Dr David and Dr Jen Unwin

Dr David Unwin has been a partner at the Norwood surgery in Southport since 1986 and a GP Trainer since 1992. He was elected to Fellowship of the Royal College of General Practice for his work in using hope as part of the consultation.

More recently, the Fellowship of the Royal College of General Practice list David Unwin, as both a RCGP National Champion for Collaborative Care and Support Planning in Obesity and Diabetes; and a RCGP Clinical Expert in Diabetes.

David was a finalist in the 2014 BMJ National Awards for Diabetes Team of the Year due to an innovative and collaborative approach to using a low-carbohydrate diet in type 2 diabetes, and mixing this with a positive, solution-focused psychological approach.

In December 2015, David was awarded the NHS North West Innovator of the Year.

Dr David Unwin, GP

Mature Onset Diabetes

I have looked after the same community for 30 years now. When I started in practice we called Type 2 Diabetes ‘maturity onset diabetes’ because it affected people in their 60’s and 70’s.

There were none under the age of 50, in our practice in 1987. Now in the same population we have 21 cases of Type 2 Diabetes in younger people – with an average weight of 245 pounds (111kg).

“For many years I followed the advice given by PHE (Public Health England) and Diabetes UK. “It didn't go well. - Patients really struggled to lose weight and their blood glucose remained high and many relied on medication.”

Five years ago I would have said the future for diabetes care in the UK was ‘hopeless,’ but now I have seen how much my patients can achieve with lifestyle change, that has totally changed my view of medicine, and the future treatment of diabetes.

Seeing the Light

Breads and cereals break down into surprising amounts of glucose as predicted by the Glycemic index. I was surprised how much.

Even after I realised the glycemic index of wholemeal bread was high, and that was a source of some diabetic problems; after 25 years of believing that wholemeal bread was good, I found it difficult to change my advice. So I can really sympathise with others struggling with change, and adapting to new ideas.

I spent 25 years nagging my poor patients about cholesterol in their diet and for whatever reason the results were very disappointing for all concerned. Now I concentrate on helping them radically cut back on all sources of sugar, whilst eating far more green vegetables. I have over a 100 patients with weight loss averaging 19 pounds (8.5kg).

The First Trial

We ran a “hugely promising” pilot study in 2014 with 19 younger type 2 diabetes patients, to test the low-carbohydrate diet with more vegetables. To show willing, I went on the low-carbohydrate diet with them, so we explored it together, though I was not diabetic.

I was surprised not to feel hungry and had a lot more energy. That was four years ago and I am still low-carb.

In the study, which lasted eight months, 17 of the 19 participants had healthy HbA1c levels after adopting a low-carbohydrate diet.

On the whole I leave the discussion on fats to others and suggest we all agree to advising far less sugar and refined carbs with far more green vegetables and nuts.

Very few people would argue that sugar is a good food for people with Type 2 Diabetes. So in a way, advising one of my patients who has a high sugar intake to cut back on sugar, is advising them to come down the glycemic index. After cutting the obvious sugar, and noticing an improvement, what should be the next target? If you let patients choose, you quite quickly improve their results.

Conflict with NICE Guidelines?

NICE say their advice is based on evidence.

The 2015 NICE guidelines say.
‘Treatment and care should take into account individual needs and preferences. Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals’.
1.3.3 Encourage high-fibre, low-glycemic-index sources of carbohydrate in the diet
1.3.6 Individualise recommendations for carbohydrate and alcohol intake

I would make a plea for doctors to give all patients the chance to try a better diet properly before starting lifelong medication. It clearly can be done in a normal GP's surgery.

Evidence of Long Term Ketosis

The longest I have personally known anyone on the low-carbohydrate diet is 16 years. Dr Wolfgang Lutz used the diet on hundreds of patients over decades and died in his nineties having been on it himself for over 40 years.

In fact, an even stricter ketogenic diet, has been a recognised treatment for childhood epilepsy for decades, starting with research in the 1920’s. From about the same time until the advent of insulin and the drugs for diabetes, a low-carbohydrate diet was the only way to treat diabetes.

On a personal level I have been on a very low-carbohydrate diet for nearly four years now as have most of the original pilot group without any problems. At a practice level we have over 100 monitored patients who have been on a low-carbohydrate diet for an average of 18 months.

