0:01 - Introduction by Dr Peter Brukner

0:09 - Welcome and National Diabetes Week

0:36 - Highlighting Low Carb Diet

1:16 - Introducing Dr David Unwin

2:29 - Dr Unwin's journey into low carb

5:18 - Practice crisis and group consultations

6:48 - Astonishing patient results

8:46 - Baseline data and publications

9:59 - Improving glucose control and cost savings

11:25 - Summary and impact on NHS

10:00 - Are we saving money?

10:20 - Significant savings from low carb approach

10:48 - Proof of drug-free diabetes remission

11:18 - Impact of low carb on diabetic population

12:24 - Global success and policy recommendations

14:13 - Health improvements beyond diabetes

16:00 - Convincing patients and behaviour change

20:03 - Planning clinical services and maintenance

20:52 - Importance of long-term care 

21:20 - Ultra-processed food addiction 

22:04 - Sugar infographics and understanding starches as sugars

23:16 - Glycaemic load and starchy foods

24:33 - Improving health by reducing sugar

25:03 - Why isn't every doctor doing this?

26:11 - Tiredness and lack of curiosity in medical field

27:46 - Influence of drug reps and prescribing practices

29:22 - The need for clinical judgement

30:36 - Essential hypertension and insulin's role

31:01 - Renal sodium retention on low carb

31:21 - Drugs first vs. lifestyle approach

31:30 - Lifelong medications: A small defeat

32:02 - Importance of prevention

33:33 - Engaging with governments on low carb policies

36:23 - The debate on sugar tax

39:22 - Diabetes Week focus on tech

40:02 - Continuous glucose monitors and behaviour change

42:11 - Personal success story

42:26 - Continuous glucose monitors

44:34 - How about Ozempic? 

45:18 - Caution on new diabetes drugs

46:32 - Ozempic for carb addiction

47:53 - SGL2 vs low carb diets

49:28 - Long-term diet successes

50:24 - Ozempic complications

53:19 - Future of drugs like Ozempic

Dr Peter Brukner (00:09.102)
Hello everyone, I'm Dr. Peter Brukner, the founder of Defeat Diabetes and I'd like to welcome you to this webinar with the wonderful Dr. David Unwin. As many of you would know in Australia anyway, it's National Diabetes Week and the theme focuses on the impact and access to diabetes technology. So we thought what better way to highlight the cheapest technology of it all, the low carb diet.

In speaking to the guru. And David has been practicing this way for over a decade with his type 2 diabetic patients and he's recently announced some outstanding results that we'll talk about in a moment and we'll also find out how he's done it. So stay tuned for a fascinating discussion with one of the real, one of my heroes anyway, and the heroes of the low-carb movement.

Dr. David Unwin. And don't forget to visit the Defeat Diabetes website for more information. But without further ado, welcome David.

Hello, I'm so pleased to be doing this today. And as you say, when we think about technology, you know, low carb, simple, works again and again and again.

It's cheap technology. David is in the north west of England and I'm further down south in the lovely spot of Henley on Thames. I've been in the country, David, for two and a half weeks and today I saw a strange thing in the sky. There was this yellow thing that I hadn't seen previously in the year. So much for the English summer. I've had two and a half weeks of

Dr David Unwin (01:50.872)
You're tight, huh?

Dr Peter Brukner (01:55.564)
Yes, well, Ryan, but anyway, but you're used to that, I guess.

Well, I think today will, it's probably the only day of summer and I'm going to spend an hour of it with you. So I hope you appreciate the sacrifice. I've got my shorts on ready to rush out the moment this is over and soak up those rays.

Right, I'm very grateful. David, look, we've had you on before, but I just, just maybe you could just quickly tell us, you know, how you've gone into this sort of, how your practice changed, that, you know, what, 10, 10 years ago now, something like that?

It's a before then, it all began in 2012 or even before then. So I've looked after the same population now just north of Liverpool since 1986. And as the decades rolled by, you just had to be worried by the epidemic of type 2 diabetes. So when I began, and probably Peter, when you trained,

Diabetes, type 2 diabetes was quite rare. And really it was just about older people. We used to call it sugar diabetes or maturity onset diabetes. And when I started in the practice where I am now, we only had 56 people with type 2 diabetes. Whereas now I think it, yeah, we've got about 590. So that's a 10-fold increase in the same population.

Dr David Unwin (03:29.966)
The problem we had in the practice was we had this tenfold increase. It was starting to affect younger and younger people. So again, when we trained, I dare say I never saw diabetes, type 2 diabetes in anybody under 55 years of age. I never saw it as a medical student and I didn't see it for the first few years as a general practitioner. And then things changed and year after year there were more and more and more and with it came obesity, all of the metabolic problems really fatty liver, obesity, essential hypertension. And it was obvious to me that the drugs I was using were best as sort of sticking plaster. didn't really see healthy animals. People didn't look great.

