BBC Radio 4 programme seeks men to talk (anonymously) about erectile dysfunction

I've had permission to post this. My friend Petra (she's the Telegraph's agony aunt among many other cool things) is involved in a BBC R4 programme looking at erectile problems and the programme's producer is looking for men who'd like (well, are willing) to be interviewed - anonymously if preferred.

There are many reasons for erection problems and diabetes can be one of them (long term raised blood glucose levels can lead to problems with blood vessels and nerves in general) which can affect any area in the body including the erectile 'machinery', and so I'm sharing this in particular with diabetes people. People who have diabetes may also experience anxiety over their health and this can be pretty antithetical to enjoying any pleasant pursuit, let alone sexual activities - it doesn't always have to mean a straightforward physical problem.

Here's Petra'a information and advice (covering a range of possible reasons for erectile dysfunction) to a woman whose partner experiences this, and below is the text of her producer's request...

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To whom it may concern

I am making a programme for BBC Radio Four looking at erectile dysfunction and erection problems and wondered if you would consider being interviewed for the project. We are looking for men to share their experiences so we can highlight this very common but little talked about condition. If you were willing to talk to us, you would not need to reveal your identity.

The programme is 30 minutes long and will be broadcast on BBC Radio Four in June. It’s presented by Dr Petra Boynton who is a psychologist with a specialism in sex and relationships and works as an agony aunt for the Telegraph. She is experienced in offering advice and support to men and women with sexual problems and will be carrying out the interviews. We are hoping making the programme will encourage men to talk and seek help if they need to.

We are looking for men of any age who have or have had erection problems. We are keen to speak to men who have had problems following health issues as well as those who have psychological barriers or unknown causes for their erection difficulties.
Questions might be:

• What erection problems do you have?
• Do you know why it came about?
• How soon did you seek help?
• How did having erection difficulties make you feel?
• How did your partner support you (or not)?
• In what way did you seek help yourself?
• What was useful and why? What wasn’t?
• What treatment has helped?
• How do you accept erection dysfunction if treatment doesn't work and you don't want surgery?
• Why do men find it hard to talk and what is key to changing that?

Interviews would take around twenty minutes and would really just be like having an informal chat. They would be pre-recorded (not live) so you could have a chance to retake answers if you were unhappy with what you’d said.

If you have any other questions do let me know. Or if you would like to chat further before you commit to an interview, my email is henriettaharrison@hotmail.co.uk and my mobile is 07740 565996

Thanks in advance.

Henrietta Harrison
Producer
Loftus Media

Small post for Sophia about genetic testing for diabetes

For Sophia - I realised this was going to take up more tweets than those following both of us might have patience for.

For everyone else - I was a diabetes science information officer for eight years until June 2012 and as such there may be newer information that I'm not aware of, if you spot any errors in my reasoning below do let me know, ta :)

General 'stuff' about genetic testing for diabetes, saving money for health service

1. What is the benefit to the individual or to the state for sequencing genome with respect to diabetes risk?
I'm not aware of researchers into diabetes genetics having called for widespread genetic testing post-birth (or at any other time), even in people at risk.

I might be wrong but I don't think genetic testing (we're really talking about Type 2 diabetes here) tells you much that you don't already know. Age, family history, weight and activity levels are possibly a better predictor of T2D. Family history obviously implies genetics, but it seems to be a pretty multifactorial sort of thing.

As the information below (which comes from Diabetes in the UK 2012) suggests, most cases of Type 1 diabetes don't seem to have an obvious family link, though there are genes that increase risk of developing the condition.

Type 1 diabetes
Although more than 85% of Type 1 diabetes occurs in individuals with no previous first degree family history, the risk among first degree relatives is about 15 times higher than in the general population.

On average: if a mother has the condition, the risk of developing it is about 2–4 per cent
if a father has the condition, the risk of developing it is about 6–9per cent
if both parents have the condition, the risk of developing it is up to 30 per cent
if a brother or sister develops the condition, the risk of developing it is 10 per cent
(rising to 10–19per cent for a non-identical twin and 30–70 per cent for an identical twin).

Type 2 diabetes
There is a complex interplay of genetic and environmental factors in Type 2 diabetes. It tends to cluster in families. People with diabetes in the family are two to six times more likely to have diabetes than people without diabetes in the family.

There doesn't seem to be very much that someone can do to prevent getting Type 1 diabetes, whereas health interventions can help reduce the risk of Type 2 (and prevent progression from "prediabetes"to full-blown Type 2 diabetes). However the lifestyle advice given to someone at risk of developing T2 is pretty much the same as would be given to anyone: eat a variety of foods, not too much, maintain a healthy weight, do a bit of exercise but doesn't need to be marathon-running to help.

Perhaps giving someone information in black and white from a genetic test might make them more likely to follow this healthy advice (but is this coercion or compliance!) however the tests themselves, even in high-risk individuals, don't appear to be all that sensitive or of use in clinical practice.

Genetic Screening for the Risk of Type 2 Diabetes: Worthless or valuable? Diabetes Care 2013

"Genetic testing for the prediction of type 2 diabetes in high risk individuals is currently of little value in clinical practice.

The limitations of genetic risk models are small effect size of genetic loci, low discriminative ability of the genetic test, small added value of genetic information compared with the clinical risk factors, questionable clinical relevance of some genetic variants in disease prediction, and the lack of appropriate models for studies of gene-gene and gene-environment interactions in the risk prediction. 

For improvement of the genetic risk models in the future, the definition of type 2 diabetes and classification of subtypes of diabetes should be more precise, new sequencing techniques should be applied to identify low-frequency and rare variants having a large effect size, non–European ancestry populations should be investigated to identify new variants relevant to type 2 diabetes prediction, studies of structural variation and epigenetics should be performed to identify new variants relevant to type 2 diabetes prediction, and modern statistical methods should be developed and applied in studies of gene-gene and gene-environment interaction in large populations." - emphasis added.

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I don't think there's much benefit in genetic testing either to a person at risk of diabetes, or the state at this stage.
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2. What is the benefit to the individual or to the state in diagnosing diabetes early?
With undiagnosed Type 1 diabetes things can go wrong very quickly as with no insulin available and rising glucose levels the person can go into diabetic ketoacidosis (DKA), a metabolic emergency that can and does result in death. So clearly a benefit to the individual there! Once T1D is diagnosed if the person doesn't take sufficient insulin this problem can re-occur.

Diabetes UK had a campaign to get parents more aware of the symptoms of Type 1 diabetes - the 4Ts: toilet, tired, thirsty, thinner (going to the loo more, drinking more water to compensate and losing weight along with being tired as the body's not getting the glucose fuel it needs).

With undiagnosed Type 2 diabetes the person may creak on fairly happily, and fairly unaware that there's a problem. Here insulin is still produced by the pancreas and the main problem is that the body (organs, muscles) become less sensitive to it). Any symptoms are generally put down to 'getting older' and that's why symptoms are pretty useless for Type 2 (good for Type 1), and 'risk factors' are much more important - as in T1 a blood test is diagnostic.

About half of people who are diagnosed with Type 2 diabetes will already have some signs of diabetic complications, so early diagnosis can help to prevent these from worsening (it's controversial but not unfeasible that some complications may be reversible if caught early). Plus people tend to feel a lot better once their glucose levels are brought back to healthier levels (also it's not just glucose, diabetes is a cardiovascular condition and blood pressure and blood fats / lipids are also problematic and need to be monitored).

There are other rarer forms of diabetes and some of these can be linked strongly to a particular gene - monogenic forms of diabetes can be probed with genetic testing however the person is already likely to have been diagnosed with 'diabetes' (probably Type 2*) and this testing really just refines the diagnosis rather than spots the existence of the diabetes. The advantage of a correct diagnosis is that the person gets the right treatment (in some cases this can be changing from insulin to tablets).

