The Big Interview – Dr Trudi Deakin

Dr Trudi Deakin is well known for writing the X-PERT Programmes, which are based upon the theories of empowerment, discovery learning and patient-centred care for type 2 diabetes.

People with diabetes see a healthcare professional for around three hours each year and have to spend the remaining 8,757 hours self-managing their condition.

Also a research dietitian Dr Deakin has written books on low-carb eating which she recommends is an important part of diabetes control.

What’s been your biggest achievement?

Developing, implementing and evaluating the X-PERT Programme and demonstrating that it is making a difference to the health and wellbeing of people with pre diabetes and diabetes (newly diagnosed and established) throughout the UK and Ireland.

The start of the journey was recognition (whilst working as a NHS registered dietitian) that people did not understand diabetes or have the knowledge, skills and confidence to successfully self-manage it.

This led to instigating focus groups with groups of patients to ascertain what information they wanted and how they would like this information to be delivered. I developed the X-PERT Diabetes Programme as part of my doctorate to meet identified needs and evaluated it with a clinical trial.

The results demonstrated highly statistically significant improvements in clinical, lifestyle and psychosocial outcomes. It was an honour to be awarded the Secretary of States Award titled Excellence in Healthcare Management for driving forward diabetes services and making a difference to the lives of people with diabetes.

Thus provided the confidence and conviction to leave the NHS, set up a charity and enable X-PERT structured education to be implemented widely to enable many more people to benefitting from attending, today this is around 250,000 and audit reports are replicating those from the clinical trial.

With only 14 per cent of healthcare professionals offering structured diabetes education and only 10 per cent of people with diabetes having attended a structured education programme, what can be done to address this?

Top tips to significantly improve uptake and engagement have been created following liaison with NHS organisations at the heart of implementation, some in the mist of high deprivation and diverse populations.

• It should be delivered by trained, competent and quality-assured educators who can support discovery learning by using simple language and visual aids, build a rapport and enable informed decisions.
• Referring agents need to be familiar with the content and delivery of the education package so that they are able to talk about it positively to patients and inform that it is integral to their diabetes management.
• There should be involvement from GPs and practice nurses. Where primary care staff received educator training, their dietary knowledge improves and is translated into improved patient health outcomes. Prior to training, there was a lack of awareness that outdated information was being delivered.
• Outcomes should be collected and analysed to ascertain if the education is effective.
• There should be patient choice i.e. attend at different times of the day (am, pm & evening) and different days (including weekends). Patients should be asked about their preferred period to attend i.e. when initially diagnosed or when they have comes to terms with the diagnosis. School holidays should be avoided for parents/grandparents.
• Venues should be easily accessible, on a bus route, have free parking and be places where people do not feel threatened. Taking note of local circumstances e.g. times throughout the day when free bus passes can and cannot be used. A full spectrum of venues such as community centres, church halls, mosques, commercial property (often available via the companies CSR programme), libraries, supermarket training rooms, social service buildings, fire stations should be utilised.
• Ensure people feel supported by inviting them to bring a family member with them to the sessions.
• Phoning patients to book them onto a programme to enable them to ask questions and alleviate any fears or misconceptions. Send reminders (email, text or phone) before each session.
• Provide alternatives to group-based sessions by ensuring structured education is also delivered via different media such as DVD and online learning.
• Provide annual reinforcement sessions.

Traditional NHS services have not always been flexible to meet the needs of the user, but if we would like people with diabetes to utilise and benefit from structured education, putting them at the heart of the service is key.

How do you continue to persuade commissioners to commission quality structured diabetes education amid NHS cutbacks?

We don’t! The X-PERT philosophy isn’t about persuasion. Persuading patients to change their lifestyle has never been effective so why should it be different persuading commissioners to implement structured education?

What does change behaviour and practice is communicating information. For patients this is about person-centred education to develop understanding and confidence. For commissioners, communicating the impact of good quality structured education is key – data talks!

Why should commissioners implement a structured education programme if it hasn’t been shown to improve clinical and psychosocial outcomes or hasn’t even been rigorously evaluated to ascertain its’ impact? This would be a waste of time, effort and expense.

We have the results of a randomised controlled trial that demonstrate that it is the most clinically effective diabetes structured education programme and a database of 90,000 patients that replicate the results of the RCT. Persuasion isn’t required with results like this!

Explain your u-turn on low carb diets?