So there was a crisis in the practice. had no more staff to deal with this. And yet it was obvious that health was deteriorating. And so we were looking for a new way to deal with this and also wondering, well, why was it happening? We were curious as to what was going on in our population, what was causing it? Because it couldn't be genetic.

in just 25 years, it had to be the environment acting on perhaps a genetic trigger. And so we were sort of looking for a cheap, effective way to deal with this epidemic, as particularly as it began to affect younger people. And there was urgency to this. I think the group I was really worried about were the ones with pre-diabetes, young people with pre-diabetes because we were not paid to do anything for those other than note they existed and establish a register. So this was obvious. It felt wrong. All we did was tell them they had a problem and wait until they became sick enough to require drugs for diabetes. So the initial worry

Dr David Unwin (05:53.614)
was younger people with pre diabetes and could we head this off? And we began with them, doing them in groups of, I think it was about 20 to 30 at a time. Because you see, we didn't have staff. So we had to do group consultations. And we've done that now, since January 2013. First of all, with the younger pre diabetics and then the people with diabetes heard about it and they were clamoring at the door, pushing in and the results. So this was where we thought a very simplistic approach really is just don't eat stuff that puts your blood sugar up. It's simple. And it's amazing that I've become well known for telling people just eat healthy food that doesn't put your blood sugar up. That's all it is.

We could stop there, Peter, actually. We could all go home and have luncheon. But this is what we were saying. But the point is the results. The results were astonishing. I'd never seen anything like it in terms of weight loss, in terms of blood pressure, lipid profiles, liver function tests, and of course, the diabetic control.

I was absolutely astonished. I got to a point where the best part of my day was looking at the blood tests. used to save it till the end of the day as a kind of treat, going through all the blood tests. Now I used to find going through blood tests the worst part of the day, and it became the best part of the day. And I just couldn't believe it was true. in fact, was, the reason I was collecting data, I should say, was

Back in 2013, generally people weren't, I could say people didn't even like the low carb approach. They were worried about it. And I got a lot of kickback in terms of what this fad diet would do to cardiovascular risk. But that actually was great because it meant I was sufficiently concerned to really carefully collect baseline data and latest follow-up.

Dr David Unwin (08:18.062)
For all the people in my practice who take on a low carb approach. And that's been the basis of the data that I have to this day and the basis for the publications because we know what happens at Norwood Avenue. So that's it really, that's the basis. Don't eat stuff that puts your blood sugar up. We started with groups to do it cheaply. It turned out to be loads more fun than I'd ever expected.

I was really at that point planning my retirement age 55. Or was I 54? Anyway, I'm 65 now and loving it. So that's a sort of quick how we got here.

Okay, and just take us through the results that you've got over that period in terms of improving glucose control, putting diabetes into remission or reversal or whatever we want to call it. Yeah, and also the cost savings. I think you've done some interesting work on how much you're actually saving the poor, beleaguered NHS in its medications and so on.

If you just summarize the impact that you've had on your type 2 diabetes patients in your practice.

I'll begin with the cost save. Funnily enough, I just.

Dr David Unwin (09:44.46)
those last night, I was adding up the cumulative cost saving because of course, if with hundreds of patients, you use a lifestyle approach, use diet instead of drugs, and people are not using drugs, then the proof of the pudding is, well, are we saving money? As it happens, every GP in the UK is monitored for our saving. So I can share with you centrally collect

data. This isn't my data. It's what the government collect on each GP. So at the moment, from I think it's from 2018 to now to April 2024, we've saved somewhere about 400,000 pounds sterling. So maybe Peter, would that work out in

That's about 800,000 Australian dollars. That's a lot of money.

That's one practice. That's what we've saved. So it's very significant. It's very, and it's proof that I'm not using drugs. I should say it isn't just me. There are nine doctors. We are a practice of 10,000 patients, nine doctors and three nurses. So now we get to the actual figures. So of course, diabetic control.

We look at that in terms of the hemoglobin A1C. And so that the headline figure is for people who choose low carb at Norwood Avenue, which at the moment is just over half our entire diabetic population. So half the people with diabetes at Norwood Avenue at the moment have chosen a low carb approach because we don't force this on people, we're offering it.

Dr David Unwin (11:36.93)
So for my patients who go low carb, about 50 to 51 % will achieve drug-free type 2 diabetes remission. And that is maintained to about 33 months on the diet. And so again, it makes sense if you look at the entire diabetic population at Norwood Avenue, 24 % of the diabetic population have achieved drug-free

type 2 diabetes remission. And this is a massive beacon of hope, showing what is possible. And of course, I'm aware of colleagues in Australia, in New Zealand, who have achieved very similar results. So it's been done all over the world. So it is possible. And what's even more exciting, so in the last, if anybody's interested, this is all published in BMJ.