From the state / money point of view - diabetes complications cost a lot of money and diabetes medicine costs a lot too. Hospital admissions and cardiovascular treatments are probably the big costs and likely to increase with an aging population. Delaying or preventing complications saves money, though offset by more people taking medication. Insulin's main side-effect arises because it's incredibly difficult to get the dose right - if too much is taken then blood glucose levels can plummet and the person may need medical treatment. If too little is taken then the person may experience the metabolic emergency DKA mentioned above, which requires hospital treatment.

See also 
Article: Health Economics
Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs Diabetic Medicine 2012

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I think a more feasible thing is perhaps to forgo predictive testing at this stage (maybe it'll be more useful in the future) but improve prompt rather than early (pre) diagnosis of any kind of diabetes so that the person can maintain good health for longer. 
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*After I tweeted this post and asked for corrections @sparklyredshoes pointed out that people ultimately diagnosed with a monogenic form of diabetes are possibly more likely to have been initially misdiagnosed with Type 1 (not Type 2 as I've said above) as they're often 'young and skinny'. However there aren't really enough stats on this so she suggested that it was probably safer for me not to commit to which type of diabetes people are commonly misdiagnosed with :)

Diabetes and language used in healthcare and research

NB. Likely a few more links to be added in, I am working on a slightly uncooperative wifi network at the moment

I took part in a work-related Twitter chat last night, about avoiding errors in the self-management of diabetes.

The project I work on, CHI+MED, is looking at ways of making interactive medical devices safer but to do this we don't just study the devices themselves but also the people who use them and the systems that the machines are used in - basically it's a "sociotechnical" model sort of thing.

People know that they make errors in using machines. Sometimes the system helps them to prevent this, for example I've made good use of the delete key while typing this post, someone had the good sense to add one in to keyboard design. Sometimes people develop their own cunning plans to prevent errors. These are 'resilience strategies' (strategies that make them resilient to error) that are either generated by the person themselves or picked up from colleagues - they're rarely 'in the instruction manual' and they're not part of any official training.

But they can be really useful - both to other people who are using that medical device, but also to researchers who want to find out the strategies people employ to prevent mishaps.

And that's what the chat was about - what are the sorts of errors that people with diabetes (particularly Type 1 diabetes who are regularly monitoring their blood glucose levels and adjusting doses of injected insulin) might make and what tricks have they developed to try and avoid making an error.

One interesting things that came up was the language used by error researchers and how this might conflict with that used by people with diabetes or diabetes researchers. Dom (a colleague on CHI+MED who was co-hosting the Tweetchat with @OurDiabetes) uses terms like slip, mistake and violation which have precise meanings in the context of human factors and ergonomics research.

One of the people participating in the chat felt that the word violation was a bit of a strong term - it certainly carries negative connotations. Suzette Woodward has a helpful post explaining some of the examples of violations (eg of policies) in a healthcare setting: Working to rule?

Language used in different disciplines often has the potential to offend, or even just misfire, when heard by other people out of context.

I remember, when working in a GPs' surgery 10 years ago, reading that "the patient denied having any chest pains" and being amused at the implication that the doctor knew full well that the patient was having chest pains but that the patient wasn't having any of it. That's not what it means of course, it just seemed a strange way to say "the patient reported that he was not experiencing any chest pains" but "deny" carries other meanings to those not immersed in this use of language.

Similarly there are terms used in healthcare research looking at situations where medication is just not taken. It might be forgotten, lost (stolen?), unusable (damaged) and so not used. Equally it might be intentionally not used.

The various terms I came across that meant "not taking his or her medication" were non-compliance, non-adherence and non-concordance. All mean more or less the same thing but non-compliant sounds a bit more "naughty diabetic*" and "non-concordance" suggests a certain disagreement between patient and doctor.

*I do of course mean "naughty person with diabetes" ;-)

Further reading

• Errordiary learning zone / brain food - explains why Dom is collecting errors for research purposes
• Can resilience strategies help with diabetes management? - from Dom's own blog
• Can Errordiary be used to support patient safety education? - from Errordiary
• Unintentional non-adherence: can a spoon full of resilience help the medicine go down? (open access, full paper freely available) by Dominic Furniss, Nick Barber, Imogen Lyons, Lina Eliasson and Ann Blandford. Dom and Ann are both on the CHI+MED project (Ann is both the Principal Investigator (PI) at the UCL site and PI of the CHI+MED project overall). BMJ Qual Saf doi:10.1136/bmjqs-2013-002276

WDDTY on Type 2 diabetes - not actually dreadful but could be a bit better

Plenty of people have been taking a keen interest in the magazine 'What Doctors Don't Tell You' lately. It positions itself as a health magazine but the advice within it has been shown repeatedly to be unhealthy and often dangerous. Sometimes the information in it is flat out wrong, other times it isn't particularly wrong, perhaps just a  bit preliminary, but that bit of information is given much more weight than is warranted.

I thought I'd take a look at the current issue (November 2013) and see what they had to say about Type 2 diabetes, having previously implied in a headline that you could sunbathe it away (a rather glib approach to the otherwise interesting relationship between Vitamin D and health). I'm afraid you can't sunbathe Type 2 diabetes away.

In this issue I found three main 'things' that mention diabetes, one about intermittent fasting, one about getting more sleep and one frankly loopy one about electricity.

The first two fall into the category of being genuinely interesting information but an awful lot is missed out meaning that it's not clear to readers what they should do with it. The third is plain old silliness and just lets someone spout nonsense for a bit while hinting at products you can buy to detect or solve the non-existent problem.

On page 12 - Fasting improves heart health
Although, given the magazine's title, I can imagine they're reluctant to add this sensible phrase the one thing that's missing from this piece is "speak to your doctor (or a proper dietitian) about any drastic changes you want to make to your diet". I don't think it's particularly controversial to add that, after all people are free to ignore it. I suppose they do say it in their liability statement on page 3 though.

LIABILITY STATEMENT
While every care is taken in
preparing this material, the publishers
cannot accept any responsibility
for any damage or harm
caused by any treatment, advice
or information contained in this
publication. You should consult
a qualified practitioner before
undertaking any treatment.

They are reporting on a review, published in the British Journal of Diabetes & Vascular Disease, of several studies looking at calorie restriction and intermittent fasting and its effects on cardiovascular disease and diabetes. The picture shown in the magazine has a plate with a small potato, bit of broccoli and a tomato on it - hopefully this is not provided as a 'serving suggestion'.

Intermittent fasting is a bit less arduous than the 600 calorie semi-starvation diet recently trialled which was widely reported as having 'reversed' Type 2 diabetes. I think it's important to note that the 11 people in that trial were relatively young (late 40s early 50s), had had Type 2 diabetes for just a few years and had HbA1c values of 'rather elevated' rather than 'yikes'. I wrote about this paper when it was published. As such they may not be representative of the wider population of people with Type 2 diabetes. Also, when we're talking about reversing diabetes I want to know more about the effects on long-term complications.

Having said that I think this research is interesting but reporting on it without offering any guidance as to how people might implement it seems a bit cavalier. Let's hope people reading it don't 'down forks' and go hungry.

I'm not medically or dietetically trained so I can't give any useful advice either, beyond go and talk to someone competent (be wary if they're a nutritionist, anyone can say they're that and there's an awful lot of bad practice in the nutrition world).

