What predicts drug-free type 2 diabetes remission? Insights from an 8-year general practice service evaluation of a lower carbohydrate diet with weight loss

BACKGROUND

Type 2 diabetes (T2D) is often regarded as a progressive, lifelong disease requiring an increasing number of drugs. Sustained remission of T2D is now well established, but is not yet routinely practised. Norwood surgery has used a low-carbohydrate programme aiming to achieve remission since 2013.

METHODS

Advice on a lower carbohydrate diet and weight loss was offered routinely to people with T2D between 2013 and 2021, in a suburban practice with 9800 patients. Conventional 'one-to-one' GP consultations were used, supplemented by group consultations and personal phone calls as necessary. Those interested in participating were computer coded for ongoing audit to compare 'baseline' with 'latest follow-up' for relevant parameters.

RESULTS

The cohort who chose the low-carbohydrate approach (n=186) equalled 39% of the practice T2D register. After an average of 33 months median (IQR) weight fell from 97 (84-109) to 86 (76-99) kg, giving a mean (SD) weight loss of -10 (8.9)kg. Median (IQR) HbA1c fell from 63 (54-80) to 46 (42-53) mmol/mol. Remission of diabetes was achieved in 77% with T2D duration less than 1 year, falling to 20% for duration greater than 15 years. Overall, remission was achieved in 51% of the cohort. Mean LDL cholesterol decreased by 0.5 mmol/L, mean triglyceride by 0.9 mmol/L and mean systolic blood pressure by 12 mm Hg. There were major prescribing savings; average Norwood surgery spend was £4.94 per patient per year on drugs for diabetes compared with £11.30 for local practices. In the year ending January 2022, Norwood surgery spent £68 353 per year less than the area average.

CONCLUSIONS

A practical primary care-based method to achieve remission of T2D is described. A low-carbohydrate diet-based approach was able to achieve major weight loss with substantial health and financial benefit. It resulted in 20% of the entire practice T2D population achieving remission. It appears that T2D duration <1 year represents an important window of opportunity for achieving drug-free remission of diabetes. The approach can also give hope to those with poorly controlled T2D who may not achieve remission, this group had the greatest improvements in diabetic control as represented by HbA1c.

Evaluation of the Low Carb Program Digital Intervention for the Self-Management of Type 2 Diabetes and Prediabetes in an NHS England General Practice: Single-Arm Prospective Study

Background

Type 2 diabetes mellitus has serious health consequences, including blindness, amputation, and stroke. Researchers and clinicians are increasingly in agreement that type 2 diabetes may be effectively treated with a carbohydrate-reduced diet. Digital apps are increasingly used as an adjunct to traditional health care provisions to support remote self-management of long-term health conditions.

Objective

Our objective was to evaluate the real-world 12-month outcomes of patients prescribed the Low Carb Program digital health intervention at a primary care National Health Service (NHS) site. The Low Carb Program is a nutritionally focused, 12-session, digitally delivered, educational behavior change intervention for glycemic control and weight loss for adults with prediabetes and type 2 diabetes. The program educates and supports sustainable dietary changes focused on carbohydrate restriction by utilizing behavior change techniques, including goal setting, peer support, and behavioral self-monitoring, as well as personalized downloadable resources, including recipes and meal plans tailored to ethnicity, weekly shopping budget, and dietary preferences.

Methods

This study evaluated the real-world outcomes of patients recruited to the Low Carb Program at an NHS general practice in Southport, United Kingdom. All of the NHS patients recruited to the program were diagnosed with type 2 diabetes or prediabetes and were given access to the program at no cost. A total of 45 participants, with a mean age of 54.8 years (SD 13.2), were included in the study. Women made up 42% (19/45) of the sample. The mean hemoglobin A_1c (HbA_1c) of the sample was 56.7 mmol/mol (SD 16.95) and the mean body weight was 89.4 kg (SD 13.8).

