GP Cuts Diabetes Drug Spending With Low-Carb Diet Advice

Tim Locke

November 19, 2018

Last week NHS Digital revealed the cost of drugs and items prescribed for diabetes patients in England had exceeded £1 billion. This week a GP from Southport, Dr David Unwin, told the Diabetes Professional Care (DPC) conference in London how he managed to return £57,000 of his unspent practice drugs budget.

   

Dr David Unwin

He did it by encouraging type 2 diabetes patients to follow a low-carb diet. In many cases this lead to weight loss, better diabetes control, less reliance on medication – and even diabetes reversal in some instances.

Reversing type 2 diabetes is a concept that's been gaining traction with Prof Roy Taylor's work on diabetes and diet at Newcastle University.

High profile cases have been in the news with Labour's deputy leader Tom Watson speaking about weight loss reversing his type 2 diabetes.

Changing the Conversation

Dr Unwin told delegates at Olympia not just about his low-carb conversion but also how he's moved the conversation away from drug treatment to patients' hopes about what improved health might mean for them, such as their looks, or being better able to play with grandchildren, as a route to motivating behaviour change.

When asked whether he reclassified his type 2 diabetes reversed patients Dr Unwin said not, as keeping to the regular follow-up appointments and clinics allows for progress checks and further conversations about health and lifestyle.

So how did his low-carb approach begin? Medscape UK spoke to Dr Unwin at DPC. "There was a patient who I'd known for a long time and I knew from the computer system she wasn't taking her metformin, that spoils our figures. So I wrote her a letter saying: I have concerns, please would you come and see me because I just want to chat through this. And when she came in, I didn't recognise her. She looked fabulous. She'd lost stones in weight.

"Not only did she look fabulous, but her husband had lost stones in weight as well. And when I did the blood tests (HbA1c) her type 2 diabetes was in remission, and she wasn't taking drugs. I'd never seen such a thing. I didn't know it was possible. It was weird, a 'Eureka' moment, I was fascinated. Her response to my interest was really humbling because she said: 'You're going to be so cross with what I've done.'

"That made me all the more fascinated: 'No please tell me', so she said: 'Well, doctor, surely I don't need to tell you that really bread is sugar, the starch itself is sugar.'

"But you know, she did need to tell me that, because I'd forgotten.


"I was so pharma-centric, I was busy prescribing and never thought about the actual cause of type 2 diabetes, it was deplorable really."

Mistaken for a Troll

The patient had researched low-carb diets and had become part of a special Diabetes.co.uk online forum. "Members of the low-carb forum were all saying things like: 'I've reversed my diabetes'. 'I've lost 3 stone, but my practice nurse says what I'm doing is dangerous'. 'My GP says, Well, if you must do it, you must take responsibility'. - I found the lack of understanding deeply troubling.

"So I learned more about it. I went low-carb myself… and it went wonderfully."

However, when Dr Unwin went on the forum to report his success and his plans to publish helpful data, he was banned as a suspected troll. He was only reinstated after the forum managers spoke to him at his surgery to check him out.

He then went on to help produce material Diabetes.co.uk were working on for a 10-week low-carb diet programme, adding a psychology section, with the help of his wife, a mental health professional. He's since produced low-carb guidance for the Royal College of GPs (RCGP) and other websites.

"I've always been told by fellow practitioners, 'my patients are not interested in change'. I just wonder who it is that is not interested in change, because I've discovered I can now motivate people, they will make a change. I couldn't have done it 6 years ago, because then I didn't believe in lifestyle medicine myself."

Do Busy GPs Have Time to Give Diet Advice?

"In terms of lifestyle medicine and how it feels as a doctor, look at me, I'm happy. The patients are so enthusiastic and grateful, I get hugs! 

"That's why I became a doctor, to make a difference. What is that worth? We all become healthcare professionals to make a difference. And I was dying on my feet demotivated and lacking a way to really help people. So the energy that this has given me, it's very rejuvenating, and worth all the effort. 

