The Weekly Wellbeing Round-Up #12: my week of learning more about low carb diets.

As those of you that read the Weekly Wellbeing Round Up will be aware, there was a bit of a scuffle last week in  the media about the low carbohydrate diet.  This all kicked off due to the  publication in the Lancet Public Health of a prospective cohort study and meta-analysis which suggested there might be an association with lower carbohydrate diets and increased mortality.  This gave rise to sensationalist headlines in the press, linking low carb diets to a grim, early death.  The low carb vs low fat battlelines were already drawn up and ready to go of course, so volleys of invective were being fired each way sooner than you could type twitterspat.  It was a particularly unedifying spectacle to outside observers, to whom it may have appeared that the anti-low carb lobby were crowing triumphantlythat this was the nail in the coffin whilst the low-carbers circled the wagons and sat with their fingers in their ears.



So in this week’s post I am attempting to make sense of the evidence, pointing out a few obvious things and making practical recommendations about the place of low carb diets.

I will start with a disclaimer:  I am currently eating a low-ish carb diet.  I mentioned this in a previous post about my real life wellbeing week.   I have lost about half a stone in weight having never managed to lose any in the past by just cutting back on the calories.  I’m not a fanatic.  I have friends and family who have found this approach similarly helpful.  I haven’t written a book on low carb, I don’t run a expensive private clinic or have any merchandise to sell.  I will occasionally raid the biscuit tin in reception when I am peckish. I still enjoy a beer and some nibbles with my colleagues in the pub on a friday.   It’s one of the best parts of my working week.  If the price I pay for this is indeed a grim and premature death, then I consider that an acceptable trade-off.

The Evidence


The problem with the evidence is that there’s both a lot of it and not enough of it.  Plenty of cohort studies asking people what they think they ate 25 years ago.  Not so many randomised controlled trials comparing low carb to very low carb to moderate carb to low fat etc, with long term outcomes that affect people’s lives (e.g. heart attack, stroke etc).  In fact for not so many, read none at all.  Plenty of data around effects on blood sugar, cholesterol and blood pressure, but not the really important outcomes.    There are lots of meta-analyses looking at the same subject which have come to quite different conclusions.  This is due either to the variable quality of the studies that were included or how the analysis was done.  The latter in turn may be affected by where the person or persons conducting the meta-analysis stood on the issue.  It is widely agreed that more good quality long term data is needed.

The negative

It’s important that advocates of a low carb diet be honest about the lack of clinically significant long term outcomes from properly conducted studies (i.e.  randomised controlled prospective studies).  Anyone that can tell you their low carb diet plan has been proved to result in fewer heart attacks and strokes is at best wildly optimistic and not understanding of what constitutes proper evidence, confused by the difference between causation and association , or just lying.   Quite a few meta analyses have found that the low carb diet is not superior to the low fat diet.  Fair enough.  Let’s think about that though…”not superior to”.  Which may also mean “just as good as”.  As in these position statements from Diabetes UK and the NHS UK website.  Drug companies make new drugs that are better than placebo and equivalent to many existing products and they get licensed, accepted and used why do we have to prove the low carb diet is better than anything else to consider using it?

To be clear, there is no credible evidence that low carb diets cause harm.   Anyone intellectually lazy enough to have read the Lancet publication and newspaper headlines and said “well, that’s that then” deserves a intellectual kick up the backside.  The study is worth discussing but it simply cannot hold all the weight that some seem to be requiring of it and it does not prove causation.  A drug would not be licensed if it couldn’t be proved it caused a positive outcome and neither would it be withdrawn unless it could be proved it caused negative outcomes (and sometimes not even then…that’s another topic!).   Here is a link to Dr Zoe Harcombe’s excellent detailed analysis of the study.

The positive

Whilst there are meta-analyses that can be drawn upon by both sides  it seems clear to me that that there is reasonable evidence from both meta-analyses and individual studies that the low carb diet is at least equivalent to the low fat diet in effectiveness and may even be slightly better in specific patient groups.  That’s as strongly as I’m putting it.  Proponents of the low carb diet should not claim it is a magic bullet, and sceptics should not dismiss it purely because it isn’t one.   The areas where there is, in my view, sufficient evidence to consider it as part of the dietary tools available to us are diabetes (including possibly gestational diabetes), pre-diabetes and obesity.  Relevant links below if you would like to do some further reading.