There hasn’t been a massive u-turn! The X-PERT Diabetes Programme has always recognised that consideration of the amount and type of carbohydrate is essential for optimal glycaemic control and Week three of the six-week programme is dedicated to carbohydrate (“carb”) awareness.

The programme has never promoted a high carb diet as it was recognised that people with type 2 diabetes have insulin resistance and therefore many are not able to tolerance a large amount of carbs.

The programme supports people in identifying how much carb they are currently consuming and then setting goals to modify their carb intake to achieve weight loss and improved blood glucose control. Lowering carb consumption has always been a consequence for many participants.

The actual u-turn has been with the recognition that it is acceptable to consume fewer than 130g carbs per day. I was taught at university that the brain and central nervous system requires 130g glucose per day and therefore it was detrimental to health if one consumed less than this daily amount.

At the time, being an undergraduate student, evidence presented is accepted and not questioned. However, undertaking a doctorate created a much more analytical, critical and questioning approach! After all, we now know that 50 per cent of what we learnt at university was incorrect, at the time, we just don’t know which 50 per cent it is going to be!

Further research and exploration has enabled a better understanding of metabolism and the fact humans can survive without an exogenous supply of carbohydrate as 56g of glucose can be derived from every 100g of protein ingested and 10g of glucose can be derived from every 100g of fat ingested.

Thus, the lower limit of dietary carbs compatible with life is zero, provided that adequate amounts of protein and fat are consumed.

With this improved understanding of metabolism and the fact that the Diabetes UK 2011 diabetes dietary guidelines acknowledge that there is a lack of evidence for the ideal proportion of calories from the three macronutrients, carbs, protein and fat, we have updated our X-PERT resources to offer participants dietary choice so that they may first of all experiment with, and then adopt, a dietary approach that enables them to enjoy food whilst also meeting their health goals for weight, waist size, blood glucose, blood pressure, lipid profile, inflammation status and liver function.

Adults are unique and one size doesn’t fit all! We do not always appreciate changing our habits and being told what to do. However, if people are provided with the knowledge, understanding and confidence to experiment and find their own solutions, it is much more sustainable.

Experimentation is key, if it doesn’t work for them, they are then much more motivated to try a different approach. This enables people to adopt a diet that enables them to eat carbs to tolerance and not to a prescribed regimen.  What are the benefits of a low carb diets for people with diabetes?

Available evidence from clinical and preclinical studies indicates that low carb diets consistently improve markers of cardiovascular (CVD) risk, achieved by lowering elevated blood glucose, insulin, triglyceride, ApoB and saturated fat concentrations (especially C16:0 palmitic acid), reducing small dense LDL particle numbers, glycated haemoglobin (HbA1c) levels, blood pressure and body weight while increasing low HDL-cholesterol concentrations and reversing non-alcoholic fatty liver disease (NAFLD).

This particular combination of favourable modifications to all these risk factors is a benefit unique to low carb high fat (LCHF) diets. These effects are likely due in part to reduced hunger and decreased ad libitum food intake, allied to a reduction in hyperinsulinaemia, and reversal of NAFLD.

Although LCHF diets may not be suitable for everyone, available evidence shows this eating plan to be a safe and efficacious dietary option to be considered.

On the Public Health Collaboration website there is a summary table of 55 randomised controlled trials comparing low carb diets of less than 130g carbohydrate per day to low-fat diets of less than 35 per cent fat of total calories.

On average low fat dieters are advised to eat 50 per cent carbohydrates, 30 per cent fat and 20 per cent protein, and are recommended to always count calories. Out of the 55 trials, six showed that following the currently recommended low fat calorie counting diet resulted in greater weight loss.

However, none showed a statistically significant greater amount of weight loss in comparison to low carb. On the other hand, low carb groups were advised to eat on average 10% carbohydrates, 65 per cent fat and 25 per cent protein, and were recommended not to count calories and to eat to appetite. And out of the 55 trials 47 showed that following an ad libitum low carb diet resulted in greater weight loss, with 28 of those showing a statistically significant greater amount of weight loss in comparison to low fat. Despite low fat recommending to count calories and low carb recommending not to, the two different arms of dieters ate the same amount of total calories.

In addition, the low carb dieters showed three times more statistically significant health outcomes other than weight loss compared to the low fat dieters. Therefore according to the most reliable form of nutrition science we have available, advising an ad libitum low carb diet for weight loss is more effective at lowering weight and improving other health outcomes than the current NICE guidelines of following a calorie counting low fat diet.

A low carb diet is also supposed to result in an improved mind as well as body, explain?