• Intermittent fasting: a dietary intervention for prevention of diabetes and cardiovascular disease? British Journal of Diabetes & Vascular Disease March/April 2013 vol. 13 no. 2 68-72

On page 14 - A lie in helps prevent diabetes
I'd have added 'Type 2' to the title but the rest of the short piece does make it clear. I don't think anyone's going to argue with the idea that getting enough sleep is A Good Thing but the article implies that getting a lie-in at the weekend can undo a week of poor sleep. I'm not sure that that's actually true but I suppose it's better than nothing.

The article also references a study of 19 healthy young men whose insulin response improved after a good night's sleep. I'm not sure that the physiological responses to sleep of these chaps can tell us much about what's going on in someone older and less healthy and who perhaps has other metabolic issues. But fair enough, more sleep is better than insufficient sleep. The article references "The Endocrine Society’s 95th annual meeting, San Francisco, June 18, 2013" but it's not clear if it was a preliminary poster presentation or just something someone said.

On page 60 - Unhealthy rays - is really where they go to town with poor information

"Starting with this issue, we are launching a monthly column on the effects of ‘dirty’ electricity on health and how to protect yourself against it" - utter guff.

They go on...

As Milham once put it: “There is a high likelihood that most of the twentieth century ‘diseases of civilization’, including cardiovascular disease, cancer, diabetes and suicide, are not caused by lifestyle alone, but by certain physical aspects of electricity itself.”1 How can a leading doctor make such a claim?

:-o is pretty much how my face looked after reading that. I wonder if having electricity also means you're more likely to stay up late, reading by electrically-powered lights (we've just seen that getting less sleep is a bad thing) or perhaps watching an electrically-powered television in a sedentary manner. Or maybe the sort of lifestyle that lets people acquire electricity is the sort of lifestyle that increases the likelihood of certain health problems. I'm not sure I'd leap to the conclusion that the electricity itself was the cause. 

They also blether on about wifi - fortunately this nonsense has already been comprehensively debunked in a post on Electrosmog in the amusingly titled blog "What 'What Doctors Don't Tell You' Don't Tell You".

Speaking of which, after reading Josephine Jones article on the fact that a number of the doctors involved in the WDDTY editorial panel aren't actually doctors I was moved to ask...

@_JosephineJones So... What Doctors Don't Tell You includes not telling you that their doctors aren't doctors? They're so meta ;) #WDDTY
— Jo Brodie (@JoBrodie) October 11, 2013

Even more surprised to see a Matt Traverso ad for 'How to reverse diabetes' on Facebook

Just spotted an advert on my Facebook page for a way to reverse diabetes. I've pointed out to Facebook that this advert (or a suspiciously similar one) has already been 'banned' in the UK - ie an adjudication was upheld against it and it must not be shown in its current form again.

In case people with diabetes are Googling to find out information about an e-book on the topic I hope they'll find this.

Save your money, the advert is full of nonsense about acids and alkalis that betrays some confused thinking about physiology as well. The person or people behind the book, Matt Traverso, has / have already had two adjudications upheld against him / them for misleading advertising about diabetes and also Alzheimer's.

This is the offending website for diabetes http://www.reverse-diabetes-today[dot]com/ (replace [dot] with a dot for link to work).

For an example of how spectacularly wrong the advert is here's a sentence that demonstrates a lack of awareness of the different ways in which Type 1 and Type 2 diabetes develop:

"If you don’t stop the attacks on your pancreas‚ you develop type 2 and eventually type 1 diabetes!"

No, Type 1 diabetes is largely an autoimmune condition. The immune system starts attacking the cells in the pancreas that produce insulin and as the cells die off the person's blood glucose levels rise. Type 2 diabetes usually begins with insulin resistance. There's plenty of insulin and sufficient cells in the pancreas to produce it but the rest of the body's organs aren't responding appropriately, so even though there's enough insulin to do the job of normalising glucose levels it's not able to do it and so glucose levels rise.

I say largely because there are obviously people whose diabetes doesn't fit neatly into these categories (some people have MODY - maturity onset diabetes of the young, or LADA - latent autoimmune diabetes in adults and there are other forms of diabetes that are also caused by a very specific genetic change).

People with Type 2 diabetes may move from managing their diabetes with diet / activity and perhaps pills to diet / activity and insulin (and possibly pills as well) - but they still have Type 2 diabetes. I'm prepared to accept that many people are confused by this (I've spoken to hundreds who are) and it's not too surprising given that diabetes used to be classified as 'insulin dependent' and 'insulin independent'. However, as far as I'm concerned this confusion is inexcusable in anyone trying to claim the status of a healthcare information provider for people with diabetes.

The website also makes some very grand claims about curing diabetes in three weeks and references as well as confusing 'normal' blood glucose levels with 'not having diabetes'. There's undoubtedly a great deal that a healthy diet can do to help glucose levels, as well as blood fats, but normal levels doesn't necessarily mean 'cure', particularly if the complications of diabetes are already underway.

It's one of those things where there's some generally sensible lifestyle advice (eat fruit and veg, move about a bit, don't survive on processed foods) that is then overlaid with some vaguely mystical nonsense that sounds sciencey, and presumably makes the advice a bit more marketable.

"Dr. Young is an American microbiologist and nutrition scientist and known as one of the top research scientists in the world. His findings are currently sending shockwaves throughout the scientific community."

This bit is rather comical given his history. Young is also an advocate of live blood analysis which appears to be a bogus diagnostic technique to help you find out how many herbal supplements you need to buy.

Here are two Advertising Standards Authority adjudications against Matt Traverso's adverts:

Matt Traverso t/a Vital Life Education
A website offering a book called "The Alzheimer's-Reversing Breakthrough" stated "Discover The Truth About Alzheimer's That Doctors And Pharmaceutical Companies Don't Want You To Know About 'At...
Date: 11 May 2011
Decision: Upheld

Matt Traverso t/a Vital Life Education Claims on a website, viewed on 13 April 2011, for a book entitled “How to reverse Diabetes”. The ad was headed "The Diabetes-Reversing BreakthroughTM Don't Even Think About Taking More...
Date: 3 August 2011
Decision: Upheld

Trying to find this year's QOF stats on diabetes - worked example

This is an unfinished post that I last saved on 10 February 2013. I was in the middle of updating my own stats website at DiabetesStatistics and (a) discovered that all the previous links to stats files were now out of date because people will keep moving things around and (b) I found conflicting numbers and hadn't managed to resolve it. I'm publishing this now as I was so surprised to read of 'new' figures today... which seem to be the October 2012 QOF figures. Odd.

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When I worked at Diabetes UK one of my tasks was to contribute to our "Diabetes in the UK" document which began to be updated annually to take account of new QOF (Quality and Outcomes Framework) figures for people with diabetes. You can see the history of the document from 1988 to the present at this page on diabetes prevalence here.

Here are the 2011/2012 figures I've found for each nation.

England: 2,566,436 people over age of 17 with diabetes (any type)
Scotland: 234,871 or possibly 247,278 (not sure about this one, see explanatory text below)
Northern Ireland: 75,837
Wales: 167,537

Total: 3,018,610 / 3044681

http://www.gpcontract.co.uk/child/UK/DM%2019/12

Numerator	Denominator	Ratio	Centile
Wales	167537	3185538	5.3%
England	2544197	55068625	4.6%
UK	3018610	65358176	4.6%
Scotland	231248	5210522	4.4%
Northern Ireland	75628	1893491	4.0%

Briefly, and probably somewhat simplistically, QOF is a form of accounting so that each GP practice in the various nations gets the appropriate payment for the number of people they are looking after with different conditions. I'm not sure that it was particularly designed to provide health charities with a handy record of how many people (over the age of 17) have a particular condition, but that info is there and that's the only reason I've ever looked at the data.