Nutrition. So our latest paper was last year. And we were looking at, well, what difference does it make how long you've had diabetes? And so even people who've had diabetes for 10 to 15 years might get remission. But those who have had diabetes, if you get them early, people in the first year,

73 % of them will achieve type 2 diabetes remission. So this really should be part of policy that people should know this and be offered when you're diagnosed with type 2 diabetes. We should be saying you stand a really good chance of drug free remission. Are you interested? Because such an important part of this work is motivating people for change. So we're getting

73 % of those newly diagnosed, the diabetes into remission, drug free remission, we're getting 50 % of the entire, everybody who chooses low carbon. Some people have had diabetes for 15 years and still achieve remission. People are coming off insulin, significant drug savings. Average blood pressure improvements.

Dr David Unwin (13:56.792)
probably about six millimeters of mercury systolic and 12 millimeters of mercury diastolic. And 20 % of everybody on drugs for blood pressure comes off those drugs for blood pressure because the BP is so good. So in a way, the actual improvements in blood pressure are better than six millimeters of mercury systolic, 12 diastolic, because of course, stopped the drugs. Then on top of that, you're getting cardiovascular risk. So again, we've seen significant improvements in every single measure of cardiovascular risk. So we yes, we're looking at fasting lipid profiles, we're looking at LDL that improves. The thing I'm really excited about is the triglyceride HDL ratios, those improved by about a third.

So again, and liver function tests. So the liver function tests improved by about 40%. And we've written separate papers on all of these things. Truly, Peter, I never thought I would live to see this kind of result. Normally with drugs, well, you'll know yourself with drugs, get a sort of maybe a 10 % improvement, something like that. But to get one intervention.

Which is improving every single measure of cardiovascular risk, liver function and diabetes. It's so exciting. I just can't leave it alone. I'm an absolute low carb bore. You can't shut me up, but perhaps I will. Does that answer your question Peter? Yeah.

That's amazing results really. And yeah, as you say, similar to results around the world really. So what's your secret then? mean, what do you think, you know, why has it been effective in convincing people? You say only half the people in your practice, you know, will take up low carb. Why only half? You're thinking what tricks do you use to sort of try and convince people to take up low carb?

Dr David Unwin (16:17.422)
This is, some of you will have heard of Professor Roy Taylor, who's an international expert on diabetes. And he was the senior author of my last paper. And the reason he wanted to co-author a paper with me was he wanted to know what's the secret source, he called it. What's the secret, what are you doing? And could it be replicated? Key, I think, is an understanding of behavior change. Because this, of course,

So much of medicine is all about behavior change and the motivating of our patients and clients for change. And so I'm very sensitive to the golden opportunities within, because mine are only 10 to 15 minute consultations, so I have to be very quick. So what are the golden opportunities within our consultations? When are people receptive to the idea they could do it differently?

And I'd highlight a few times. When you're first diagnosed with pre-diabetes, at that point, if only clinicians would say, right, you have an opportunity, it's worrying, but hey, you don't have to be ill. You could choose your future. You could choose your future. Are you interested in doing something so that you never have type 2 diabetes? When I do that, Peter,

People are interested. I have never been turned down. If you give people a chance for better health, they are interested. And then moving on up, you know, I actually have type two diabetes myself and it's quite a blow, you know, when you get that blood test, there's a shade of mortality to it. You know, God.

What will happen to me, we're all aware of perhaps relatives who've died of this. And you can see the idea of a progressive deteriorating disease with increasing drug usage. How about though, if we say to people, okay, you know, it's true, you are a bit overweight, your blood pressure is not so good and your blood's very sugary. But you know, in six months, this could all change. You could have really brilliant health.

Dr David Unwin (18:40.384)
Again, people are interested. And the same goes for those with established type 2 diabetes who come in to be told that the blood tests have gone worse. So you see, there are opportunities throughout the natural history of type 2 diabetes. I'd started even before pre-diabetes. Insulin resistance probably starts 10 years before.

hemoglobin A1c starts to rise. I would start taking action when liver function starts becoming abnormal or triglycerides raise. I think the other thing is, we haven't, I never, I never accept say 50%. The number of patients in our practice low carb goes up year on year on year. Because within the local community, this approach is now famous and giving hope.

Everybody in Southport, which is where I practice, everybody knows one of my success stories. And then on top of that, we'll be talking later about use of the media. So we've had immense success with the BBC, with all of the big newspapers carry stories that I supply. And so the number of people thinking

Okay, I give in, Dr. Unwin, you've mentioned it a couple of years. Here I am, I'll do it now. It's going up and up. The other key thing, the absolutely key thing is when you're planning a clinical service, factor in maintenance. All sorts of good things can be done. And we can all be good for a week or two or a month or two. But I'm trying to establish good clinical care.

ongoing care. And that means thinking about how you're going to care for your patients long term, how you're going to rescue them after Christmas, after that all inclusive cruise, all those people who've slipped. And I think finally, the work of my wife, Jen, she's a clinical health psychologist. And she's becoming really a world expert, a world leader in the subject of ultra processed food addiction.

