NICE advises in NG28 1.3.3 Encourage high fibre, low glycaemic index sources of carbohydrate in the diet and NG28 1.3.6 Individualise recommendations for carbohydrate and alcohol intake.
Our hunch was that a better understanding and promotion of this could help improve care for people with diabetes.
In 2012 looking at the guidelines, thinking about people with type 2 diabetes (T2D) making dietary choices, we found that most doctors and people with T2D struggled to comprehend the glycaemic index (GI) and also the glycaemic load (GL) derived from it.
This caused difficulty in translating the GL of carbohydrate foods to expected blood glucose levels & dietary choices as advised by NICE guidelines.
Was it because many were unfamiliar with glucose itself, the very basis of the glycaemic index? So we reinterpreted the GL of 800 foods in terms of the far more familiar, standard 4g teaspoon of table sugar and produced Twitter friendly infographics.
So a 150gram portion of boiled rice is equivalent to 10 teaspoons of sugar!
Aims and objectives
Our aim was to improve patient involvement in diabetes care by enabling wiser dietary choices using the glycaemic load as advised by NICE. We planned to represent this by our teaspoon of sugar equivalents as both individual facts and set into patient and internet friendly pictorial infographics. An example would be that a 150 gram bowl of boiled potato affect blood glucose to the same extent as ten teaspoons of sugar.
Most people with T2D know to avoid sugar itself but few realise that starchy foods like bread or potatoes digest down into surprising amounts of sugar. We planned to measure the following outcomes; HbA1c, weight, lipid profiles, liver function and blood pressure, while hoping to reduce expenditure on drugs for diabetes. A particular hope was to increase the number of people putting their T2D into drug-free remission.
We remember a time before the diabetes epidemic - would it be possible to turn the tide without using drugs?
We wanted to see how our sugar infographics changed behaviour at a practice level with an initial pilot, then roll it out practice-wide.
Next our aim was a national approach via publishing a Royal College of GPs (RCGP) eLearning module available to all 52,000 GPs.
Finally our aim was international; via the media, social media and a partnership with Diabetes.co.uk to produce an on-line low GI module which can be translated into different languages.
Another ambition was to gain credibility for individualising care as per NICE; a core belief being doctors should offer a trial of relevant lifestyle approaches to chronic illness before the initiation of lifelong medication. We want to see greater patient and professional interest in improving dietary habits for people with T2D by publishing peer reviewed results alongside significant media exposure using TV, radio, newspapers and Twitter. A further hope was that this information could be used to individualise diet and general care as enshrined by NICE as no one diet suits everybody. Could we make diabetic clinics optimistic places where new young doctors would want to work?
Finally we planned to investigate the psychology around behaviour change to optimize our impact. We suspected that people need not just relevant information but also hope of better health to become sufficiently motivated to make sometimes challenging lifestyle changes.
Reasons for implementing your project
In 2012, our GP practice of 9400 patients was overwhelmed by an eight-fold increase in cases of type 2 diabetes (T2D) since 1986. A particular worry was diabetes was presenting at progressively younger ages than in 1986. Our quality and outcome framework figures (QOF) for the care of this group of patients was poor compared to all local and national standards. At the time our model of T2D was that it was a chronic, progressive, deteriorating disease requiring ever greater doses of lifelong medication. Our diabetes clinics were difficult to staff as this was not perceived as a fun clinic to work in. None of the partners had ever seen a case of T2D put into remission. This depressing picture is mirrored internationally.
We had baseline figures for all the QOF diabetes outcomes via our practice computer register of all 472 people with T2D. Openprescribing.net was the ideal way to monitor our drug budgets, compared to national trends as we suspected that with better dietary choices much prescribing would become redundant. Our central problem was that most patients and doctors knew to avoid sugary foods but failed to see the perils of starchy foods like cornflakes. How to best explain the glycaemic consequences of poor dietary choices to our patients as per the NICE guidelines 1.3.3 in a way that could be easily understood and set this in a psychological framework of hope?
We hoped to motivate for change and then use the teaspoons of sugar equivalents as relevant information so patients could easily work out how much sugar starchy foods like bread, potatoes, rice or cereals would digest down into. Lack of funds and staff initially forced us to look at group work involving patients and their families by running regular evening sessions for up to 30 people at a time (for 6 years now). These surprised us by being far more popular and more enjoyable than we had expected. Patient feedback from these sessions was crucial to the successful eventual national rollout of the approach.
Our extensive Twitter network told us there was a need for a convenient, relevant GP teaching so we involved the RCGP. A logical next step from group work was the economies of scale that internet use can bring. As voluntary advisors to Diabetes.co.uk we had access to feedback from 70,000 members of the low carb forum, an amazingly rich resource. We added lessons from this to those from our practice work to design an international online low carb programme now also available as an NHS App.
How did you implement the project
Our first step was to get help (given for free) from a consultant health psychologist who taught us to set the guidelines into a flexible framework starting with patients' individual best hopes for their condition. It turns out they are more interested in losing weight, having more energy or avoiding lifelong medications rather than improved blood test results as we supposed.