"Three years of treating people with diabetes."

I ask new patients what they understand about Type 2 diabetes. I tell them the there is nothing about the disease that they can't be sort out for themselves, with a little bit of help. They have to be in control.

We ask they what their best hopes are for future? We talk about improving their well being and reducing to a minimum any medication.

It possible for diabetics to visit the doctor much less often, to have excellent control of their disease, and to have many extra healthy life years.

Each patient needs to decide, where they are now? Then, what's the next step to improved health, or to some other important goal they have in mind. That might be breathing better or walking better.

The Patient Tool Box

The best tool on the tool box is Hope, but hope supported by correct knowledge and understanding. That give people control over their disease.

Many people have no ideas where the sugar in their blood comes from. We give them a modified glycemic index, with all the carbohydrate foods lists as teaspoons of sugar. Suddenly they see what the problem is.

To succeed in the LCHF programme they need to do a lifestyle change. We put them into an 8 week educational programme. They need to learn how to shop differently, new ways of cooking, new ways of thinking about food, new ways of measuring what they are eating, and new ways of measuring their own health.

We encourage them to keep a chart of their progress.

Achievements

Winning NHS Innovator Of The Year in March meant a great deal to me, I'm not sure a GP has ever won it before.

It was partly because our GP practice has improved standards of diabetic care while spending over £40,000 less per year on drugs for diabetes.

Dr Unwin commented: “This great result helps show what a rewarding job general practice can be when we work together with our patients for better health. Diabetes is a national emergency, my patients have shown that many will choose healthy living over lifelong medication and that the low-carbohydrate diet is one way to achieve that goal”

Much of this was by offering our patients dietary alternative to starting medications. An extra ‘innovation’ was helping people in groups of 20, assisted by ‘patient experts’ a newish thing in general practice.

Impact of the study

Reversing type 2 diabetes is challenging, but possible, and a low-carbohydrate diet requires less insulin to be produced, taking the strain of insulin-producing cells and reducing insulin resistance. Entering remission from Type 2 Diabetes is much more likely through a low-carbohydrate diet than eating moderate and high carbs, which necessitates further insulin production.

The impact of this study remains to be seen, but Dr. Unwin is optimistic regarding its significance. “The very fact that the BMJ agreed to publish shows great progress,” he wrote on the DCUK Forum. “On top of which partly because of the world wide low-carb community the article itself is currently ranked in the top 5% of published articles. It’s being read from Argentina to New Zealand.”

However, most medical guidelines in the UK do not recommend the diet. The NHS advocates eating relatively high-carb and low-fat foods, while Diabetes UK highlights a lack of evidence regarding the “long-term safety” of the diet

NHS and NICE say there is no cure for type 2 diabetes. This study is yet another example of how the low-carbohydrate diet can be influential in helping patients come off medication, usually completely.

While this study alone is unlikely to result in dramatic U-turns from Diabetes UK and the NHS, it is additional evidence that the low-carbohydrate diet benefits for people with diabetes.

Support from Other Doctors

Other doctors are watching what we are doing. Some are conducting their own studies. Some are concerned that the higher fat content of the diet will increase cholesterol and could potentially cause a heart attack. They are cautious. Nobody wants to do any harm.

I'm our own clinic, most of the staff are now also LCHF, and one obvious difference is that no biscuits are served at morning tea anymore.

The low-carbohydrate diet is continually gaining backing, especially through success stories posted in the DCUK forum. It was these accounts that originally left Dr. Unwin “impressed and moved” before his own experiment began.

"I try very hard to help all the doctors, dietitians and nurses who email me for information and estimate there must be well over 80 now in the UK trialing this approach. At a broader level we just finished filming for a TV documentary to come out in the New year."

In May 2016, Dr. Sarah Hallberg told us to ignore the guidelines and eat low-carbohydrate high-fat foods. “Carbohydrate intake is the single biggest factor in blood sugar levels and therefore the need for medication,” she said. “We are essentially recommending that they eat exactly what's causing their problem.”

A year ago Diabetes.co.uk launched a 10 week low-carbohydrate on-line programme. Amazingly so far 160,000 people have done it and the results are looking really good.