Taking England (because I live there and it's got the biggest population) as an example, the data is available at the level of 'everyone in England', 'everyone in a particular Strategic Health Authority', 'everyone at a particular practice' - using the latter you can also find out information about how many people in a particular town (eg with 5 practices) have a particular condition.

I won't pretend that I've ever gone to the QOF's landing page and gone straight to the relevant file and picked out the answer I want. Usually it's a case of clicking on a few things, trying to remember how I did it last year and eventually finding it. Or asking a colleague.

The QOF figures for 2011/2012 came out in October but I paid little heed to them as I'm no longer in the business of updating statistics, but then I remembered my very large DiabetesStatistics google site and I thought... I really ought to try and update it.

Easier said than done.

I created it largely for me but also for colleagues and anyone else who might be interested in statistics. Its strength, for me, is that I left reasonably good instructions on how I got hold of the figures rather than just the figures themselves.

However an additional challenge is that statistics websites often move things around, so while the instructions are good, you can't 'follow along' using previously captured figures as a guide to how to do it now because all the pages and files are '404 not found' or worse, take you to the sites' homepages.

Every single link in this section below, of this QOF overview page is now non-functioning ;)

NHS Information Centre's pages on QOF ENGLAND

Landing page (2010/2011) » data tables » Prevalence data tables » SHA level QOF tables (opens .xls)

Below is the very detailed record of my attempts to correct the links for 2010/2011 data and find 2011/2012 data. It's quite long...

In the text below the addresses are shown as embedded links but for URL hackers I've left the full addresses at the end, though the NHS IC ones don't really lend themselves to that unfortunately.

Firstly, I found where the 2010/2011 data for England had been moved, here are the links for each of them... this was partly to correct the links but also to refamiliarise myself with the process of where to look for the relevant number.

2010-2011 QOF data for ENGLAND - published in 2011

• Start at landing page for Quality and Outcomes Framework - 2010-11 
• then look for Quality and Outcomes Framework - 2010-11, England level - click to open page
• Once on page, look for: Quality and Outcomes Framework - 2010-11, England level: Prevalence data tables [.xls] - clicking will open a spreadsheet, called qof-10-11-data-tab-prev-eng.xls
• Once opened look for Column A, Clinical Area and find Diabetes Mellitus (Diabetes) (ages 17+) then read corresponding figure in Column B = 2,455,937

So, now onto the four nations...


2011-2012 QOF data for ENGLAND - published on 26 October 2012

• Start at landing page for Quality and Outcomes Framework - 2011-12
• then look for Quality and Outcomes Framework - 2011-12, England level - click to open page
• Now on page http://www.ic.nhs.uk/catalogue/PUB08661 =
• Once on page, look not for the diabetes spreadsheet but keep scrolling for Quality and Outcomes Framework - 2011-12, England level: Prevalence data tables [.xls] - - clicking will open a spreadsheet, called qof-11-12-data-tab-eng-nat-prev.xls
• Once opened look for Column A, Clinical Area and find Diabetes Mellitus (Diabetes) (ages 17+) then read corresponding figure in Column B = 2,566,436

Checking as we go...
For fun (your mileage may vary) you can also fact-check you've got the correct stat by googling that number along with the word diabetes - I found this question asked and answered in Parliament, which mentioned this specific figure, so this is an independent verification.

I also searched on Google for million Diabetes UK and then restricted to the most recent month to see any instances of things like "there are X million people" on DUK's site, or "According to Diabetes UK there are x million people with diabetes". I found a couple of references to 3.7 million, so then searched for that to find their September 2012 report which specifically mentions 3.7 million people with diabetes in the UK - this will include all England, Scotland, Northern Ireland and Wales 'known cases' of diabetes - this just tells me that once I've got all my figures they should probably combine to form 3.7 million (unless they're including an estimate of people with undiagnosed diabetes which is about 850,000 but I doubt it).

NORTHERN IRELAND

• Start at landing page for NI Direct's QOF data - this landing page doesn't seem to change location, it just updates with each new year's data which is helpful. I already had the link on my own stats pages for Northern Ireland.
• Scroll down for the right year, choose Local Commissioning Group Level 
• Look for 'Achievement in the Clinical Areas' and select Diabetes PDF or Diabetes XLS, whose filename is diabetes_indicators_by_lgc_2011-12.xls 
• Look for Total register size (cell F13) = 75,837

And Googling for 75,837 diabetes brings up plenty of evidence that others have picked the same figure, which is always heartening.

SCOTLAND
This one was a wee bit tougher because the relevant spreadsheet has macros and regardless of whether or not I enabled or disabled them the file wouldn't work on my computer (a Mac) and I couldn't select the QOF register I wanted to look at. Fortunately I spotted there was a second tab, which presents the data in a different way, so I went for that one instead. On Googling the resulting number (234,871) I didn't find much evidence of it having been used by anyone, so possibly another figure is in use.

However it is similar to the figure for last year's Scotland prevalence 2010/2011 on Diabetes UK's page (223,494) and slightly larger, so it's pretty plausible.

It's also possible that I picked the wrong file, so corrections would be appreciated! So many files...

• Start at ISD Scotland's Quality and Outcomes Framework
• Scroll to 'Links to QOF data tables for Scotland' and make sure you're on the right year (2011/2012 data table links) 
• then click on Register and prevalence data at Scotland, NHS Board and CHP level
• scroll down to NHS Board and Scotland level data and from the spreadsheets below that I chose the one called Prevalence reported from QOF registers (practices with any contract type)
• Once opened I clicked on the second tab 'by QOF register' and read off the number for Diabetes which, in cell i21, is 234,871 (*)

Incidentally my page on Scotland stats took me to the 2011 register information, from which I was able to work out the landing page above.

(*) It should be possible to do it using the first tab ('by NHS board') but the macros weren't friendly. Where it says (near the top) 'please select QOF register' it should be possible to select Diabetes from a drop-down menu and get the relevant information for NHS Scotland as a whole, and then for each NHS region.

Other figures I found
Diabetes rate in Scotland continues to increase BBC News (20 August 2012) - 247,278 people, this figure comes from the Scottish Diabetes Survey.

The Scottish Diabetes Survey seems to be consistently a bit higher than QOF because for 2010/2011 prevalence Diabetes UK was using QOF figures of 223,494 and SDS for 2010 had it as 237,468.

Last year I probably knew why there was a difference ;)


WALES

• After a lot of false starts, I discovered this helpful page from the GP Contract website, called QOF Database - Wales - DM 19
• Look for DM 19 | 2012 = 167,537

• Or StatsWales has it too: Patients on Quality and Outcomes Framework (QOF) by local health board and disease registers (make sure you select the correct year from drop down menu)

• Start at the landing page for the Welsh Government's General Medical Services Contract: Quality and Outcomes Framework Statistics, 2011-12. You can also use the StatsWales pages
• Scroll down to the Document Download bit and click on QOF Data Summary for Wales and LHBs, 2011-12

GP Contract - QOF Database - Wales - DM 19
  http://www.gpcontract.co.uk/timeline/WAL/DM%2019

http://www.gpcontract.co.uk/child/WAL/DM%2019/12
167,537

42,713

General Medical Services Contract: Quality and Outcomes Framework Statistics, 2011-12
  http://wales.gov.uk/topics/statistics/headlines/health2012/1209271/?lang=en
QOF Data Summary for Wales and LHBs, 2011-12
  http://wales.gov.uk/docs/statistics/2012/120927datasummaryen.xls

StatsWales
  https://statswales.wales.gov.uk/Catalogue/Health-and-Social-Care/NHS-Primary-and-Community-Activity/GMS-Contract

