 142 that's the average cholesterol I began with and that's the average HDL so that is the heart age of my average patient he is 65 but the British society gives him a heart age of 77 so that's cardiovascular risk right there they start with a risk they start with a risk and that is an increase of what's that 12 years in heart age according to that so what we're going to deal with press the bonding ah there we are gain of 12 years yes okay get on with it right so what happens afterwards now yes again it's only illustrative but if you then put in the systolic the average systolic blood pressure the end was 131 the cholesterol went down from 4.8 to 4.5 as I told you and the HDL went up look what happens to that heart age so if this is a valid thing and if it's blood pressure matters and if HDL matters they telling me the heart age has dropped from 77 to 68 and there has to be good news it has to be of interest at least and it goes some way I hope to reassuring Diabetes UK that we're thinking actively about cardiovascular risk and measuring things and ology measure stuff and see that's what I'm doing particularly it's reassuring for patients I use it as feedback they love it they're delighted that the triglycerides come down so there we are measuring stuff I can't remember anyway yes there we are so now here's a really important thing so I just gave you the heart age and bear in mind the patient is two years older of course because in average of two years so they've actually aged two years but they've still lost all that completely additional because if you remember I did not factor in here what's happened to the diabetes so if you read the British society prevention if you read the whole rulebook this is very important absolutely additional to the improvement of about 12 years in cardiovascular risk additional to that is this in addition to this improvement trial results suggest a 10 to 15 percent reduction in cardiovascular events for every 10 millimoles reduction in hemoglobin a1c okay and I'm getting an average of 17.7 millimoles so that on top of this is that for my cohort which is good news for them and if the rest of you can get similar results and I know now I'm getting figures from GPS all over the country we are replicating this work in fact it's been replicated all over the world moving on oh here's an interesting that we're coming to near the end we're coming to near the end back to triglycerides do you know I think there may be more interesting and we thought and this particular paper really caught my published only a few weeks ago in London the international journey of a big journal of obesity and it says triglyceride cross the blood-brain barrier and induce central leptin and insulin receptor resistance I wonder what note that means what does that mean and why is it important so let's have a look I didn't really watch leptin right here's leptin leptin it two hormones - green tea by fat crosses the blood-brain barrier acts on the brain and stops you eating so it's part of homeostasis really I get fat I eat less now it's something unique about domesticated animals and ours we get fatter we don't eat less odd isn't it so you never saw like a I don't know you don't see fat animals much there's a reason they're in homeostasis and we seem to broken out of homeostasis we've we've lost balance we don't know when to stop eating anymore we're hungry I was hungry for decades I was ravenous for decades something was wrong with my leptin I think perhaps I don't know but here we are so here's a thing apparently triglycerides induce leptin resistance so your leptin doesn't work as well how interesting because the one thing that patients tell me again and again and again is how odd I'm not as hungry as I expected that's what they always tell me I always say anything surprise you about the last month and there were say I wasn't nearly as hungry as I thought I'd be how odd so this is a study but it does fit in with my personal life and also the research I've done it seems to fit in that they are not as hungry that the cravings died down and there is another thing as well triglycerides and cognitive impairment how many of us have experienced brain fog I remember one Christmas I could just I could be asleep from about midday I was so sleepy and lethargic it was one of the things driving me I've told you before I used to have a little nap on my own examination couch so at 1:30 I would press do not disturb lock my door lie down on my couch and go to sleep for half an hour that isn't normal it's not normal behavior you know maybe people were ill at gp's all of the country perhaps they're all asleep on their couches I don't know but I was asleep on my couch and it's so interesting because many of us have experienced the most amazing awakening an increase in energy and the patient's start exercising and doing other things very very interesting and we have a model here I don't know here's a study look up the study here is a model is triglyceride is leptin important maybe the triglycerides these important maybe they're doing other things but we do know for homeostasis in weight loss has been something has short-circuited our automatic control of appetite something's going on oh we not look at that was secret you're not allowed to see that right so I hope I've taken you through low-carb it's not just about diabetes I really don't think it is with so many things so many things and I think to finalize low-carb for me what it has done is given patients choice and control and how wonderful for patients not to need me or you doctor sitting in the audience because I have you know like the guy that just went away he went away for a few years and then came back because he thought I needed him you know well how many consultations are you having like that I think I can help you dr. Unwin really well yes you know you need my data it's amazing it's wonderful so it's not just about diabetes I think it is it's about being the best human being that we can be it's about having control over our lives it's about not being a patient it's about for me collaborating with patients to give patients information rather than drugs and to give patients hope which I wasn't doing for 25 years I did not give them hope I just said you know this is a chronic deteriorating condition and you know as you get worse please come back and we will monitor your eyes and your kidneys may fail and your feet may go black and we'll monitoring you'll be fine but I'll add the drugs oh come on you know that is so depressing and for many patients as as we have shown in Norwood and Simon's doing that work as well we are getting people we're getting them off insulin even the type 2 diabetics we're getting them off insulin there's such proud people I thank you from the bottom of my heart for coming thank you so much

Channel: Public Health Collaboration

Views: 78,099

Rating: 4.7131476 out of 5

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

Id: TEYtRiPKBVA

Length: 52min 22sec (3142 seconds)

Published: Mon Sep 17 2018

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