Dr David Unwin (21:04.718)
Because we have really now internationally a situation where intelligent people are doing stupid stuff that they know is damaging their health with Gaia. And how is this different from smoking or alcohol? So it's complex. There's a lot to put in there, but the results are so exciting. It's really worth the effort. And we still save money.

One of the great things that you've done is produce your infographics that I think are widely used around the world. And I think we've had a recent one come out showing starches in particular, because as we know, most people sort of get sugar. They sort of get, okay, we know sugar is not good if you're a diabetic or pre-diabetic. But what they don't really understand is that starches are just sugars.

Dr David Unwin (21:56.814)
And that was my challenge years ago in 10 minute appointments as they were then. How am I gonna help people understand the glycemic consequences of dietary choices? And of course the patients all knew that they should give up sugar, but they had missed. In fact, let's be honest, Peter, I had missed starch. I don't know how, but I was not telling people about about about rice, about potatoes. And of course, this is all based on the glycemic index and the glycemic load. So you can see the infographic here. So what we did is we looked at the glycemic load of portions of food. So we've got here 150 grams of boiled potato, 150 grams of boiled rice, and 180 grams of spaghetti.

You look at the glycemic load of those portions of starchy foods. You divide the glycemic load of the food by the glycemic load of a teaspoon of sugar. And so we can tell you or help people understand that 150 grams of boiled rice, which is a small bowl really, can be expected to affect your blood glucose. To a similar extent as 10 teaspoons of sugar. This is astonishing and it helps people realize that maybe they could have their curry but have it perhaps with a stir fry or green veg. Again, eat steak but could you instead of the potatoes, could you have it with broccoli and garlic butter? And again, do you have to have spaghetti bolognese? You don't. You could put that bolognese sauce on green veg.

So these infographics, they've been translated into 35 languages and downloaded millions of times. That particular one, I think has been released on Twitter today. Please follow me, at locarbgp. So these are the infographics. If you want the ones in different languages, all you have to do is Google Unwin.

Dr David Unwin (24:23.31)
PHC, which is a charity I helped set up and Unwin. And those infographics of which there are great many, as I say, are in 35 languages now. They're not copyrighted, so I'm hoping people will steal them and use them, which so far, as I say, people have. I think the point is, I mentioned already, we choose our future with every meal that we have. And so if you could just eat meals that were less sugary, you could really improve your health and fast too. That's what those infographics are about.

So David, you've obviously had great results and saved the NHS a lot of money. Why isn't every doctor doing this? Why isn't the NHS and the government mandating that people or advising people to go to eat this way if they're if they're pre-diabetic or diabetic or anyone? What are the obstacles there?

Dr David Unwin (25:29.038)
That's fascinating, well, it's an interesting question, Peter. Right, so, well, let's try and be fair at the beginning. You know, I wasn't doing very well for the first 25 years. I was tired, I was exhausted. We're facing in primary care, these, an avalanche of ill people. And I was very tired and

When you're very tired and somebody said, I've had this great idea for you to work a bit harder. You know, I used to be booing and hissing when people said to me, you could start all day, you could do this. I know I could, but I felt that I was exhausted. What I'd not realized was how exciting this work is and how much energy it's given me and what a privilege it is. I mean,

We all become doctors hoping to be effective and hoping to make change. And what I'd say to doctors listening is, yes, this is extra work, but it's work so rewarding and such fun. So that's the first thing. Many, many doctors are tired and exhausted and nurses too. COVID has just added to our woes. It hasn't gone away. We are struggling.

I think the other thing, when I look back through my career, is a lack of curiosity. You know, we think of ourselves as scientists, Peter, but doctors, are we really? And what is a scientist? I think a scientist is somebody who's curious and prepared to disprove what you're doing already. I found it very difficult to admit.

That my advice was rubbish. you know, what was, so there I was giving out the same advice for years and I blamed the patients for not doing as I told them. And I was so arrogant really, because I blamed the patient and who, what was the common denominator, Peter? It was me, it was me. And it's very hard to admit that

Dr David Unwin (27:53.826)
What I've been doing for 25 years was suboptimal, let's say that. It's really hard. Also, there was a lack of curiosity. I wasn't thinking. And I think I'd got the wrong paradigm. The paradigm I was using was I do tests and then broadly I'm wondering what drug to put you on. How depressed are you?

How bad is the diabetes? If you're in pain, what painkillers? What I wasn't doing is thinking about the true causes of illness.

And I don't know, did that start in medical school? How did it happen? I'm not sure. But when you're tired and when you're just treading water using the same thing and then I didn't notice. And then if I'll be honest, I think I was affected by the drug reps. We used to have them coming in, know, every day with a little gifts with their, you know, they bring the sandwiches for your lunch and delicious.

Cakes and this, that and the other, and then the freebies. And I failed to see that they were doing that for a reason. I failed to see what was happening to my prescribing and that it was influencing it. And I think this paradigm, this idea that don't think about why people are ill, just, you what does the protocol say?

