1. ‘Shaking up’ routine diabetes care: the role of the Very Low Calorie Diet Dr Anthony Dixon Elaine Jennings

2. Outline Identify the problem Obesity ‘epidemic’ Diabetes will ‘bankrupt’ the NHS by 2025 Identify the evidence Put the evidence into practice What we have learnt to put experience into practice!

3. It’s just the obese who get type 2 diabetes? 1.Patients in the very obese/morbid obese are the small minority 2.Most patients with Type 2 diabetes are overweight or only just into the obese category 3.Weight gain for normal to diabetes is only moderate and varies between individuals 4.Clinically meaningful weight loss 5-10%

4. Confusion over current diets in Type 2 diabetes Carbohydrates / Fats / Protein / Fibre Glycaemic index / load Use of ‘starchy carbohydrates’ / rapidly digestible starch / slowly digestible starch / resistant starch ‘Mediterranean diet’ High Protein / low carb (Atkin’s) diet ‘5 a day’ Normal eating

5. We listen to our patients – what do they want? Something easy to follow Immediacy of action – if I make a substantial change in my diet I want to see a quick change in my results! Greater self-management and control of their diabetes To feel better To come off medication

6. Counterpoint Study- 2011 (Counteracting Pancreatic Inhibition of Triglyceride) 14 patients Very Low Calorie Diet 3 sachets of liquid meal replacement (Optifast) – total calories 600-800kCal/day Non-starchy vegetable or salads By end of first week: Plasma glucose reduced from 9.2 mmol/L to normal 30% reduction in liver fat mean body weight reduction 3.9kg By end of week 8: 15.3kg weight reduction At follow-up: Remission of diabetes in 11 patients at 12 weeks

7. Putting evidence into practice Real (too busy) dietitians, doctors and nurses in the real NHS Real patients – compliant, non compliant … Real cancelled clinics and appointments Real DNA’s Real chaos, poor communication and misunderstandings Real enthusiasm for a different form of treatment and prepared to try something new and to learn

8. One-to-one discussion with dietitian - Full dietary and weight history 2-hour group session - Education & medication management - Resources & set start date 8 week 800cal/day - Weekly telephone call from dietician - Weekly weight & BP – hospital or GP practice Week 4: Group meeting* - Peer support Week 8: - Re-introduction of normal eating - Long term weight management Individualised follow-up - Discharge - Group session 3-months - Individual follow-up Linking in, as required, of: - DSN - Doctor Outline of the programme

9. The results HbA1cWeightBMICost of drugs Baseline:68mmol/mol or 8.4% (42-91mmol/mol) 97.5kg (81-120kg) 35.6kg/m 2 (26-45kg/m 2 ) £49.47/month End of 8-weeks (n=17) Reduction: 3-6 months after intervention (n=9) Reduction: 17 patients M:F = 8:9, Mean age 53 years (47-65), Duration 8.5 years

10. The results HbA1cWeightBMICost of drugs Baseline:68mmol/mol or 8.4% (42-91mmol/mol) 97.5kg (81-120kg) 35.6kg/m 2 (26-45kg/m 2 ) £49.47/month End of 8-weeks (n=17) Reduction: 50mmol/mol 18mmol/mol 86.0kg 12% 31.6kg/m 2 12% 3-6 months after intervention (n=9) Reduction: 17 patients M:F = 8:9, Mean age 53 years (47-65), Duration 8.5 years

11. The results HbA1cWeightBMICost of drugs Baseline:68mmol/mol or 8.4% (42-91mmol/mol) 97.5kg (81-120kg) 35.6kg/m 2 (26-45kg/m 2 ) £49.47/month End of 8-weeks (n=17) Reduction: 50mmol/mol 18mmol/mol 86.0kg 12% 31.6kg/m 2 12% £13.91/month 72% 3-6 months after intervention (n=9) Reduction: 17 patients M:F = 8:9, Mean age 53 years (47-65), Duration 8.5 years

12. The results HbA1cWeightBMICost of drugs Baseline:68mmol/mol or 8.4% (42-91mmol/mol) 97.5kg (81-120kg) 35.6kg/m 2 (26-45kg/m 2 ) £49.47/month End of 8-weeks (n=17) Reduction: 50mmol/mol 18mmol/mol 86.0kg 12% 31.6kg/m 2 12% £13.91/month 72% 3-6 months after intervention (n=) Reduction:15mmol/mol11% 85% 17 patients M:F = 8:9, Mean age 53 years (47-65), Duration 8.5 years Cost saving over one-year on diabetes drugs: £7,254

13. What we have learnt! A lot! There is a demand for this Practicability of putting evidence in to practice in the real NHS The importance of experiential learning Cost saving The future – funding! GP clusters - Newly diagnosed type 2 diabetes / high diabetes risk Patients with established diabetes