Improved HbA1c, triglycerides and HDL in Type 2 Diabetes

Best dietary approach for reducing HbA1c in Type 2 Diabetics

A low glycaemic index diet improves glycaemic control in women with gestational diabetes, and reduces birth weight of their children


obesity 2

PLOS One meta-analysis of LCD vs LFD in obese or overweight patients

Long term weight maintenance is superior on a higher protein LCD.  A modest persistant effect was shown with less lean muscle mass lost compared to a LFD

LCD’s result in decreased fat mass, if not a greater long term weight loss than LFD’s.



Everyone has either a starting position, personal experience, bias or vested interest in this area.  We should acknowledge this. For most people, a low carb diet inevitably involves calorie restriction, which will clearly contribute to weight loss.   Low carb diet advocates should acknowledge this.  There are a variety of dietary options that are available to us and some will work better than others for each individual…so health professionals and individuals need to explore what is likely to be the best option in each individual and their situation e.g. I would not recommend low carb high fat diet in someone with Familial Hypercholesterolaemia (an inherited condition causing very high cholesterol).  Neither would I recommend a moderate to high carb intake in someone with diabetes.  We need the right tools for each situation.

We are not coming from a healthy, normal baseline in developed western societies such as UK and US…we massively over-do beige carbs and our rising obesity and overweight figures bear witness to this.  It feels intrinsically right to me that we aim to reduce the portion of our diets that has very little if any nutritional value and is clearly contributing significantly to the rise in obesity and related conditions. Evidence changes all the time.   When I was a junior doctor, I would have failed my exams for membership of the Royal College of Physicians for recommending betablockers to patients with heart failure, which was considered dangerous at the time.  Now it is recommended by NICE and GP’s are expected and incentivised to do exactly this.

In reality, very few people are going to follow a very low carb diet for practical and financial reasons.  A very low carb diet (< 50g per day) is unrealistic in the general population.  A low carb diet (<120-130g a day) is more sustainable.

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Extreme views and practices of whatever kind are unlikely to be useful, safe or achievable in real life.  As a GP and commissioner I am interested in getting the greatest amount of bang for my buck.  When it comes to physical activity, the greatest health gains (and risk reduction) comes from people moving from doing nothing to doing something.  When it comes to diet then from a public health perspective the greatest benefit would come from large numbers of people at significant risk of cardiovascular disease adopting a modest, sustainable reduced carbohydrate diet rather than a smaller number of people (many of whom are already highly motivated and “healthy”) adopting a more extreme, harder-to-sustain, very low carbohydrate diet.

The best medicine is the one that a person will take.  The best diet is one that a person can stick to and lose weight.

That’s it for this week. The weekly Wellbeing Round up will be back next week. Until then…take care of yourselves!


The Weekly Wellbeing Round-Up #11

Good morning and welcome to the latest edition of my weekly wellbeing round up.  Plenty to cover today, so let’s get started…


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This BBC news article reminds us that passive smoking has effects way beyond childhood, including a significantly increased risk ischaemic heart disease and chronic lung disease in adulthood.  Participants were questioned about their exposure to smoking throughout their lives, and then their health was tracked over the next 22 years. As I reported last week, children were also more likely to end up with respiratory illnesses and spending time in urgent care or the local emergency department.   Now when I talk to people about quitting smoking, if they are parents I explore this as well.  We might feel comfortable making a decision that affects only our own health…hopefully most of us would feel less comfortable if we were reminded it affects others too and there is no safe level of smoking.

If people are thinking about quitting smoking, they might well consider using increasing popular e-cigarettes.  Whilst there has been some debate about potential safety issues (as reported in this article about changes to immune cells exposed to vaping chemicals in a laboratory setting), the House of Commons Science and Technology committee has published its report on vaping, and strongly recommends that more be done to encourage it.   The report states:

“These recommendations are based on a fair and accurate assessment of existing evidence from the UK that suggests vaping is significantly less harmful than smoking, few young people who have never smoked regularly vape, smoking in young people continues to decline, and e-cigarettes are helping smokers to quit.”

In one line?  E-cigarettes are much less bad for you than real ones.  Duh.