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Unless you are tasked with trying to find information from scratch and the links above don't work you probably don't need to look further. If the links above don't work you may be able to draw some conclusions about site hierarchies from the links' structures below.\

Other useful resources
Association of Public Health Observatories (APHO)'s Diabetes Prevalence Model
  http://www.yhpho.org.uk/default.aspx?RID=81090 (England, Scotland, Wales only)

Raw URLs / addresses
2010-2011 QOF data for ENGLAND - published in 2011
Quality and Outcomes Framework - 2010-11
  http://www.ic.nhs.uk/catalogue/PUB04396
Quality and Outcomes Framework - 2010-11, England level
  http://www.ic.nhs.uk/catalogue/PUB05673
Quality and Outcomes Framework - 2010-11, England level: Prevalence data tables
  http://www.ic.nhs.uk/catalogue/PUB05673/qof-10-11-data-tab-prev-eng.xls


2012 data
ENGLAND 
Quality and Outcomes Framework - 2011-12
  http://www.ic.nhs.uk/catalogue/PUB08135
Quality and Outcomes Framework - 2011-12, England level 
  http://www.ic.nhs.uk/catalogue/PUB08661
Quality and Outcomes Framework - 2011-12, England level: Prevalence data tables 
  http://www.ic.nhs.uk/catalogue/PUB08661/qof-11-12-data-tab-eng-nat-prev.xls

The chances are that next year's file might be called qof-12-13-data-tab-eng-nat-prev.xls which you can search for, although it's not clear from the PUB0123 type numbers in the URL where it will be located so file searching probably best unless the landing page helps you.

My DiabetesStatistics page on England
  https://sites.google.com/site/diabetesstatistics/uk-and-local-stats/nations/england


NORTHERN IRELAND
NI Direct QOF data
  http://www.dhsspsni.gov.uk/index/stats_research/stats-resource/stats-gp-allocation/gp_contract_qof/qof_data.htm
Local Commissioning Group Level (for relevant year)
  http://www.dhsspsni.gov.uk/index/stats_research/stats-resource/stats-gp-allocation/gp_contract_qof/qof_data/statistics_and_research-qof-lcg-2011-12.htm
Achievement in the Clinical Areas table:  Diabetes XLS 
  http://www.dhsspsni.gov.uk/diabetes_indicators_by_lcg_2011-12.xls

My DiabetesStatistics page on Northern Ireland
  https://sites.google.com/site/diabetesstatistics/uk-and-local-stats/nations/northern-ireland


SCOTLAND
ISD Scotland's Quality and Outcomes Framework
  http://www.isdscotland.org/Health-Topics/General-Practice/Quality-And-Outcomes-Framework/
Register and prevalence data at Scotland, NHS Board and CHP level
  http://www.isdscotland.org/Health-Topics/General-Practice/Quality-And-Outcomes-Framework/2011-12/Register-and-prevalence-data.asp
Prevalence reported from QOF registers (practices with any contract type)
  http://www.isdscotland.org/Health-Topics/General-Practice/Publications/2012-09-25/QOF_Scot_201112_Boards_all_prevalence.xls

Scottish Diabetes Survey
  http://www.sci-diabetes.scot.nhs.uk/

My DiabetesStatistics page on Scotland
  https://sites.google.com/site/diabetesstatistics/uk-and-local-stats/nations/scotland
 

WALES

Quality and Outcomes Framework (QOF) by local health board and disease registers
  https://statswales.wales.gov.uk/Catalogue/Health-and-Social-Care/NHS-Primary-and-Community-Activity/GMS-Contract/PatientsOnQualityAndOutcomesFramework-by-LocalHealthBoard-DiseaseRegister 

My DiabetesStatisitcs page on Wales
  https://sites.google.com/site/diabetesstatistics/uk-and-local-stats/nations/wales

Does aspartame have any effect on insulin production?

I think there was an article in one of the tabloids recently which implied that drinking diet soda might increase weight gain - I didn't pay too much attention to it to be honest as I assumed that it would simply be down to larger people offsetting a few calories with a low calorie drink.

But then a pal asked if I knew of anything in the literature that looks at the effect of aspartame on insulin production (I think in people with diabetes rather than the general population). I didn't.

Since I've not been working at Diabetes UK for almost a year and no longer do literature reviews and whatnot I'm perhaps a bit rusty, so feel free to join in and help us out :)

I did a very basic search on PubMed at http://ncbi.nlm.nih.gov/entrez so that it was only searching within papers that were reporting on work done in humans. Undoubtedly there will be umpteen million papers claiming doom and gloom about aspartame, based on work done in mice. That's not to discount that work and it may well be useful in pointing to interesting things to study, it's just I would avoid rushing to conclusions based on that.

And to be honest I'd avoid rushing to any conclusions anywhere along the line in this process.

So... I wanted to search for insulin aspartame (where these words appear in the title, keywords or abstract etc) and I wanted to filter the results so that only those articles relating to human were returned.

This scary long URL might do the trick http://www.ncbi.nlm.nih.gov/pubmed?term=%28%28%22aspartame%22[MeSH%20Terms]%20OR%20%22aspartame%22[All%20Fields]%29%20AND%20%28%22insulin%22[MeSH%20Terms]%20OR%20%22insulin%22[All%20Fields]%29%29%20AND%20%22humans%22[MeSH%20Terms]&cmd=DetailsSearch

Clicking on that will bring up 39 (at time of writing) abstracts and it will also populate the search box with the search terms, so these can be tweaked to suit.

Things I would look out for might include - teeny tiny studies where only a handful of people were involved, studies where the people didn't have diabetes or were unusual in their diabetes (newly diagnosed or perhaps people with Type 2 not yet on any medication etc), studies in people who consume an abnormally large volume of unsugared soft drinks and who also use other unsugared products heavily. Also see if any studies specifically mention insulin secretion or changes in insulin production and how this is measured.

That might be a place to start.

ASA adjudicates on misleading diabetes advert on World Diabetes Day ;)

Fairly often, on a Wednesday, I take a look at the rulings from the Advertising Standards Authority and today I was surprised to see this one - and on World Diabetes Day! It's not one of my complaints (see more after the line).

The advert is available in full at the link above, here's an excerpt - note that the advert talks only about Type 2 diabetes and not Type 1:

The aim of any reversal programme is to help people to control their condition and, where possible, reduce or eliminate the need for medication.

His diabetes was so out of control that he had been told he would need to begin taking insulin ... After following the [redacted] ... his diabetes was totally under control without medication...

As far as I can tell it's a residential programme with access to properly qualified healthcare professionals (doctor and nurse) and people lose weight on it.

The word 'reversal' makes me twitchy though and in their response to the ASA's questions about this the company said that "a reversal of Type 2 diabetes could be defined as a reduction in an individual's blood glucose levels, a reduction in their medication, and in some cases an elimination of the need for medication."

Well... a bit... I suppose. I've always felt that a reversal of diabetes would also include significant improvements in blood fats (cholesterol etc) and blood pressure. Glucose is a big part of diabetes but there's a lot of cardiovascular stuff going on too.

I'm not sure if reversal would also mean an elimination of the threat of future complications too - although we might be getting into the tricky semantics of what is meant by 'reversal' or 'cure' and the company were very clear in their acknowledgement that there's no cure for Type 2 diabetes.

They also said that until recently "the charity Diabetes UK had not used the word "reversal" in relation to Type 2 diabetes, even though it was in common usage in the United States. They explained that that had changed in June 2011 when a small scale study undertaken by Newcastle University, funded by Diabetes UK, showed that Type 2 diabetes was reversible through diet. They stated that as a result of the study Diabetes UK had accepted that a change in diet could lead to a reversal of the symptoms of Type 2 diabetes."