Results

Of the 45 study participants recruited to the program, all of them (100%) activated their accounts and 37 (82%) individuals reported outcomes at 12 months. All 45 (100%) patients completed at least 40% of the lessons and 32 (71%) individuals completed more than nine out of 12 core lessons of the program. Glycemic control and weight loss improved, particularly for participants who completed more than nine core lessons in the program over 12 months. The mean HbA_1c went from 58.8 mmol/mol at baseline to 54.0 mmol/mol, representing a mean reduction of 4.78 mmol/mol (SD 4.60; t₃₁=5.87; P<.001). Results showed an average total body weight reduction of 4.17%, with an average weight reduction of 3.85 kg (SD 2.49; t₃₁=9.27; P<.001) at the 12-month follow-up point.

Conclusions

A digital app prescribed to adults with type 2 diabetes and prediabetes in a primary care setting supporting a transition to a low-carbohydrate diet has been shown to be effective in improving glycemic control and enabling weight loss. Further research to understand more about factors affecting engagement with the app and further positive health implications would be valuable.

Prior task experience affects temporal prediction and estimation

It has been shown that prior experience with a task improves temporal prediction, even when the amount of prior experience with the task is often limited. The present study targeted the role of extensive training on temporal prediction. Expert and intermediate runners had to predict the time of a 5 km running competition. Furthermore, after the race’s completion, participants had to estimate their running time so that it could be compared with the predicted time. Results show that expert runners were more accurate than intermediate runners for both predicting and estimating their running time. Furthermore, only expert runners had an estimation that was more accurate than their initial prediction. The results confirm the role of prior task experience in both temporal prediction and estimation.

Prospective and retrospective time estimates of children: a comparison based on ecological tasks

Children's time estimation literature lacks of studies comparing prospective and retrospective time estimates of long lasting ecological tasks, i.e. tasks reflecting children's daily activities. In the present study, children were asked to estimate prospectively or retrospectively how much time they played a video game or read a magazine. Regardless of the task, the results revealed that prospective time estimates were longer than the retrospective ones. Also, time estimates of the video game task were longer, less accurate and more variable than those of the reading task. The results are discussed in the light of the current literature about time estimation of long lasting ecological tasks.

Temporal accumulation and decision processes in the duration bisection task revealed by contingent negative variation

The duration bisection paradigm is a classic task used to examine how humans and other animals perceive time. Typically, participants first learn short and long anchor durations and are subsequently asked to classify probe durations as closer to the short or long anchor duration. However, the specific representations of time and the decision rules applied in this task remain the subject of debate. For example, researchers have questioned whether participants actually use representations of the short and long anchor durations in the decision process rather than merely a response threshold that is derived from those anchor durations. Electroencephalographic (EEG) measures, like the contingent negative variation (CNV), can provide information about the perceptual and cognitive processes that occur between the onset of the timing stimulus and the motor response. The CNV has been implicated as an electrophysiological marker of interval timing processes such as temporal accumulation, representation of the target duration, and the decision that the target duration has been attained. We used the CNV to investigate which durations are involved in the bisection categorization decision. The CNV increased in amplitude up to the value of the short anchor, remained at a constant level until about the geometric mean (GM) of the short and long anchors, and then began to resolve. These results suggest that the short anchor and the GM of the short and long anchors are critical target durations used in the bisection categorization decision process. In addition, larger mean N1P2 amplitude differences were associated with larger amplitude CNVs, which may reflect the participant’s precision in initiating timing on each trial across a test session. Overall, the results demonstrate the value of using scalp-recorded EEG to address basic questions about interval timing.

Neonatal pulse oximetry screening: a national survey

AIM

Studies suggest that universal pulse oximetry (PO) screening of all neonates before hospital discharge improves the detection rate of congenital heart disease (CHD). The aim is to survey the use of Pulse Oximetry (PO) screening in UK.

METHODS

 A telephone interview was conducted between late 2009 to mid-2010 of all maternity units using a standardised questionnaire.

RESULTS

 209(93%) of 224 responding units did not routinely use PO. Among the 15 that performed PO, 5 measured pre and post ductal saturations, 9 measured only post-ductal saturations, and 1 measured only pre-ductal saturations. There were differences in the values used to trigger further investigation, ranging from <94% to <96% and/or difference of > 2-3% between pre and post-ductal saturations. When saturations were abnormal, 13 units performed echocardiography locally. In addition to an echocardiogram, 2 units performed chest x-ray (CXR); 2 units performed electrocardiogram (ECG) and 2 units performed both CXR and ECG.