More good news for ex-smokers and those trying to quit came in this article in the New England Journal of Medicine.  The headline is that smokers are better off (in terms of health gains) after they quit, even if they gain weight.  To quote the Journal Watch commentary, “even quitters who gained over 10 kg had a 67% reduction in cardiovascular mortality and a 50% reduction in overall mortality, relative to current smokers”.  The next time I am talking to someone about quitting smoking and they say that weight gain is one of their reasons not to, I will explore this a little bit more with them to check whether it’s just gaining a few pounds they are worried about, or the consequence of weight gain on their health…in which case I will encourage them to quit first and work on the weight later.


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A few weeks ago I posted about the revised american guidance on hypertension and the explosion in the numbers of people labelled with the disease that would occur should this frankly bonkers approach be adopted around the world.   One thing to consider is how much more time and capacity will be needed by the NHS to help all these people control their blood pressure, should such an approach be taken.  This study published in the Journal of the American Medical Association reports on the effectiveness of a low dose 3-drug pill in controlling hypertension.  We already know that multiple drugs at a low dose are more likely to achieve blood pressure control than slowly titrating up one drug at a time to a higher dose. This result is not surprising. It is worth noting that adverse events were reported to be no higher taking this approach.

Take home message for me? Whilst I will always try to encourage lifestyle measures where relevant to lower or control BP, when considering starting therapy it may be worth adopting a different mindset, considering multiple drugs not to necessarily be a bad thing.  Particularly if GP’s have patients with hypertension coming out of their ears, so to speak.


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On the back of this report on the worrying rise of children with Type 2 Diabetes in the UK, there was some encouraging news for people with diabetes who are trying to control their risks factors in this study published in the New England Journal of Medicine.  Patients with type 2 diabetes who had five risk-factor variables within the target ranges appeared to have little or no excess risk of death, myocardial infarction, or stroke, as compared with the general population.   So whilst I would much rather focus my efforts on helping people not to become diabetic to start with, we can encourage our patients who have diabetes that with good control of their blood pressure, blood sugar, cholesterol etc, their risk of developing these complications is not significantly different from those without diabetes.

Carb Wars…the saga continues.

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You may well be aware of this prospective cohort study and meta analysis published recently in the Lancet Public Health.  The headline is “Moderate Carb Intake Seems Best for Longevity”.  As you can imagine, the publication of such an article made Twitter explode as troops on either side of the Low Fat vs Low Carb war lined up to either crow jubilantly or defend their positions respectively.  I will summarise in a moment but if you would like to do some further reading around the responses to and limitations of the study, here are some links:

Consultant Cardiologist Dr Aseem Malhotra’s response on the BBC news (YouTube clip, pro-low carb)

Science Media Centre briefing (anti-low carb)

As most readers of my blog will know, I am broadly in favour of a lower carb approach.  I no longer eat cereal, have cut back on bread, love my eggs for breakfast, enjoy some nuts each day and tend to have salads for lunch with either chicken or oily fish.  However, I still have the odd sandwich for lunch and am known to enjoy a bag of pork scratchings and a pint with my work colleagues during our friday evening debrief in our local.   It is rumoured that fish and chips made an appearance last week when neither my wife nor I could be bothered to cook after a long day.  The study cannot fully bear the weight of the headlines because it is observational and there are some concerns about the statistics and claims arising as a result (check out Dr Zoe Harcombe’s comments here and Luis Correia’s comments here ).

So what will I tell my friends, colleagues and patients when we end up talking about this over the next few days?  I will say that moderation is the key.   All extreme diets pose health risk.  The one thing that we do NOT consume “in moderation” at present in most western diets is carbohydrates.  In fact, you could argue that the western world is in the grip of an extreme high carb diet experiment.  We consume far too much, driven by decades of messages about low fat and the evil genius of the food companies who produce cheap, highly processed foods (with “low fat” labels on them) which are almost impossible to avoid.   So don’t worry about no or very low carb diets, just think a bit lower than most of us are eating now.   Less in the way of beige carbohydrates (most of which have zero nutritional value), lots of vegetables, more protein (fish, meat, eggs).  Eating a lower carb diet does not mean eating bacon every day and dying early of bowel cancer or heart disease.    Polarising the debate is unhelpful and will leave most people bewildered.  Let’s be pragmatic –  eating a lower carb diet will result in weight loss partly because of it being lower carb and partly because it will inevitably result in reduced calorie intake for most people.  Having debated evidence based medicine, I will give you a bit of anecdote based medicine:  I have lost over half a stone on a lower carb diet and no longer need to use medication for my inflammatory bowel disease.