"At the beginning, the partners took a dim view of this work, they said, 
'you're wasting time'."

So Dr Unwin and his wife set up special weekly sessions for 20 patients at a time, using the surgery's waiting room after the practice closed on a Monday night.

"The partners are now completely happy because they've seen what I've done. The partners are all low-carb now. 

"The practice has been revolutionised, so that now it's mainstream in my practice even within 10 minute appointments.

"Before you were still having to explain drug side effects. Starting someone on life-long medication takes time, and then they need blood tests. 

"I don't think it takes me any longer. I still run on 10 minute appointments, and I've taught other GPs to do the same."
 

The Role of Dietitians

Shouldn't diet advice be given by a registered dietitian? "When I look back, I'm ashamed because I abrogated responsibility. I was dismissive of diet and I would say, 'diet is quite important so I'll just make you an appointment with the dietitian'. I wasn't really helping that dietitian as the patients then didn't keep their appointments for the dietitian, because they didn't think that I felt it was important."

Even if he is referring a patient to a dietitian, Dr Unwin says: "I am telling them we'll make a start today, let's talk about sugar and where it comes from, then our dietitian will take it further with you. By then the patient knows I care about diet, that makes a real difference. As we've already explained that this approach could mean he doesn't have to go on medication: the patient is hooked and interested, plus I'm cooperating with whoever comes next. Whether it's a dietitian or a practice nurse, or whatever, the patient is starting to make a change themselves. That's really critical.

"You see it in their eyes, the hope."

Of course, with diabetes no one size fits all. However, using this approach Dr Unwin says: "I've started insulin on a single occasion in 5 years, and metformin on only three occasions, and an SGLT2 inhibitor just once. Against this many of my patients have been able to come off their drugs, hence the practice drug budget savings.

"People would rather avoid lifelong medication if they can. I would."
 

Type 2 Reversal Headlines

With type 2 diabetes reversal now hitting mainstream media headlines, does he feel others are catching up with his approach? "In the beginning there was immense resistance and uncertainty. I think the breakthrough for me was finding that the UK NICE (National Institute for Health and Care Excellence) guidelines particularly advise 'low glycaemic index sources of carbohydrates'. Surely that means low-carb?"

That, he says, made him "much braver. I thought, what does this statement mean, and how can I interpret it more clearly for healthcare professionals and also patients?

"So really this idea of low-carb is not new, we were always advising low glycaemic sources of carbohydrate, I've merely reinterpreted that statement. It was actually always part of our UK NICE guidelines."

In an earlier session at the London conference NHS England officials talked about meal replacement, featuring a very low calorie diet. 

"What would patients prefer?" Dr Unwin asks. "The very low calorie diet works, but I find in my own practice, low-carb works just about as well. So I would say to a patient which would you prefer to do?

"Why don't we just begin with low-carb, and if I fail on that [first choice], well then we could try the very low calorie diet. It wouldn't be my choice because I don't see how a very low calorie diet fits with family life."
 

Updating Guidelines

Dr Unwin's approach hasn't been universally welcomed but there are some hopeful signs.  On the eve of his conference session the British Dietetic Association (BDA) published a policy statement "clarifying its long-held position that a low-carbohydrate diet should be one of a number of possible dietary approaches suitable for managing type 2 diabetes in adults".

It also pointed to new guidelines being developed for publication next year.

Dr Unwin says: "I can understand their caution. But I would say again, all I've done is reinterpret existing type 2 diabetes NICE guidelines in a way that patients can better understand. After all bread is never low glycaemic index, breakfast cereals are never low glycaemic index, rice is not too low glycaemic index, even potatoes are not low glycaemic index.

 “So in a way, I just defined a version of the low-carb diet using the glycaemic index, pleasing my patients - 55 of whom have put their diabetes into remission - and saving tens of thousands of pounds into the bargain. Why on earth wouldn't we just give this approach a go if patients want to try it?"

Dr Unwin made no relevant disclosures and does not take any payment for his work on diets

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