The other thing is the use of protocols, where now people are confusing a protocol. They think that's a rule. It isn't a rule. A protocol is a guideline, which a guideline can be trumped by either the patient's wishes or your clinical experience. And I think increasingly, young doctors and nurses are memorizing protocols.

Dr David Unwin (30:02.55)
Instead of thinking about physiology, why is this patient presenting in this way today? And thinking about causes and this drills down into, you know, we call it essential hypertension. I remember one time I said to the partners at coffee, I wonder what the cause of essential hypertension is. And they all laughed at me. They said, David, don't be ridiculous. We don't know the cause.

That's why it's called essential hypertension. And I said, isn't it odd that, maybe the second largest killer in the world and we don't even know what causes it. How odd. And they said, you know, you're being annoying again, David. Just, you know, don't start again. But when we look into essential hypertension, insulin is there. We've known since 1932 that insulin causes renal sodium retention. And when you go low carb, that's low insulin, and you start weeing out the sugar that you were hoarding or being hoarded by the insulin. So many things, so many different things have led to us a paradigm where we're thinking drugs first and we're beginning to just nod at lifestyle instead of it being something. So for me,

Every time I start lifelong medications, it's a small defeat. I do it, of course I prescribe drugs. I see it as a small defeat and that maybe there's something I could have tried. Whereas before I just, you know, said, of course you should lose weight and sort of told people off. I think many of my colleagues were a bit trapped by the paradigm.

Of believing in drugs are the only way to deal with the problem. And my final word is about prevention. We have given up on prevention and this is an international crime. To allow young people to have pre-diabetes and not to knock it on the head, to leave it and let those people come to harm. And this is happening all over the world. And pre-diabetes at Norwood Avenue,

Dr David Unwin (32:27.214)
93 % of the people with pre-diabetes, I can sort it out with one or two consultations. And that's a crime. We are not investing properly in prevention. I mean, how can we just accept that demand is rising inevitably? Why is nobody, you know, that we need more doctors, more drugs, we never have enough money for health?

We should look at going upstream of this inexorable increase in demand is the idea of prevention. And I really hope the politicians will see that they cannot afford the drugs and the increasing drug budgets. And the answer is to have a really hard look at prevention and all that's involved in preventing these metabolic diseases.

Dr Peter Brukner (33:25.548)
And obviously you've been talking to... Thank you.

Dr David Unwin (33:31.501)
Your music.

Sorry, you've been talking to other governments and to governments and other bodies in the UK as we have in Australia. What has been their response and your success in getting them to change some of their policies or to at least acknowledge that a low-carb approach is a reasonable one?

That's interesting. Yes, I think I've spoken to four health secretaries now over the last 10 years. And what's interesting is one of them went low carb himself and loved my teaspoon of sugar equivalents. He was honest enough to tell me, this is a few years ago, that the problem with the lobbies.

that my approach is about whole food, it's about cutting out sugar, and that the supermarkets and the food producers will never agree. I'm really happy to tell you that I have also spoken to Wes Streating, who is the current, the new Labour Health Secretary. And the Labour Party have understood that the health service will die to be dashed to death on the rocks of demand and that prevention is key. And the Labour Party have said that prevention is key plank to their policy. We'll have to see whether that comes out, but there has been, I'm encouraged because otherwise it's a disaster. We are facing younger and younger people with type 2 diabetes.

Dr David Unwin (35:23.692)
I've got people in their 20s now and they're losing, they will lose a third of their life expectancy. We're seeing it's affecting fertility and everything. So it is improving as far as I know, but let's see, will they do something about advertising? For instance, how difficult is it to stop the advertising of junk food?

You know, what, what, what are the, is that going to harm the nation that we stop this advertising of junk food? And any government that fails to do that, I believe is not interested in prevention. And the only reason they would, would not ban the advertising of junk food is that they have been got at by, by the food lobby.

What about the sugar tax? mean, in the UK now you've had a sugar tax for 10 years maybe or nearly that. A lot of talk in Australia about and other countries about introducing a sugar tax and the recent parliamentary inquiry into diabetes has been a bit controversial on that and as some of them have recommended a sugar tax. What's the experience in the UK or your experience of a sugar tax?

Yeah, it was surprisingly effective. Of course, it was massive moaning. And the world will end, you know, with a sugar tax and unemployment and all the rest of it and earthquakes and volcanoes. But it was moaned about. But the point is now when they when they've done the research, actually, it's even helped with a number of admissions of children having their teeth removed. So we've got hard evidence in the UK that

Number one, you make money. And number two, there are actual real health outcomes. And why are we defending sugar is absolutely an empty calorie. You know, what is there a need for sugar at all? None at all. It's addictive, it's harmful. And again, anybody that defends sugar needs a hard look and we need to question why. So the sugar tax

Dr David Unwin (37:48.526)
Yes, it was effective. What actually happened was the drinks manufacturers reformulated the drinks and included less sugar in them to avoid the sugar tax. And so the actual amount of sugar consumed went down. The manufacturers still made money, but the Treasury also made money. So it turned out to be a win-win situation.