Once shared goals are agreed we move onto next small steps to progress towards these goals. Only then do we supply relevant dietary information in the form of our teaspoons of sugar equivalents of the Glycaemic index and glycaemic load. Setting this in a context of physiology relevant to diabetes where sugar is harmful. An example; a breakfast of corn flakes, milk, a single slice of brown bread and a glass of pure apple juice will affect blood glucose to the same extent as 21 teaspoons of table sugar. This could be compared to a breakfast of cheese omelette, tomatoes and coffee, equivalent to less than 2 teaspoons. This information really helps with dietary choices.
The final psychological point involves giving timely feedback via HbA1c, weight, blood pressure or waist measurement. The teaspoon of sugar system was our idea but the calculations for 800 foods were worked out by Dr G Livesey one of the originators of the Glycaemic index. The idea was also checked by a number of academics before being peer reviewed and published in 2015 by the Journal of Insulin Resistance. In 2016 it won Dr Unwin the NHS Innovator of The Year award. This brought press interest from TV, radio and even The New Scientist which gave national impetus to the idea.
Then a benefactor donated £16,000 to help Dr Unwin design an e-learning module published in 2018 - Royal College of General Practice Guidelines:Type 2 diabetes and the low GI diet. Available free to all 52,000 UK GPs. Dr Unwin has also just published a 20 minute RCGP screencast: Type 2 diabetes in adults: management. Free to all, it is based on the latest NICE guidelines.
This year we were also involved in the making of a BBC1 documentary 'The Truth About Carbs' which featured our methods and was seen by 4.7 million viewers. Dr Unwin is the voluntary unpaid senior medical adviser to Diabetes.co.uk so a next step was to design an online program by amalgamating what we had learnt in the practice and the College with feedback from the 70,000 members of their online low carb forum to create an online resource that can be rolled out worldwide.
Using the glycaemic index and load as per NICE guidelines, we were able to produce a number of patient friendly infographics to enable people with diabetes to make wiser dietary choices. These were used at first in the practice, but later, nationally by the Royal College of GPs in both an e-learning module and also a few months later in a screencast of NICE diabetes guidelines. The infographics were deliberately made to be Twitter friendly for international impact. The most popular shows the glycaemic consequences of a carby breakfast as equivalent to 21 teaspoons of sugar and has had 217,686 hits to date.
Results: The Norwood Practice now has completely transformed its NHS Quality & Outcome Framework results that have gone from well below all national average measures to well above since 2012. At the same time, our practice now has the cheapest diabetes drug budget per 1000 head of population in our locality (Southport and Formby CCG) as measured by Openprescribing.net (BNF 6.1.2).
This year we were in the very unusual situation of being able to return £57,000 of unspent NHS drug budget to the treasury. For those patients involved we saw significant average improvements in diabetic control (HbA1c) of 21mmol/mol. This enabled many patients to come off medication including 5 previously on insulin. So far 58 patients are delighted & proud to have achieved drug-free T2D remission. Other significant average improvements include: 8.5Kg weight loss. Improvements in liver function of 50%. Improvements in triglyceride levels of 30%. Improvements in blood pressure resulting in significant deprescribing of hypotensive agents. The group's work initially started to save money, has proved to be a great success and six years on is loved by staff and patients alike.
Some of the proud ‘patient experts’ the process has generated have demonstrated the success of the teaspoon equivalent system nationally in The Daily Mail, The Times. Channel 4 TV but most dramatically on BBC1 in "The Truth About Carbs" in Summer 2018 with 4.7 million viewers. Dietary lessons learnt mean many of the doctors and staff have lost weight. The practice midwife has lost four stone! As part of the process of data assessment the practice has had to learn both how to write peer reviewed papers and how to deal with the statistical analysis involved, having previously hardly ever read journals,never mind written for them! We have peer reviewed dietary pieces in The BMJ, Journal of Insulin Resistance, Practical Diabetes & JMIR Diabetes.
Key learning points
It was key to agree between staff and patients the outcomes we would measure to indicate success. So much of the management of chronic disease is centred on behaviour change it made sense to involve both a clinical health psychologist and patients from the start. We were lucky that our financial constraints forced us to experiment with group work in 2013 so we started off with a great bunch of patients who remain actively involved in guiding the project to this day.
We worry that the core values of NICE guidelines around patient empowerment, individualising care and lifestyle are ignored by many doctors who rush to prescribe lifelong medication. We have found that given the chance, and support, most patients prefer to have an opportunity to avoid such drugs. Over time, significant drug budget savings and a richer, more resilient practice accrues by working with our patients in this collaborative way.
When making change it helps to find like-minded people to swap good practice and enthusiasm. In the early days we did this in isolation, only later joining Twitter -we now have > 24,000 followers, many of them people with diabetes or interested doctors/scientists who have latterly supplied support and great ideas. Also late in the day, we started a Google ‘doctors only’ group on sugar and diabetes. We now have an international group of 346 doctors working with us on this project. A general observation would be to look for the opportunities supplied by the internet. In the early days I saw social media as a distraction, now as a powerful motor of change.
Another observation was, we started out with a focus on quality, preferring to work for free rather than compromise. The rewards of doing good work have more than compensated for the lack of earning in terms of doctor resilience, fun and so many delighted patients whose diabetes has been put into drug-free remission. Now our new service is well established and making drug budget savings, with good practice spreading nationally and internationally.