Reversal of symptoms... reversal of Type 2 diabetes - which is it. Many people with Type 2 diabetes have no symptoms or any symptoms they have can easily be explained as 'just getting older'. People with well-controlled diabetes might not have the symptoms of diabetes either, but that's not a reversal of T2 diabetes.

I can't help thinking that companies that make health claims could be keeping skeptic bloggers on some sort of retainer, periodically sending them advertising material to pre-snark at before it goes live. Sort of like testing your prototype to destruction. (No, I am not offering my services).

The statement "a small scale study... showed that T2 diabetes was reversible through diet" was the thing that made me sit up on the bus this morning when I read it. They're referring to a small pilot study - that I wrote about in detail here - in which the trial participants underwent a fairly extreme diet which was very low in calories (600cal), and lasted for probably a bit longer (two months) than you might undertake on a residential healthy holiday. The trial diet and the residential programme seem to be two very different and non-comparable things and although the advert doesn't make any claims linking the two I'm really surprised that this was used in the evidence given to the ASA afterward.

The company also volunteered several satisfied customers who were prepared to offer testimonials about reductions in medication and improvements in their health... oh dear.

Not all negative though - I was pleased to see that if "a guest decided they wanted to reduce or stop taking their diabetes medication, an appointment would be made for them to discuss any changes with the doctor. They also stated that when a guest left the retreat they were given a letter to pass on to their own GP detailing the programme, and were encouraged to make an appointment as soon as possible on their return to discuss their future medication requirements."

I suppose it's also a plus that they're not offering live blood microscopy or live blood analysis or anything like that.

---

I have previously blogged about the company after putting in a complaint about them myself, however this particular complaint and ruling didn't come from me (and I don't know who it came from). Not long after I blogged about about my complaint the owner of the company got in touch and sent me the world's politest email asking if I wouldn't mind taking the post down. Their reason was that because the previous misleading text had now been removed - I was basically blogging 'after the fact' - my record of it wasn't doing them any favours in google as, for some reason, my blog was coming up in the first few pages. 

They were pleasant, agreed that they didn't want to mislead anyone and sounded reasonable so I happily took down the post and the comments with it. Some of the comments had been a bit snarky, but nothing unpleasant, but I said I'd leave the post for another day as I don't think it's fair to take down a post straight after someone's posted a comment disagreeing with me. The post has been down ever since and I've no plans to repost it or mention the company by name although you will easily find it from the link above.

Today's ruling amazed me. The claims were clearly pushing up to the boundaries (I agree it's quite a grey area) and I cannot understand why the company didn't agree to amend things. That way the end result would be 'informally resolved' and the company mentioned on the informally resolved page and that's it. I suppose they were confident that they could provide evidence for the claims and felt that the ASA board would agree, however there's now another page on the internet which highlights misleading claims made and I don't think it's going to be taken down no matter how polite the request. When I googled the company (and bear in mind that Google does personalise stuff) the ASA ruling was on my first page of results.

Since I am feeling kindly disposed towards pleasant people, even if I disagree with their claims, I will remove the company's name from any comments. 

Someone is wrong on the internet - diabetes and live blood analysis

Update 20 April 2018: Today the subject of this post was fined £2,200, ordered to pay costs of £15,000 and given a Criminal Behaviour Order (which, if breached, puts him in contempt of court). The Advertising Standards Authority referred his protracted case(s) to Camden Trading Standards who brought proceedings, resulting in a trial at Blackfriars Crown Court which concluded in March 2018 with sentencing today. The ASA has said that it welcomes the outcome. See also info from Court News.


Update 12 October 2014: On Friday the subject of this post was fined £4,500 and lost his appeal at Southwark Crown Court. I don't know if the £4.5k is an adjusted figure or an addition to the previous fines. 

Update 20 March 2014: Today the subject of this post was fined £9,000 for nine counts of the Cancer Act of 1939 at Westminster Magistrates Court and handed a total bill (including costs) of over £19,000. He did not attend this final court hearing and did not represent himself. 


Musical accompaniment for long post: Prodigy - Climbatize

I used to work at Diabetes UK and one of the things I was often called on to do (along with my colleagues) was provide a fairly low level critical appraisal of unproven claims. This isn't the same as the sort of critical appraisal you'd do on a newly published paper, where you'd consider the type of study, the number of people involved (if it was in people), if the conclusions drawn were appropriate and things like that. This was just looking to see if there was any evidence for the slightly odd claims made by people with very colourful websites or glossy adverts.

Often we were asked, by people with diabetes, to look into things that at first glance looked to be utter nonsense. I don't think it's ever useful to dismiss something as nonsense without giving it a 'fair hearing'. Plenty of the people contacting us about some of these items were pretty convinced that they were nonsense but they wanted to hear (a) why it was nonsense (eg what was the evidence for or against) and they were also interested in knowing why (b) no-one seemed to be able to stop these misleading claims. I've never really got to the bottom of (b), I think that will always be with us.

A toy microscope, from spike55151 on Flickr

Live blood analysis also known as nutritional microscopy is an example of something that looks and sounds sciencey but for which there's no good evidence. It can't be used to diagnose diseases nor can it be used to determine what their treatment might be. It seems that some of the practitioners are very confused about physiology and even more confused about the use of blood smears in microscopy.

While I've done some basic microscopy in my time (biology degree, worked in various labs) I'm no expert myself so why do I think I can pass judgement on live blood analysis?

Partly it's that it's pretty implausible, but there's also a bit of 'well that's just not true' in the mix as well, and a good portion of evidence from other sources (and some blogs too) that shows how and why it isn't any use.

The reason I think it's important not to just dismiss live blood analysis out of hand is because it would be wrong to say 'well you can't tell anything just by looking at blood', that's obviously not true. Similarly the practice of iridology is nonsense as well but there are some things you can surmise about some people's health just from looking at their eyes.

Photomicrograph of red blood cells and bacteria (gonorrhea) - the blood has been stained to pick out the bacteria.
Picture source: CDC Public Health Image Library ID #15018, taken by Bill Schwartz, CDC.
Basically, you can spot some stuff in blood smears...

For some time I've been a bit troubled by the claims that Errol Denton has been making for his live blood analysis service which is based in Harley Street. He doesn't appear to be a fan of me either and recently tagged one of his blog posts with my name and the words 'racist nazi blogger' (1). That doesn't really strengthen his case much.

I've written before on the nonsense that is live blood analysis, as have others, so I shan't retread those steps. Today I spotted that Errol had written a blog post about diabetes, my post below is about correcting the misinformation in his post.

(1) see tags at the end of his post, which I prefer not to link to directly requiring you to copy and paste I'm afraid: http://erroldenton.wordpress.com/2012/11/05/errol-denton-live-blood-quack-or-super-hero-natural-health-physician/

Incidentally the tags in the original version of another of his posts did not mention either Josephine or me, or for that matter racist nazi bloggers, though it does now: http://erroldenton.wordpress.com/2012/10/18/errol-denton-complaints-about-racist-nazi-bloggers-highlights-big-cover-up-against-alternative-medicine/

Here's a screenshot of the original - click to enlarge. He's insulted us retrospectively ;)

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Errol's post can be found here: http://erroldenton.wordpress.com/2012/11/06/errol-denton-solves-another-diabetes-complaint-with-live-blood-analysis-harley-street/

Duty calls, from xkcd

"Diabetes is a growing epidemic in the world with over 150 million sufferers worldwide"
Well, we're off to a reasonably good start in that this figure (unreferenced) is roughly within an order of magnitude of being correct. The IDF Atlas for 2012 estimates the figure to be nearer 366 million people with diabetes worldwide in 2011.