But again, the lobbying, the political lobbying has meant that it hasn't been, you know, I would hope that they would advance that and so far not. Let's see what the Labour Party do. I'm fascinated to hear that in Australia this is being debated. But I imagine that the debate is like we had here five or six years ago with talking about the nanny state and you shouldn't interfere and so on.

But it's really now something we are, it's a bit like seat belts. We just accept them now as a good thing. So I wish you well in Australia. It would be a great thing if you could do that. Quite interesting to think about how you might, what are the levers of power? I think politicians need persuading that large numbers of the public know about the evils of sugar and that want something to be done.

Yep.

As I mentioned at the start, it's diabetes week in Australia and the focus is on tech. you know, obviously, the defeat diabetes program is a tech, if you like, because it's an app-based program. But I'd to get your thoughts on the CGMs, continuous glucose monitors, because there's a lot of talk in Australia and other countries about making them more freely available and subsidizing them. At the moment, in our country, they're subsidized for people with type 1 diabetes.

Dr Peter Brukner (39:49.666)
But not people with type 2 diabetes. What's your thoughts on CGMs and do you encourage their use in your patients?

Yeah. The fundamental thing about CGMs is to do with behavior change. So I was talking right at the beginning about behavior change and one of the key aspects of successful behavior change is feedback. And we know it's scientifically proven that the faster the feedback comes on the behavior, the faster we learn. And that's what CG continuous glucose monitors give.

Because instead of a hemoglobin A1c, a blood test, which comes months, who can remember what we ate two months ago? I haven't the foggiest. But if you've got a continuous glucose monitor and you will get a spike half an hour after a bowl of cornflakes, well, you know that that was an unwise choice. So they are spectacular in terms of behavior change and feedback.

And the other problem, of course, I was telling you about is maintenance. So in the UK, actually, we're ahead of you. You can, I can prescribe on the health service, a freestyle Libra to somebody with type 2 diabetes is using insulin.

But I've gone way beyond that. I've been breaking the rules for years because I think actually morally, why do we wait until somebody's using insulin to give them the help they need? So what I'm doing with patients, I'm saying, listen, I'm gonna break the rules for you. You've got type two diabetes. You can have a month's worth of readers and the results are, I'll give you an example.

Dr David Unwin (41:44.398)
I've got a 25 year old and he'd got a very high hemoglobin A1c. I gave him a freestyle Libra and he went off to Brazil on holiday. He came back and the hemoglobin A1c when he went was about 60 millimoles per mole. When he came back, it was 32. Well within the normal range. I only saw him once.

and gave him a freestyle Libra and he learnt it helped him individualise. So he knew what put up his blood sugar. He then ate other things. He's 25. He's lost 30 kilos in weight. He's transformed. His skin is amazing. That boy, wow. And this is what drives me. So I am breaking the rules in every clinic I do. I am prescribing these.

And I'm saying to the authorities, go on, put me in jail. I dare you to pursue me for this because morally I'm on strong ground. We should not wait until people are ill. The continuous glucose monitors, I'm using them in pre-diabetes. I'm helping people understand where is the sugar in your diet? What gives you those spikes? I mean, what I would say is somebody with diabetes, I could show you

CGM readings that I have they're flat lines. I can eat enormous meals and I don't get so much as a blip. So I get perfect blood sugar control eating tasty food and isn't that really what good diabetic control is all about eating food that you enjoy with good health outcomes and CGM's I'm really interested. This is the beginning it's

It's the cavalry coming over the hill in my opinion. So actually, I don't know how big this is going to get, but I was, I'll tell you, I was a special advisor to an enormous insurance company in North America. And for the people with type two diabetes that would wear a CGM, they could have their health insurance for hundreds of dollars a month more cheaply.

Dr David Unwin (44:07.736)
The insurance companies are very interested in this. And I think governments should be interested. And this is a wall that will come down because the public are buying. can get in the UK, patients are buying CGMs on Amazon. you've now got Sibionics in China. This is really very exciting. And it's because of the potential for behavior change. I'd say to any health care professional listening, get one, try one yourself. It's interesting, you'll learn loads.

Fascinating. think ultimately, hopefully, it'll be incorporated into the Apple Watch or something like that. They'll find a mechanism where they can actually monitor it on your watch. It'll be a lot cheaper. But let's hope that's coming in the next few years. OK, let's move on to the popular topic of the day. Our friends Ozempic and other similar drugs becoming very popular, very attractive because they seem to have quite dramatic effects on like glucose and on weight. But there are some serious buts. so what do you say to a patient who comes to you, David and says, you know, I want to try one of these fancy new drugs like azembicum.

Well, again, you and I, we're older doctors, aren't we? And really, this area is littered with failures of drugs that have come in and I've been told, here's the miracle drug. And then you go, it's causing heart failure or arrhythmias or depression. I did this on Twitter. I just went back through all the drugs, all the miracle drugs we've had in the last 50 years for obesity.