CONCLUSION

Only a minority of hospitals across the UK use PO to supplement the postnatal examination with inconsistent practice. National guidelines should be developed if PO screening is implemented with an agreed management plan if abnormal results are obtained.

An ecological approach to prospective and retrospective timing of long durations: a study involving gamers

To date, most studies comparing prospective and retrospective timing have failed to use long durations and tasks with a certain degree of ecological validity. The present study assessed the effect of the timing paradigm on playing video games in a “naturalistic environment” (gaming centers). In addition, as it involved gamers, it provided an opportunity to examine the effect of gaming profile on time estimation. A total of 116 participants were asked to estimate prospectively or retrospectively a video game session lasting 12, 35 or 58 minutes. The results indicate that time is perceived as longer in the prospective paradigm than in the retrospective one, although the variability of estimates is the same. Moreover, the 12-minute session was perceived as longer, proportionally, than the 35- and 58-minute sessions. The study also revealed that the number of hours participants spent playing video games per week was a significant predictor of time estimates. To account for the main findings, the differences between prospective and retrospective timing are discussed in quantitative terms using a proposed theoretical framework, which states that both paradigms use the same cognitive processes, but in different proportions. Finally, the hypothesis that gamers play more because they underestimate time is also discussed.

Enhancing the ethical conduct of genetic research: investigating views of parents on including their healthy children in a study on mild hearing loss

Clinical genetic research is often regarded as more ethically problematic than other forms of research, and in some countries is subject to specific regulation, requiring researchers to follow specialised guidelines. In this paper, an approach to enhancing the ethical conduct of genetic research is proposed, which is believed to be more effective than simply attempting to follow general guidelines. The potential concerns, likely areas of misunderstanding and negative reactions of the participant group are systematically investigated before starting a study on genetics. This would constitute, in effect, an ethical pilot study, similar to a feasibility pilot study to test equipment, procedures and logistics. The findings of the ethical pilot study would be used to help in designing ethically important aspects of research protocol, such as recruitment procedures, written and other information for potential participants, informed consent processes and reporting of results including ambiguous or uncertain results.

BDNF genetic variants are associated with onset age of familial Parkinson disease: GenePD Study

Brain-derived neurotrophic factor (BDNF) stimulates neuronal growth and protects nigral dopamine neurons in animal models of Parkinson disease (PD). Therefore, BDNF is a candidate gene for PD. The authors investigated five single-nucleotide polymorphisms in 597 cases of familial PD. Homozygosity for the rare allele of the functional BDNF G196A (Val66Met) variant was associated with a 5.3-year older onset age (p = 0.0001). These findings suggest that BDNF may influence PD onset age.

The exploding worldwide cancer burden: the impact of cancer on women

Although age-adjusted cancer death rates have started to decline in the United States and other developed nations - thanks in large part to widespread screening programs that detect cancers at early, treatable stages - cancer in developing countries is on the rise. Ironically, rising life expectancy in those nations along with the adoption of 'Western' lifestyles will leave many more people vulnerable to cancer. Unfortunately, the early detection tools and treatment technology that have helped control cancer in wealthier lands are often not readily available in many other countries. Much of this increased cancer burden will take the form of cancers that affect women - not only breast, cervical, and other gynecologic cancers but colorectal cancer, lung cancer, and other malignancies related to tobacco. Physicians specializing in cancer care for women need to be alert to every opportunity to improve cancer screening and prevention among the growing, aging populations of less-developed countries. Less precise but less costly and more widely available screening techniques may save thousands more lives than the most sophisticated technology because low-cost programs can be applied widely instead of being reserved for a fortunate few. In addition, education and prevention efforts directed toward tobacco use need to be put in place to help stem an epidemic of tobacco-related cancers that has largely peaked in developed countries but looms ominously in the future of developing nations.

The exploding worldwide cancer burden

Although age-adjusted cancer death rates have started to decline in the United States and other developed nations – thanks in large part to widespread screening programs that detect cancers at early, treatable stages – cancer in developing countries is on the rise. Ironically, rising life expectancy in those nations along with the adoption of ‘Western’ lifestyles will leave many more people vulnerable to cancer. Unfortunately, the early detection tools and treatment technology that have helped control cancer in wealthier lands are often not readily available in many other countries.