"The answer from the medical fraternity is to create more and more drugs for their victims to consume which only suppresses the symptoms."
I suspect anything I say here will only convince Errol further that I'm a big pharma shill (I'm actually paid by the taxpayer) so I will acknowledge that there is indeed a great deal of medication going on of people with diabetes. I'm not sure what he means by 'only suppresses the symptoms' - the drugs suppress symptoms of high blood glucose levels by helping glucose to be taken up and used... I'm not quite sure what is meant here.

"With the NHS spending 3.9 Billion on Diabetes care but yet 24,000 die needlessly each year isn’t it time to look at Errol Denton’s safe natural alternative using live blood testing?"
Goodness me. Diabetes UK's key statistics on diabetes suggests that it's probably nearer £10 billion on diabetes care - it's difficult to know where he's getting his figures from as there don't seem to be any references. I think the 24,000 comes from the York & Humber Public Health Observatory (YHPHO)'s 2008 publication on 'diabetes attributable deaths' which did suggest that, in England "26,300 deaths between the ages of 20 and 79 years in 2005 can be attributed to diabetes" so that's pretty close. The registered deaths for diabetes in England and Wales tend to hover around the 5-6,000 mark but these are an underestimate and only include registrations where diabetes has been listed (diabetes can be a contributory factor but people tend to die of something else, although there is space on death certification to record contributory factors).

Edit: 7 Nov 2012 - pal at Diabetes UK has pointed out that 24,000 is actually a perfectly reasonable figure as it's cited by the fab NHS IC.

The final clause suggesting that it's time to look at his 'safe natural alternative' is not at all contingent on the earlier clauses outlining the scale of the problem. Yes, diabetes is crap, but live blood testing doesn't do anything to help. I'd definitely concede that if someone is given the advice to improve their lifestyle that'll help, but they don't need to spend any money on this (or buy expensive supplements) as that service is available completely free from their doctor or dietitian.

"Errol Denton says this is complete nonsense as Diabetes is not actually a disease it is simply caused by poor nutrition."
I'm not sure if Errol writes his blog in the third person or if someone else writes it but this statement is a bit of an oversimplification. For starters I think the author really needs to clarify that they're talking about Type 2 diabetes as opposed to Type 1 diabetes. But I won't deny that nutrition plays a role - this isn't a big secret and any doctor will tell you that lifestyle (which includes nutrition, though not to the exclusion of physical activity, good night's sleep etc) is important in managing the condition and in preventing the development of Type 2 diabetes.

Tokyo Tower lit in blue for World Diabetes Day, from Flickr user Clint Koehler

"He says that there is absolutely no reason that anyone should have to take any medication for this condition if they follow the natural laws of nutrition."
I think this should be much clearer that it is Type 2 diabetes that's being discussed, not Type 1 diabetes which definitely requires insulin to prevent hyperglycaemia and diabetic ketoacidosis. While people with Type 2 diabetes who have made lifestyle changes may sometimes be able to reduce or stop some of their medications (which is fantastic) this statement is a bit un-nuanced and this won't be the case for everyone.

"He asks when was the last time that we saw a Diabetic animal just to make the logical point that is the diet of humans that is at fault."
I once took a call from a zoo vet asking about diabetes in Old or New World Monkeys (I forget which but that was a fun afternoon looking on PubMed). Possibly Errol won't accept diabetes cases in captive animals as they're fed by human beings. It's probably difficult to get the prevalence of diabetes in animals in the wild - if it's Type 1 diabetes the chances are the animals won't survive for very long, although they can probably survive for much longer with Type 2 diabetes - though I suspect that it is probably pretty rare in wild animals anyway.

In captivity the animals can often live for longer and Type 2-like diabetes is more likely to occur spontaneously in older animals.

The rest of the blog post talks about a case study of a man who, after working with Errol was apparently "able to discard all his medication in a very short space of time as he no longer had blood sugar or cholesterol problems."

I hope the decision to come off medication was made after discussions with the man's own doctor - I hope Errol isn't offering anyone medical advice.

His blog's tagline is "Harley Street Natural Health Physician Getting Results Where Conventional Medicine Has Failed" - bit puzzling to use the word physician.

Some thoughts on the recent "Type 2 diabetes reversal" paper

"Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol"

Shortened URL for this post is http://is.gd/nbqdYX

Let me first of all make it very clear that the following thoughts are mine alone - I do work for Diabetes UK but I'm not a spokesperson so in the unlikely event that anyone wants to attribute any of the following to someone, please make sure it's to me, Jo Brodie - thank you :)

I'm also going to dual-post this to my ScienceDiabetes blog.

Other important things to note are that (a) I'm not medically or dietetically trained and therefore in no fit state to give anyone medical, or dietary advice and (b) I'm writing this at home without full access to the full 'diabetesphere' that I can log in to from work. So I might come back to this.

I do not think anyone should try this drastic diet and certainly not without full medical support (don't forget these people were in a trial which meant that the researchers had to take a great deal of responsibility for their wellbeing). I also think it's rather too soon to be talking about 'cures' and that we've no idea what effect this diet will have on people who've had Type 2 diabetes for longer than four years, and who have complications.

What does reversal of Type 2 diabetes mean
Forgetting for a minute that this was a tiny study (11 people) I'm always a bit wary of the terms 'cure' or even 'reversal' as it's not really what I'm used to in discussions and readings about diabetes. I've heard endocrinologists refer to people having their diabetes "pushed back along the continuum / curve" if they've undergone bariatric surgery (eg stomach stapling) and it seems to be fairly well accepted that losing weight (often a combination of losing weight and increasing physical activity) can help delay progression to Type 2 diabetes in those at risk. And people making dramatic lifestyle changes / improvements do seem to be able to come off tablets (I suspect some people with Type 2 diabetes using insulin may also be able to come off that too).

But Type 2 diabetes is generally thought to be a progressive condition (however the authors of the latest study suggest that this mightn't be the case). Progressive in this means that the way in which Type 2 diabetes is treated tends to change over time, in a way that it doesn't really in Type 1 diabetes (people start on insulin and remain on it, whereas people with Type 2 might go through the stages from diet plus physical activity controlled to tablets plus diet plus physical activity controlled to insulin plus diet plus physical activity controlled. Note the constant through each of these (diet and physical activity!) - it's not quite diet > tablets > insulin.

When someone comes off medication I never think that they no longer have diabetes. I think they've jumped back a stage, perhaps even two - but I don't know if they're necessarily 'off the conveyor belt'. The progression of Type 2 diabetes involves a combination of insulin resistance (when the body is less able to respond to insulin produced - and in the earlier stages this can lead to hyperinsulinaemia because the pancreas secretes more insulin to compensate) and 'beta cell dysfunction' - basically the insulin-producing cells begin to struggle to produce enough insulin.

Type 2 diabetes takes a while to develop and during its development the person might have no symptoms whatever. It's estimated that, at diagnosis of Type 2, someone will already have had the condition for several years (~8-12, however with better awareness this is probably dropping). That's why doctors, and my employers, generally recommend a focus on risk factors in preference to symptoms as symptoms are notoriously unreliable anyway.

An important aspect of this could be that damage done to tissues and organs may, or may not (I don't know) be irreversible - even if glucose levels are brought back to normal later on. If someone has been hyperglycaemic (too much glucose in the blood) for some time, before diagnosis or a few or many years afterwards, then there's scope for damage.

Glycaemic memory / legacy effect and later complications
There is this idea of a "glycaemic memory" in which the body somehow retains an imprint of whatever the glucose status is now, later down the line.

