The Big Interview – Dr David Unwin
Dr David Unwin is an advocate of the low-carb diet and has dedicated a lot of time and research to the subject, proving how beneficial it can be to people with diabetes.
The award-winning GP tells The Diabetes Times why he wants to see more healthcare professionals embracing low-carb diets and why he thinks it may hold the key to future treatment.
What’s the biggest challenge today in diabetes?
I think it’s the sugar laden, ‘treat yourself’, obesogenic environment that has developed over the last 30 years.
As an example look at what’s on sale next time you buy petrol or go to the pictures.
The growth of ‘treats’ and snacks along with energy drinks and fast food outlets have changed the nation’s diet, so we take in far more poor quality food and far, far too much sugar.
I have looked after the same community for 30 years now. When I started in practice we called T2D ‘maturity onset diabetes’ because it affected people in their 60’s and 70’s.
There were none under the age of 50 in 1987, now in the same population we have 21 cases of T2D in younger people –with an average weight of 17 ½ stone.
Why do you support low carb diets?
It’s important to state first that diet is a very personal thing, there are as many diets as there are people.
We all develop our diet according to personal tastes, budget, culture and beliefs. If someone is on a diet, is in great health and looks really healthy then perhaps leave them alone.
I spent 25 years nagging my poor patients about cholesterol in their diet and for whatever reason the results were very disappointing for all concerned.
I began to lose faith in my patients’ ability to change behaviour –perhaps they lacked the willpower?
In fact, I suspect it was something about my advice, because now I concentrate on helping them radically cut back on all sources of sugar whilst eating far more green veg. I have over a 100 patients with weight loss averaging 8.5Kg.
In the beginning we started with a pilot study of younger patients and to show willing I went on the low carb diet with them, so we explored it together, though I was not diabetic.
I was surprised not to feel hungry and had a lot more energy. That was four years ago and I am still low carb.
Why are low carb diets so hotly disputed?
This is something of a shame. Very few people would argue that sugar is a good food for people with T2D.
So in a way, advising one of my patients who has a high sugar intake to cut back is advising a lower carb diet.
What I failed to notice for so many years was that most breads and cereals break down into surprising amounts of glucose as predicted by the Glycaemic index- so if a patient still has poor control after cutting the obvious sugar perhaps this could be their next target?
After 25 years I found it difficult to change my advice when I realised the glycaemic index of even wholemeal bread was high so I can really sympathise with others struggling with change. The NHS is an exhausting place to work even without new ideas.
Much of the dispute and heat in this centres around the role of fat in the diet and what are healthy fats, but I don’t think we should let that distract from what I see as the central problem for many people with T2D -sugar
NICE say their advice is based on evidence, so how can it be wrong?
I am so glad you asked this because just look at what is actually in the 2015 NICE guidelines.
‘Treatment and care should take into account individual needs and preferences. Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals’.
1.3.3 Encourage high‑fibre, low‑glycaemic‑index sources of carbohydrate in the diet
1.3.6 Individualise recommendations for carbohydrate and alcohol intake
I could not have written it better myself! I would make a plea for prescribers to give all patients the chance to try diet properly before starting lifelong medication.
Opponents of low carb diets say there is no long-term evidence, how do you respond to this?
On a personal level I have been on a very low carb diet for nearly four years now as have most of the original pilot group without any problems.
At a practice level we have over 100 monitored patients who have been on a low carb diet for an average of 18 months.
The longest I have personally known anyone on the low carb diet is 16 years. Dr Wolfgang Lutz used the diet on hundreds of patients over decades and died in his nineties having been on it himself for over 40 years.
In fact, the stricter ketogenic diet has been a recognised treatment for childhood epilepsy for decades starting with research in the 1920’s.
From about the same time until the advent of insulin and the drugs for diabetes, a low carb diet was the only way to treat diabetes.
To be honest I cannot be certain what will happen to any particular case, but to encourage starchy carbs again after the improvements in weight, diabetic control, BP, cholesterol and liver function I have seen would seem a retrograde step.
What is the biggest challenge you face in the low carb debate?
For me it’s time and energy. It takes hours out of every day on top of my practice. Also I’m conscious of becoming something of a low carb bore, so perhaps I need to learn when to stay silent!
What are you doing to change opinion and conventions about low carb diets?
At a professional level I have written a number of peer reviewed papers. My favourite, reworks the glycaemic index so I can tell you a small baked potato affects your blood glucose to the same extent as eight 4g teaspoons of sugar.
I try very hard to help all the doctors, dieticians and nurses who email me for information and estimate there must be well over 80 now in the UK trialling this approach. At a broader level we just finished filming for a TV documentary to come out in the New year.
The National Obesity Forum said it was time to ‘bring back the fat’, as a keen supporter can you explain this logic?
You see, there you go getting all contentious again! On the whole I leave the discussion on fats to others and suggest we all agree to advising far less sugar and refined carbs with far more green veg and nuts.
What’s been your biggest achievement?
Winning NHS Innovator Of The Year in March meant a great deal to me, I’m not sure a GP has ever won it before.
It was partly because our GP practice has improved standards of diabetic care while spending over £40,000 less per year on drugs for diabetes.
Much of this was by offering our patients dietary alternative to starting medications. An extra ‘innovation’ was helping people in groups of 20, assisted by ‘patient experts’ a newish thing in general practice.
What is the future of diabetes in the UK?
Until five years ago I would have said ‘hopeless’ but now I have seen how much my patients can achieve with lifestyle change it has totally changed my view of medicine.