Much of this increased cancer burden will take the form of cancers that affect women – not only breast, cervical, and other gynecologic cancers but colorectal cancer, lung cancer, and other malignancies related to tobacco. Physicians specializing in cancer care for women need to be alert to every opportunity to improve cancer screening and prevention among the growing, aging populations of less-developed countries.

Less precise but less costly and more widely available screening techniques may save thousands more lives than the most sophisticated technology because low-cost programs can be applied widely instead of being reserved for a fortunate few. In addition, education and prevention efforts directed toward tobacco use need to be put in place to help stem an epidemic of tobacco-related cancers that has largely peaked in developed countries but looms ominously in the future of developing nations.

Trends and affordability of cigarette prices: ample room for tax increases and related health gains

BACKGROUND

Increasing the price of tobacco products is arguably the most effective method of curbing the prevalence and consumption of tobacco products. Price increases would reduce the global burden of disease brought about by tobacco consumption.

OBJECTIVES

To compare cigarette price data from more than 80 countries using varying methods, examine trends in prices and affordability during the 1990s, and explore various policy implications pertaining to tobacco prices.

DESIGN

March 2001 cigarette price data from the Economist Intelligence Unit are used to compare cigarette prices across countries. To facilitate comparison and to assess affordability, prices are presented in US dollars, purchasing power parity (PPP) units using the Big Mac index as an indicator of PPP and in terms of minutes of labour required to purchase a pack of cigarettes. Annual real percentage changes in cigarette prices between 1990 and 2000 and annual changes in the minutes of labour required to buy cigarettes between 1991 and 2000 are also calculated to examine trends.

RESULTS

Cigarette prices tend to be higher in wealthier countries and in countries that have strong tobacco control programmes. On the other hand, minutes of labour required to purchase cigarettes vary vastly between countries. Trends between 1990 and 2000 in real prices and minutes of labour indicate, with some exceptions, that cigarettes have become more expensive in most developed countries but more affordable in many developing countries. However, in the UK, despite recent increases in price, cigarettes are still more affordable than they were in the 1960s.

CONCLUSIONS

The results suggest that there is ample room to increase tobacco prices through taxation. In too many countries, cigarette prices have failed to keep up with increases in the general price level of goods and services, rendering them more affordable in 2000 than they were at the beginning of the decade. Opportunities to increase government revenue and improve health through reduced consumption brought about by higher prices have been overlooked in many countries.

Fever in returned travelers: review of hospital admissions for a 3-year period

We reviewed 232 consecutive patients admitted to a tertiary-care hospital under the care of an infectious diseases unit for management of febrile illness acquired overseas. A total of 53% presented to hospital within 1 week of return and 96% within 6 months. Malaria was the most common diagnosis (27% of patients), followed by respiratory tract infection (24%), gastroenteritis (14%), dengue fever (8%), and bacterial pneumonia (6%). Pretravel vaccination may have prevented a number of admissions, including influenza (n=11), typhoid fever (n=8) and hepatitis A (n=6). Compared to those who had not traveled to Africa, those who had were 6 times more likely to present with falciparum than nonfalciparum malaria. An itinerary that included Asia was associated with a 13-fold increased risk of dengue, but a lower risk of malaria. Palpable splenomegaly was associated with an 8-fold risk of malaria and hepatomegaly with a 4-fold risk of malaria. As a cause of fever, bacterial pneumonia was > or =5 times more likely in those who were aged >40 years.

Community action success in public health: are we using a ruler to measure a sphere?

The Community Action and Public Health study explored how Ontario public health practitioners interpret and implement guidance in community action. In-depth interviews were conducted with 107 public health professionals and community members in 6 Ontario health units. This report briefly describes the study methods and presents results pertaining to the measurement of success based on interviews with 67 public health professionals. Data substantiate the view that evaluation methodologies employing quantitative measures of epidemiological outcomes inadequately capture "success" in community action, possibly attributable to an unproductive dichotomization of "process" and "outcome". Results suggest two kinds of "success": a) changes related to stated goals and targets; and b) more iterative and process-oriented changes, including necessary but often undocumented shifts in relationships, structures, social conditions and processes. In order to legitimize and validate results that might otherwise pass unrecognized, we suggest a methodology that records project "milestones" as successes in their own right.