Going low carb may actually benefit brain function in the long term because glucose and insulin surges along with insulin resistance that occurs in prediabetes and

type 2 diabetes can actually impair cognitive function. Additionally people have reported better emotional control and moods when they followed a low carb diet.

Nutritious brain-healthy low carb foods include salmon, chia seeds, flaxseed and walnuts. These supply omega-3 fatty acids, nutrients the brain needs to make myelin, an “insulator” that helps nerves communicate properly. Meats, leafy green veggies, nuts and beans contribute B-complex vitamins, which help you make myelin as well as produce brain hormones, like serotonin. Protein supplies tryptophan, an amino acid needed for serotonin production. Lower-carb fruits, like berries, also boosts brain health by supporting communication between brain cells and by extending brain cell survival.

As stated previously, the recommendation to consume 130g of carbohydrate per day for adequate brain function is incorrect as:

• If we do not consume glucose, we can make it from protein and fat (gluconeogenesis).
• 80 per cent of brain energy can be deprived from ketone bodies that are actually a much cleaner fuel resulting in fewer reactive oxygen species (ROS) or free radicals than glycolysis.Low carb opponents say restricting carbohydrates results in an unbalanced diet and over time this could result in vitamin and mineral deficiencies, how would you respond to this?

Of the 55 clinical trials undertaken comparing a low carb diet with a low fat diet there have been no health hazards and nutritional deficiencies reported. Low carb diets encourage the consumption of real unprocessed foods that are nutrient dense.

In comparison, processed carbs, even cereals and bread, need to be supplemented with vitamins and minerals due to the fact that the natural ones have been destroyed or removed during their processing. We have assessed low carb diets using nutritional analysis software and found them to be nutritionally complete.

We have also assessed the five daily menus released by Public Health England when they launched the Eatwell Guide and have found these to be nutritional unbalanced.

Low carb diets can result in higher blood fat levels due to higher fat intake and result in kidney and bone problems from having too much protein, how do you respond?

The low carb clinical trials have not shown this to be the case. However, we do know that eating more saturated fat can increase blood cholesterol levels in some individuals whilst having no impact in others, thus, there appears to be individual variation. However:

1. Cholesterol is essential to health for brain function, cell membranes, vitamin D production, sex hormones and bile acids, we would die without it;
2. If cholesterol levels are raised, it is the cholesterol carried in HDL particles and large buoyant LDL particles that do not result in fatty plaque formation;
3. There is no cause and effect evidence that cholesterol causes CVD;
4. Low carb trials demonstrate reduced CVD risk factors such as reducing inflammation, blood glucose, blood pressure, body weight, waist circumference and triglyceride levels.

A common misconception is that a low carb diet is a high protein diet. This is incorrect. The number of portions that someone is recommended to consume is the same whether they are following a low carb, Mediterranean or low fat diet and amount to approximately 1g protein per 1kg body weight.

This may be calculated as 15-20 per cent of the total calories but this percentage would increase if any individual, no matter their dietary approach, was on a reduced energy diet i.e. the total percentage of protein calories would increase.

Although protein can help people feel fuller for longer and therefore less likely to snack between meals, a very high protein diet is not recommended as it can spike glucose levels due to gluconeogenesis. Additionally some amino acids directly spike insulin levels, which would be detrimental in pre diabetes and type 2 diabetes where hyperinsulinaemia is already a concern.

In protein’s defence, it has been unfairly blamed for a number of health problems. It has been said that a high protein diet can cause kidney damage and osteoporosis. None of this is supported by science. Although protein restriction is helpful for people with pre-existing kidney problems, protein has never been shown to cause kidney damage or bone problems in healthy people.

Why do you think there is opposition to low carb diets?

Lack of knowledge, understanding and willingness to change. Healthcare professionals have been taught to promote a low fat diet and changing the advice we provide to patients is never easy. I know, I’ve been there!

However, this change is now happening and I am in communication with many GPs, nurses, dietitians and diabetes educators who are supporting people in adopting a low carb diet and observing the benefits it brings. Confidence comes with experience.

What is your position on fats?

There are many common myths surrounding fats that are not backed up with science. These include:

1. Eating fat will make you fat

It seems plausible that eating fat would make you fat. After all, dietary fat and stored body fat (adipose tissue) is the same thing – triglyceride! Therefore you can understand why people may think that eating more fat will increase body fat stores.