Dr David Unwin (46:02.348)
Not one of them survives 10 years before there is something or other. And again, it goes back to, are we dealing with the problem? Why are people heavy? They're heavy because the food makes them hungry and they eat more of it. When we come to interfere, there are consequences.

So about Ozempik. Now, I have actually used it. does have, it's very interesting to think about, well, what is its place? What is its place? I am using it for the really bad carb addicts. The ones who panic at the idea. I have people, the idea of giving up bread causes them to panic and gain weight because they eat more. The very idea of giving up bread makes them eat more. Now, where a Zempik can help?

is in people who need kickstarting. But we must never see it. mean, what are the long-term consequences of this? Can anybody tell me what will happen to young people in 20 years time? We don't know. How can we possibly use our patients as a guinea pig like this when you have no idea of what will happen long-term? What we must do, of course, is weigh up the pros and cons of what we do.

I'm thinking about as Zempik. So I have patients whose health is in real danger because of their weight. And I try everything I can to help them with the food addiction. And I still can't help them. And some of them as Zempik can be good initially. And it helps them. It gives them a bit of peace while they think about how did they get in this mess and can they eat differently? But I'm using it as a stepping stone. I'm not using it.

Dr David Unwin (47:58.574)
I've used sweetness in the same way. They're a stepping stone to help you off sugar. A similar thing, of course, is the STL2 inhibitors. They're now being sort of, well, these are the miracle thing because they improve all cardiovascular risk. I wrote a paper on this actually with Scott Murray, a consultant cardiologist.

This is specifically about the STL2 inhibitors. And of course, what they do is they cause you to wee out the sugar that perhaps you shouldn't have eaten. And so the STL2 inhibitors, in my opinion, are a pale copy, a doppelganger of actually the low carb diet. So, you you're weeing out all this sugar. I've seen some horrific cases of thrush, really horrific.

Cases of thrush because of all the sugar in the urine? And also, what is the long-term consequence of irritating the bladder with all that sugar over years and years? Will it be bladder cancer? Because chronic low-grade irritation is not good for epithelia. So these drugs are useful. Again, I use STL-2 inhibitors. But I really, let's try lifestyle first. And let's also weigh up properly.

the possible side effects. You know, what's the possible side effect of a low carb diet? Weight loss, blood pressure improving. Okay, maybe a bit of constipation, and then you'll eat more green veg or use some magnesium. So I haven't, you all these years now since 2013, hundreds of patients on the low carb. The ones who struggle with it are the carb addicts, but most of the rest do well. Whereas I've had two patients in intensive care because of SGL2 inhibitors, because of euglycemic diabetic ketoacidosis. Now that's, you know, that's serious. So again, when we use drugs, we should be weighing up the pros and cons. We should be honest about the fact we do not know the long-term consequences for younger people. Whereas, you know, people would say, the low carb, we don't know the long-term.

Dr David Unwin (50:25.688)
term consequences of low carb. Well, you know, I've been in nutritional ketosis for about 12 years now. I've got patients who've done it for 20 years. And also what about the Aboriginal people? What about the way they used to eat? Were they not on a low carb diet all their lives? So that's my thought. It's a worry because as always the drums are being thumped, we're being told this is a miracle and patients think it's an easy solution. are how easy solutions in life are rare. You know, they're just rare. The idea that you'll just come and wave a magic wand and you'll be fine with a complex thing like diabetes is unlikely. It requires commitment over time and then the results are really good. So there it is. Yes, I use drugs. I'm not against them.

I'm still experimenting with them, but that's it. They are, to my mind, experimental and we're still sorting out where they fit in the clinical picture, whereas low carb for me is right there as number one.

Yeah, I think there's significant concerns with the Zephyc class of drugs. mean, the fact that they, as well as losing fat, you lose lean mass, you you lose muscle mass and bone mass, which unlike when you're on a low carb diet, where you just lose fat, mean, it it swings it heavily in favour of a low carb diet compared to those drugs, I believe.

Dr David Unwin (52:05.602)
Yeah, there's one extra thing I wanted to say. So I've actually had a patient in hospital for weeks because of the Zempik. What happened to that person was she got the most it just of course it works because it stops your gut from emptying it just so you get a Zempik burps where you burp you can taste what you ate yesterday because it's still sitting there in your stomach. And this poor woman, the stasis became a clinical emergency because she wasn't emptying her bowel. And that was really frightening. Really, really frightening. was very ill. So the way it works, yes, it works. But, you know, that woman, she didn't understand when she started at Enzyme Peak that she could end up in intensive care in a Liverpool hospital. And that, you know, there are a few surprises. It's not a miracle cure. Sorry, I just thought I should say that.

Yeah.