The policy context for community development practice in public health: a Canadian case study

The Community Action in Public Health Study explored how public health managers, frontline staff, and community participants interpret, implement and receive policy guidelines urging collaboration with community groups in public health work. In-depth case studies of 6 public health units in Ontario, Canada focussed on 19 community development projects in 3 program areas (107 interviews). In the absence of formal policy guidelines on community development at provincial or local levels, informal policy predominated. Local senior management frequently set the tone, distinguishing health units in which community development was a basic philosophy underlying a broad spectrum of public health practice from those in which it was seen as only one among many possible strategies. Uncertainty and risk associated with informal policy lead many frontline staff to adopt strategies intended to preserve autonomy in community work, including "seeking forgiveness rather than permission" and maintaining relative "invisibility."

Extracapsular cataract surgery in Vietnam: a 1 year follow-up study

PURPOSE

Unoperated cataract is the leading cause of blindness in the developing world. Many developing countries now use extracapsular cataract extraction (ECCE) with intra-ocular lens insertion (IOL) in their cataract blindness-prevention programmes. To date, little research has been directed at visual outcomes and complication rates of ECCE/IOL surgery in developing countries.

METHODS

We conducted a follow-up study of 155 eyes approximately 12 months after ECCE/IOL surgery by eight local eye surgeons in Central Vietnam. We report the findings for the 144 eyes (93%) successfully reviewed. All subjects underwent manual ECCE with insertion of a three-piece posterior chamber IOL. All eyes were also assessed for the presence and severity of posterior capsule opacification (PCO) using a newly developed grading system.

RESULTS

Overall, 110 eyes (75%) had uncorrected visual acuities > or = 6/24 and 107 eyes (74%) had best spherically corrected visual acuities > or = 6/18. Some degree of PCO was found in 40% of eyes, but was graded as visually significant in only 4% of eyes. No major sight-threatening complications were noted. A portable neodymium:yttrium aluminium garnet (Nd:YAG) laser was used to perform capsulotomies on all eyes with visually significant PCO. There were no laser complications noted.

CONCLUSIONS

At approximately 1 year after ECCE/IOL, the visual outcomes for subjects in this cohort were favourable and complication rates were low. Posterior chamber opacification was not a major cause of vision impairment in this cohort. Portable Nd:YAG lasers may provide an effective solution to the problem of visually significant PCO occurring in developing countries as a late complication of extracapsular surgery. These findings support an increasing role for ECCE/PCIOL surgery by trained local eye surgeons in developing countries.

Thyroiditis in the BB rat is associated with lymphopenia but occurs independently of diabetes

The spontaneously diabetic BB rat is an excellent and well studied model for human insulin-dependent diabetes (IDDM), sharing many important features with the human disease. Similarities include an equal frequency of IDDM in males and females, production of antibodies against pancreatic cell antigens, and an MHC disease association. In addition, the BB rat shares with human IDDM patients an increased frequency of autoantibodies against the parietal cells of the stomach and colloid cells of the thyroid gland. Here we investigate the genetic basis of thyroiditis in the BB rat. Based on crosses between BB, Lewis and Fischer rats, we show that two susceptibility factors for diabetes--the lymphopenia trait present in diabetes prone BB rats and the MHC--also appear to be risk factors for thyroiditis. However, the nature of the susceptibility was different for the two autoimmune diseases, with lymphopenia being absolutely required for diabetes although it only conferred increased risk for thyroiditis. Also, in contrast to IDDM, the MHC conferred dominant susceptibility to thyroiditis. Despite these shared risk factors, diabetes per se did not show significant correlation with thyroiditis.