This seems appears to work both ways (or I've misunderstood it!):

High blood glucose levels early on, and for a long time, can be 'remembered', so that even when glucose levels are normalised, complications can still arise several years later -

"... studies in type 1 diabetes (e.g. DCCT) and type 2 diabetes (e.g. UKPDS) have shown that a period of poor glycaemic control earlier in the course of the disease is associated with an increased burden of complications much later in the course of the disease, even when glycaemic control is latterly improved. The Veterans Affairs Diabetes Trial suggested that more than 12—15 years of poor control in older type 2 patients minimised the benefits of subsequently improved glycaemic control. The delayed adverse effects of hyperglycaemia emphasise the importance of effective early glycaemic control." Source: Bailey CJ and Day C (2008) Glycaemic memory British Journal of Diabetes & Vascular Disease 8 (5): 242-247. doi: 10.1177/1474651408098784

Or, a period of good control might have a protective effect down the line

"Furthermore, there appears to be a beneficial ‘legacy effect’ or ‘glycaemic memory effect’ following a period of intensive glucose control that has also been observed in other studies.(5)" Source: Younis N, Soran H and Hassanein M (2009) Cardiovascular disease and intensive glucose lowering in type 2 diabetes Quarterly Journal of Medicine 102 (4): 293-296. doi: 10.1093/qjmed/hcp001

It seems pretty clear to me that good blood glucose control is a good idea, but importantly it's not just glucose that needs to be considered, but blood pressure and blood fats (blood lipids) too.

If someone already has diabetic complications then it's not always a done deal that dramatic weight loss or improvements in glucose control is necessarily going to make that much difference to those complications (it depends on the complications though).

There are exceptions of course - sensory neuropathy can resolve over time by itself anyway, I think it can also be improved with better glucose levels too. Some eye damage can actually get temporarily worse with improving glucose levels although I think there can be some improvements there too. Not sure about kidney or cardiovascular damage though (yeah I should probably find out!). What I want to emphasise is that 'resolution' of diabetes doesn't automatically mean resolution of all accompanying complications. A point put forward much more pithily by @EvidenceMatters

For me, a cure would have to mean resolution of all threats, glycaemic (blood glucose), lipidaemic (blood lipids), hypertensive (blood pressure) and any complications. I don't think we know yet what the long-term effects or benefits are of the various gastric surgeries that resolve cases of Type 2 diabetes. It should be noted that these procedures are not risk free and one effect is poorer absorption of some nutrients (obviously this can lead to weight loss).

Drastic diets
There are potentially very serious risks to health from following a drastic diet without medical supervision or support. I have read a couple of anecdotal horror stories of young women going on extreme diets and dying from heart failure - bit grim (hat tip @landtimforgot). But in general, the body just needs energy to function. I didn't spot any mention in the paper suggesting the participants had an electrocardiogram / EKG / ECG.

The 11 people on this trial were not just sent off with diet packs but given access to telephone support and regularly monitored every four weeks (in weeks 1, 4, 8 and then 12 but they stopped the diet after 8 weeks). It's also worth pointing out that three trial participants dropped out because they didn't stick with the diet in the first month and 1 dropped out for other reasons (so 3 / 15 = 20% drop out). The diet was about 46% carbohydrate but this shouldn't be taken to mean that it was medium-high carbs because the overall amount of all nutrients taken in was so low.

A diet of 600 calories a day is tough going and not really something anyone should attempt without proper support from someone like a dietitian who knows what they're talking about (this usually excludes anyone calling themselves a 'nutritionist' as anyone can call themselves that). I'd suspect that such a low calorie diet would be 'prescribed' by a doctor first as it's pretty extreme. Most of the reports I've seen have stressed this which is good.

Enough people have tried to tell me, while hoping to get me to promote their miracle cure, that being off medication means they're cured of Type 2 diabetes but that's an oversimplification I think. Additionally, 'coming off medication' doesn't mean that that was actually the appropriate thing to do!

Having said that I've seen a couple of commenters on news sites raising the issue about relative risks - devastating complications from diabetes are rather serious too... I don't have a snappy answer I'm afraid.

Insulin physiology
The paper talks about the dual problems in Type 2 diabetes of beta cell failure and insulin resistance (it also distinguishes between hepatic (liver) insulin resistance and peripheral (I assume this refers to skeletal muscle) insulin resistance.

The liver produces its own glucose and can do so in two ways: gluconeogenesis (or de novo synthesis) which means creating from scratch from precursor molecules, and glycogenolysis which means freeing glucose previously stored as glycogen.

If the body gets the message that there's not enough glucose it takes steps to get some released from the liver. Unfortunately, in diabetes the bloodstream may be swimming with glucose but the cells aren't getting it and so they're 'reporting' a lack of glucose and the liver is chucking more into the bloodstream. This has been described as "starving in the land of plenty" as the cells go hungry but there's plenty of glucose available, but inaccessible without insulin (Type 1) or the ability to respond appropriately and to dwindling supplies of insulin (Type 2).

Insulin, when all is working well, suppresses this hepatic production of glucose. When all isn't working well, it doesn't.

Fasting glucose levels (ie, not after a meal) tell you what's going on in the liver in terms of it just getting on and chucking out some glucose into the bloodstream. It does this because it's failing to respond to the insulin signal which should be telling the liver to suppress its glucose production. But after following this diet for just a week, fasting glucose levels plummeted, as did hepatic glucose production.

Observations on the people studied in the paper
There were eleven people studied, two women, and they all had been diagnosed with Type 2 diabetes for less than four years. I thought it was interesting that no-one appeared to have an HbA1c of more than 7.7%. This is a reasonably high HbA1c (I think normal values are lower than 6% and people with diabetes are generally recommended to keep it lower than 6.5 per cent) but some poeple with diabetes will have really much higher HbA1c values than this.

They lost a lot of weight, very quickly - an average of 3.9kg in the first week (of which 61% was fat loss) and 5.7kg from weeks 1-4 (I assume they mean a total of 5.7kg over the four weeks and not 5.7kg each week which would be a bit alarming) of which 86% was fat. In the final stretch they los another 5.7kg over the last month (assumed) of which 94% was fat. Gosh. They shifted a rather large 15% of their bodyweight, an amount which is generally achievable (for most people) but over a much longer time.

But the rapidity with which the weight was lost is suggested to be behind the disappeareance of triacylglycerol (TAG or triglycerides) from the liver and pancreas. Triacylglycerol consists of a glycerol molecule (the 'backbone') to which is bonded, by an ester linkage, three fatty acids of varying length. Un-attached fatty acids (called free fatty acids FFAs, also known as non-esterified fatty acids NEFAs) can interfere with an organs ability to do its job and apparently impede the normal production of insulin from the pancreas.

I'll probably come back to this as I've written a few notes from my first reading of the paper, but I expect it will bear further reading and digestion.

Please let me know if you spot any mistakes or omissions, thank you.
Please don't go cutting your diet dramatically without speaking with your doctor.

Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC and Taylor R (2011) Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol Diabetologia

[Published online 9 June 2011] doi: 10.1007/s00125-011-2204-7 (html) (PDF)

This was funded by Diabetes UK who also happen to employ me, but my blog post and thoughts are my own :)

Further reading

• Can diet alone reverse Type 2 diabetes? Diabetes UK website 24 June 2011
• Type 2 diabetes in newly diagnosed 'can be reversed' BBC News website 24 June 2011
• ‘Reversing’ type 2 diabetes? Quality in Care Programme blog 24 June 2011
• Is this a ‘wonder cure’ for type 2? DiabetesChoices website 24 June 2011
• 'Crash diets' studied for type 2 diabetes NHS Choices "Behind the Headlines" website 24 June 2011