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Cardiac rehabilitation

bright cardiac cardiology care

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Finally, we will finish on a more positive and entirely uncontroversial note.

Over the years I have had the privilege of working with our local cardiac rehabilitation team.  They are a great team of people, providing an important service to all of our patients with heart disease.  They work with patients with angina, heart attacks, stents, coronary artery bypass grafts, valve replacements and heart failure.   I have taken part in some of their sessions.  Many patients speak very highly of the service.  One of the trickier aspects of the job is proving what a difference the service makes.  This can be either because it is hard to prove that something was prevented from happening or sometimes because the service hasn’t been set up to properly collect the necessary outcome data.   So this systematic review and meta analysis published in Heart is most welcome.  It concludes that there is evidence of physical activity in patients who have had cardiac rehab, whilst also recommending that further high quality studies need to be conducted to give us more detail and measure other outcomes.  Shockingly, only about 50% of patients who have been offered cardiac rehab actually take it up.  Take home message?  All health professionals should strongly encourage patients to take up this offer, and encourage them to stick with the programme.

In Herts Valleys Clinical Commissioning group we have taken the principles of cardiac rehab and commissioned a cardiac prehab service for our patients at high risk of cardiovascular disease.  Working with my colleagues in cardiac rehab, public health and the CCG I designed the specification for this service.  For the first time this year, practices will be identifying such patients and offering education and support in the hope of improving outcomes and preventing disease occurring.  I will report back at a later date.

That’s it for this week’s wellbeing round up.  Stay tuned for next week’s edition and in the meantime, take care of yourself!

Dr Richard Pile.


The Weekly Wellbeing Round-Up #6

Welcome back to the Weekly Wellbeing Round Up!   I hope you have had a good weekend, enjoying the weather and the world cup final.  Having overcome the disappointment of England not getting to the final,  I made the decision not to watch the entirely meaningless 3rd/4th place playoff , and so missed watching England lose to Belgium (again)…which was probably much better for my overall wellbeing!  Let’s start off today with…


Cardiovascular disease 

Today instead of watching the final, I spent the afternoon with my wife.  This is partly because I am a very caring and considerate husband (hopefully she won’t read this or at least will have the good grace not to contradict me in the comments) but also because I am an evidence based husband as well and had read this systematic review and meta-analysis in Heart concerning marital status and the risk of cardiovascular disease (subscription required for full article).  Being married was associated with a decreased rate of death from heart disease and stroke.  Being divorced was associated with increased CHD mortality, being widowed with increased risk of stroke, and never being married with an increase in mortality in the event of a heart attack.  The article points out the obvious that association does not mean causation, but does raise the idea that marital status could be considered as part of CVD risk calculation in future.  I have shared this with my wife.  She says she needs more evidence before she is convinced.

Whilst I would like to spend all my time helping patients not to get premature cardiovascular disease (such as heart attacks and strokes), clearly a part of a GP’s workload is helping people who have developed it look after themselves as well as possible.  Again, I like to focus on lifestyle measures such as food, physical activity and sleep but inevitably most if not all people in this situation will also be taking a number of medications to reduce the risk of their conditions worsening.  The world health organisation stats for adherence or compliance (i.e. people taking their tablets as prescribed) are truly shocking.  Take for example hypertension or raised blood pressure:  it is estimated that only half of people diagnosed with hypertension are taking their meds regularly (80% or more of the time) within a year of being diagnosed.  Clearly I must have the best patients in the world, because they all look me in the eye and reassure me that they take their drugs every day.  But for doctors out there whose patients are not as well behaved, this systematic review, also published in Heart, may make useful reading.  Three interventions were found to improve adherence and clinical outcomes:  SMS (text) reminders to take medication, a fixed dose combination pill (interesting to consider as these drugs may be more expensive and less flexible in dosing but if the outcomes are better maybe doctors should be prescribing more of them) and a community health worker-based intervention.  It is worth noting that these demonstrated relatively short term improvements so we need longer term outcome data to confirm this.