Predicting surgical compliance in a cohort of women with trichiasis

Trichiasis/Entropion are the severe consequences of chronic trachoma during early life. Blindness and vision loss is preventable with timely lid surgery to correct trichiasis. In a trachoma hyperendemic region of Central Tanzania, a two year follow-up survey was conducted among 205 women with trichiasis to determine the proportion who had had surgery and the barriers to having surgery. Only 18% of the women had undergone surgery by the 2 year follow-up. Those who had surgery tended to report more eye problems at baseline and have more corneal opacities at baseline. Barriers preventing women from going to surgery were costs, problem of children left at home alone, and difficulties in identifying someone to accompany them to the health center. Over 2/3 of those who had surgery reported a significant decrease in pain, improvement of vision, and improved ability to carry out activities of daily life. Ways to improve compliance with recommendations for trichiasis surgery need to be developed.

Incidence of pathogenic bacteria in raw milk in Ireland

Raw milk from 70 farms was sampled over 13 months for salmonellas, listerias, Escherichia coli, Staphylococcus aureus and mastitic streptococci; total bacterial counts (TBC), coliforms and somatic cells were also counted. TBC < or = 30,000/ml were obtained in 63% of samples. High count milks were found mainly during the winter months: 13% of samples had > 10(4) mastitis pathogens/ml of milk. The mean somatic cell count varied from 4.0 x 10(5) to 8.0 x 10(5)/ml throughout the year with highest counts during the late lactation period. Coliforms were present in all samples, but 65-71% of samples had < 100 coliforms/ml. Up to 60% of supplies had < or = 10 E. coli/ml. One of the 589 samples tested (0.1%) was positive for salmonellas. Yersinia enterocolitica and Y. enterocolitica-like organisms were isolated from 39% of samples with up to 68% of samples positive at some sampling periods. A total of 222 strains of yersinias were isolated; Y. enterocolitica (59%) was the most common strain followed by Y. fredriksenii (35%), Y. kristensenii (1.0%), Y. intermedia (4.5%) and Y. aldovae (0.5%). Listerias were isolated from 8.3% of samples tested; 4.9% were Listeria monocytogenes and 3.4% were L. innocua. There was a significant rise in the isolation rate between December and April from a base line of 0-5% during the spring and summer to 35-37% during the winter months while the cows were indoors. Of 66 silage samples tested from the farms involved in the survey 9% of samples were positive for listerias; 3% of these were L. monocytogenes and 6% were L. innocua.(ABSTRACT TRUNCATED AT 250 WORDS)

The prevalence of trachoma in preschool and school children in Olimpia, Guaraci and Cajobi, Sao Paulo, Brazil

A school-based prevalence survey of trachoma was conducted in three rural municipalities in the state of Sao Paulo, Brazil, in 1989. A total of 950 children aged 4-11 years were examined. The prevalence of inflammatory trachoma was found to be 6.3%, peaking at 24.1% in the 4 year-old age group. The prevalence of trachomatous scarring was 2.7% and was more prevalent in older children. Risk factors included household sleeping arrangements and nasal discharge.

Pediatric emergency review: a "hands-on" approach

A "hands-on" approach to pediatric emergency review was developed to improve retention of psychomotor skills and instill critical thinking for pediatric nurses in anticipation of pediatric emergency situations.

A chicken leukocyte common antigen: biochemical characterization and ontogenetic study

A monoclonal antibody, designated CL-1, was produced by immunizing mice with chicken peripheral blood lymphocytes (PBL) and selected in an indirect immunofluorescence assay. CL-1 characterizes a cell surface antigen expressed on all chicken hemopoietic cells except mature erythrocytes. Cells stained by CL-1 were detected at early stages of embryonic development in the various hemopoietic compartments. CL-1 reacts with two chicken PBL proteins of 200 kDa and 215 kDa which are probably the homologues of the T-200 and B-220 antigens previously described in the mouse. Moreover, CL-1 does not react with quail hemopoietic tissues and can be useful in experiments using quail-chick chimeras to study the ontogeny of the hemopoietic system.

How reliable are commercial allergy tests?

The ability to diagnose allergic disease was studied in 9 fish-allergic and 9 control subjects, who provided specimens of blood and hair for testing. All fish-allergic subjects had previously been shown at Guy's Hospital to have a positive skin prick test to fish. The specimens were submitted as coded, duplicate samples to five laboratories which all offer a commercial service in carrying out diagnostic tests for allergy. All five laboratories were not only unable to diagnose fish allergy but also reported many allergies in apparently non-allergic subjects and provided inconsistent results on duplicate samples from the same subject.