I think we're going to hear more more of these. We're already hearing issues with with thyroid issues, pancreas issues, all sorts of things. I actually think they'll be off the market in a couple of years time. I know that's a bit radical. But as you say, every other drug has been taken off the market due to complications. You know, it's obviously a massive, massive publicity campaign to promote these. know, it's a pity we don't have as much money to... promote their low carb diet. might have a lot more effect, but anyway. So where do you see the future now? mean, and as far as basically getting acceptance of low carb in both state and medical community, by governments. I think the public is already being won over fairly quickly. But our medical colleagues, as you mentioned before, we're a very conservative profession. We tend to believe everything we're taught in medical school for the rest of our lives.

Dr Peter Brukner (54:05.1)
And we're heavily influenced obviously by drug reps and pharmaceuticals and so on. So it's a real challenge to convince our colleagues that this is a good way to go.

Well, Peter, essentially, this has been the most amazing grassroots revolution enabled by social media. I learned a great deal of what I know about this from Twitter. And it started with intelligent members of the general public helping themselves. And then of course, it's leaking up through medicine.

Of course, primary care, we were the first ones to be aware of this because we were seeing patients getting better. And some of us were curious enough to have a go ourselves. And this process being enabled by social media is continuing. It's continuing. And it's very interesting that my most recent paper is the most popular paper that BMJ Nutrition has ever published. So what you've got here, is just a simple audit published by, let's be honest, the GP from the back of beyond is the most popular paper. And it's because it's the social media are driving this interest, but it's beginning now to affect the academics because now you can publish. There's a real appetite. I get asked 20 times a day for any of my next paper.

Anything I want to publish. When I started, nobody would publish my work at all. There's real appetite because of social media. And then the social media is leading into the mainstream media. Everybody wants coverage. So it's like, are we to do better? I think I'd say to one of the things that really helps convince people are before and after photos.

Dr David Unwin (56:10.966)
So anybody that comes to any of my talks will see that I have a kind of deal with my patients, which is, would you take a photo of yourself today? Because maybe today is the fattest you're ever gonna be. And if what we do together works, the only thing you owe me is a before and after photo. And so what I've got now is the most wonderful library of consented patients who are proud of what they've done. And this interests the media.

So again, if you in Australia can start to do this with your clients, the before and after photos fascinate the public and the media love it. So I can always get in our main media, if I can have a patient before and afters and that gets to the politician. So I've written 35 articles now for the Daily Mail, which is our largest paper, 35.

And of course, the politicians are very sensitive to what's appearing in the social media and the main media. So I would say this is a battle, it's a war, and we need to be savvy. And part of it is about content, it's about exposure, it's about getting our reasonably simple messages out there. Also, I'd say to clinicians,

audit your clinic, because data is power. It's very difficult for people to attack me now, because I can say, well, I know the average weight loss. The average weight loss for my patients is about 9.8 kilos. So that's on average what they're going to, I know the blood pressure, I know all of these things, simply by baseline data, latest follow up.

And the more clinicians who collect data, you can publish it. And then that becomes power. And all of this is adding, all of it adding fuel on social media and then in mainstream media, which is helping bring pressure to bear on the politicians. And the great thing is there's something that everybody can do. Everybody can support Twitter. Everybody can do this.

Dr David Unwin (58:40.398)
I've thought about this a lot, but I think the media are reasonably key. think the Freestyle Libra is, as I've said, this is a new thing. think the insurance companies, who has got similar power to the big drug companies? Who's paying? Most of the world, actually, it's not governments, it's the insurance companies.

And if you look at maybe the work of Swiss Re, who are the second largest reinsurance company in the world, they've been following Low Carb very closely and actually supporting me and my work for, I think about seven years now. So those are some of the pointers I've got thinking about this. What do you think, Peter?

Yeah, look, I agree. it's from ground up. You know, it's from the bottom up, really. It's our patients who are educating their doctors and government and so on. that's, think every one of our listeners has, you know, got the power to impact government policy and their own doctors. You know, so often you see someone, you know, who wants, who does some research and looks up low carb and then goes to their doctor and their doctor talks them out of it.

And I think when we do have successes, we need to educate our doctors. But we're running out of time, unfortunately. And I'm sorry we haven't got to your questions. I must admit David has answered most of the questions that are on my list here. So I hope your question has been answered. But David, thank you. Firstly, for today, obviously, we really appreciate your time. But also thank you for what you've done to...

For the world of diabetes and pre-diabetes. And you've been a passionate advocate and a real leader in this area. And I just want to say thank you on behalf of everyone who's listening and myself and congratulate you and hope they're going to keep going. And we look forward to talking to you again in the future. Thank you very much.

Dr David Unwin (01:00:51.458)
Peter, thank you so much. The admiration is absolutely mutual. What you've achieved in Australia, particularly now this partnering with Diabetes Australia gives me hope. It's a great thing. I wish I was partnered with Diabetes UK, you know. So listen, well done. I'm off out into the very red here and it's great pleasure as always to chat on. Thank you very much. Goodbye.

Thanks David. Bye bye.