Instead of talking about cardiovascular risk, the focus of this article is about calculating Cardiovascular Health.  CVH is a concept developed by the American Heart Association.  It takes into account 4 ideal health behaviours: non-smoking, body mass index < 25, regular physical activity and adopting a healthy diet.  It also factors in cholesterol, blood pressure and blood sugar level.   It has been suggested that CVH could be a proxy for wellbeing.  Of course that leaves the question as to what comes first..wellbeing or health.?   What are the practical implications of this for me?  The next time that a patient comes into my consulting room and says that they would just like a bit of an MOT, this is perhaps where I could start, rather than asking them a lot of questions about their bodily functions and sending them off for a load of blood tests.

greyscale photo of person taking blood pressure

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Speaking rather less positively about the American Heart Association, I was deeply troubled by their suggestions about changing the threshold for diagnosing and treating hypertension.  The guidelines suggest that a blood pressure of greater than 120 (systolic) and/or 80 (diastolic) should be considered “elevated”.   This would result in a huge increase in numbers of patients diagnosed with a disease and then potentially medicalised by offering them drugs…with the associated risks of this.  The author of this article in the BMJ estimates that this would result in half of the adult population over 45 being diagnosed with hypertension.  My view?  Utterly bonkers.  We should be sticking to identifying people who already have undiagnosed hypertension (>140/90, as defined by the European Society of Cardiology), giving appropriate lifestyle advice as first line management where appropriate, and offering a personalised approach to risk reduction based on an individual person’s risk factors.  I would be very interested to learn more about the individuals and organisations who had input into the AHA guidelines, and where they might have potential conflicts of interest…big pharma, anyone?



The low carb debate continues and I for one am more than a bit fed up of the unedifying content and behaviours on social media, particularly twitter.  Yes, it may well be that it’s hard to prove that there is something intrinsically good about eating a diet low in carbohydrates because it is almost inevitably associated with also reducing calories, but then again this is a food group that, plant based carbohydrates aside, we have largely manufactured for ourselves (often with a lot of processing involved) has very little if any nutritional value, and the increased consumption of which (particularly in the US) has been associated with sky rocketing obesity levels.   So its nice to see this article in the BMJ on the role of carbohydrates , quality and quantity, in chronic disease.  It takes a  fairly measured approach to the subject.  It’s well worth a read as it’s too detailed to really summarise, but the key messages are:

  • Human populations have thrived on diets with widely varying carbohydrate content
  • Carbohydrate quality has a major influence on risk for numerous chronic diseases
  • Replacing processed carbohydrates with unprocessed carbohydrates or healthy fats would greatly benefit public health
  • The benefit of replacing fructose containing sugars with other processed carbohydrates is unclear
  • People with severe insulin resistance or diabetes may benefit from reduction of total carbohydrate intake

My view on this is that there might be a number of reasons why a lower carbohydrate diet is of potential benefit for some patients, but really…who cares if the end result is better health outcomes and wellbeing?  It’s particularly worth considering in people who are diabetic, pre-diabetic, or need to lose a significant amount of weight…especially if they have struggled with weight loss in the past.

Staying with diabetes and pre-diabetes, this Cochrane review found that  in order to delay or to prevent the onset of Type 2 Diabetes, there wasn’t sufficient evidence in the meta analysis it carried out for diet or physical activity alone…but both combined together produced results.   Patients who have been told by their doctors that they are pre-diabetic should have be advised accordingly.  I used to talk mainly to patients about their diet and weight loss and say that physical activity didn’t contribute particularly to the latter…but we now know that physical activity is protective in itself and has favourable effects on the way that your body deals with both sugar and cholesterol.  The greatest benefits in reducing the risk of disease and death are seen in patients who go from being inactive to moderately active.   It doesn’t require a gym membership, donning lycra, or dragging a tyre round your local park whilst someone in combat fatigues with anger management issues barks instructions at you.   Just ten minutes a day of heart raising exercise, such as brisk walking, is enough to get you going in the right direction.

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Last week I confessed that sleep is one of the areas of my life that I have struggled with.  Not because I can’t get to sleep but because I choose not to get what I really need.  I have done better this last week, inspired by having started to read Why We Sleep by Matthew Walker.  My favourite podcast this week has therefore been Episode 26 (Part 1) of Feel Better Live More podcast by Dr Rangan Chatterjee, who interviews Professor Walker, on this subject.     There’s a quote early on in the book which makes the point (and I’m paraphrasing) that if sleep does not serve a purpose and yet almost all animals spend a third of their life in this state, then it’s the biggest mistake that the evolutionary process ever made. Thought provoking stuff.

That’s it from me for this week.  Until next week…look after yourself!

Dr Richard Pile