However, it’s not as simple as that. Despite fat having more calories per gram than protein or carbohydrates, diets that are high in fat do not make people fat i.e. a calorie may be a calorie when burnt in a lab but how our body metabolises calories from different sources is very different to the lab.

Obesity is a hormonal condition and there are many hormones involved in appetite regulation and in the production and storage of body. Insulin is one of the main players and is therefore classed as an anabolic (weight promoting) hormone. In the absence of insulin as in undiagnosed type 1 diabetes, there is considerable mobilisation of fat (lipolysis) and resulting weight loss.

The opposite applies when insulin levels are high (hyperinsulinaemia) due to insulin resistance and lifestyle choices such as frequent snacking, highly refined carbohydrate diet and sedentary behaviours. The body is then in “fat storage” mode and it is a physiological fact that insulin promotes lipogenesis.

A diet that is high in carbs AND fat will make you fat, but it’s NOT because of the fat! Eating carbohydrate to excess will result in the excess being converted to fat via the process of de novo lipogenesis (DNL). Think about cattle, are they fattened up by feeding them fat?

No, they gain fat by feeding on grains! Albeit, humans are not cows but is this what we are doing to people with pre diabetes and diabetes? Fat does not directly raise insulin levels but carbohydrate does. Therefore, if people significantly reduce the carbs and instead become satiated on natural unprocessed fats, they are less likely to stimulate insulin production and store body fat. Studies consistently show that diets that are high in fat (but low in carbs) lead to much more weight loss than diets that are low in fat.

1. Saturated fat will clog up the arteries

For many decades, people have believed that eating saturated fat can increase the risk of heart disease. In fact, this idea has been the cornerstone of mainstream nutrition recommendations. The “war” on fat was based on an unproven theory that somehow became common knowledge. Studies published in the past few decades prove that saturated fat is completely harmless and the 2015 Cochrane systematic review on this subject undertaken by Lee Hooper and her team demonstrated that in eight clinical trials involving 52,000 participants, significantly reducing dietary saturated fat intake did not reduce total mortality, cardiovascular (CVD) mortality or CVD events. The matter should now be put to bed and research funds directed at other possible causes of CVD.

The truth is that, as stated above, saturated fat raises HDL cholesterol. It also changes the LDL cholesterol from small, dense LDL particles (very, very bad) to Large LDL particles, which are benign.

Other myths are:

• All saturated fat is the same and has the same impact on the body

This is nonsense as there are 36 different types of saturated fatty acids. Albeit, not all are common but short-, medium-, long-, very long-, odd- and even-chain saturated fatty acids are all metabolised differently in the body and thus, have a varying impacts on health. The only saturated fat shown to be detrimental are the long-chain, even-chain fatty acids (c12:0, c14:0 and c16:0). Interestingly, circulating levels of these saturated fatty acids have been shown to be better predicted through excessive intake of dietary carbohydrate via de novo lipogenesis (DNL – the production of new fat) rather than dietary fat!

• Processed food is high in saturated fat

No foods contain just one type of fat but processed food in the main is a combination of refined fats (vegetable oils) and refined carbohydrate deprived of micronutrients and fibre. Real foods, by comparison are often the combination of saturated and monounsaturated with only a small amount of polyunsaturated fat with a healthy balance between the omega-3 and omega-6 fatty acids.

• We should consume low fat milk and dairy food

Full fat milk and dairy contains a mix of short-chain fatty acids that are excellent nutrition for the gut cells and microbiome; medium-chain fatty acids that are immediately metabolised by the liver for a quick energy source; odd-chain fatty acids that have been linked to a reduced prevalence of Type 2 diabetes.

How do you overcome the keto flu, where people start a low carb diet and the body is adapting to burning ketones instead of glucose?

Some people struggle when initially starting on a low carb diet and complain of symptoms such as headaches, leg cramps, tiredness and constipation.

This often referred to as keto or low carb flu. The main solution is to increase the intake of water and salt especially during the first week. More information on preventing or treating side effects can be found here.

Where should people go for support, advice and information if they want to start a low carb diet?

Diabetes.co.uk’s Low Carb Programme: https://www.diabetes.co.uk/lowcarb/

X-PERT Health: http://www.xperthealth.org.uk/Research/Useful-Resources and http://www.xperthealth.org.uk/Research/X-PERT-Blogs

Public Health Collaboration: https://phcuk.org/

Diet Doctor: https://www.dietdoctor.com/low-carb

Authority Nutrition: https://authoritynutrition.com/search/?q=low+carb