Anarchy Exists Where Dietitians Rule

Gary Fettke, who has promoted the high fat low carb lifestyle for a long time is like many others, has been ruthlessly attacked for doing this. Professor Tim Noakes was accusedof exactly the same thing, and the South African authorities dragged him to court in order to silence him (not yet sure of the verdict).

Gary Fettke is an Australian orthopaedic surgeon who has suffered the same fate as Tim Noakes. However, in Australia it seems you can be accused, tried and found guilty without having any chance to defend yourself in person. This is not a court of law, but the Australian Medical Board (AHPRA) who can – as with the General Medical Council (GMC) – strike you off being a doctor. Which for a doctor is a gigantic punishment.

Previously, Gary had been told that he could not comment on any area of nutrition for advocating a reduction in sugar intake (to what are now WHO guidelines). Of course, as with all such cases the ‘authorities’ changed the goalposts from a discussion on low carb high fat (LCHF) and turned the discussion into something else.

Namely, that Gary Fettke, as an orthopaedic surgeon should never give advice on dietary matters. “The fundamental fact ‘is’ that you are not suitably trained or educated as a medical practitioner to be providing advice or recommendations on this topic as a medical practitioner.”

This of course allows the AHPRA to silence him, without discussion any of the science, and no chance of any appeal. So, his suspension about discussing any matters of diet has now been turned into a lifelong ban. Please read Gary’s e-mail: (This was sent to Dr. Malcolm Kendrick)

Hi everyone,

It is with frustration that I write to inform you that I have been ‘silenced’, forever, by the Australian Medical Board, known as AHPRA.

We have a draconian system here in Australia where anonymous notifications can go in and they are investigated for public safety. The accused can only submit material but never have right of reply. It is a star chamber.

I recently got to present that ‘opinion’ of the process and the fabricated evidence at a Senate Inquiry. My evidence on the failings of AHPRA was granted parliamentary privilege which allowed a tell all opportunity. Within a few hours, I received an email final determination of the 2 ½ year investigation. Coincidence or just another kick in the guts?

My verbal submission and the whole issue of bullying and harassment in the hospital system is linked from http://www.nofructose.com/introduction/senate-inquiry-into-medical-complaints-process-in-australia/

My first notification in 2014 was from an anonymous dietitian for me advocating cutting back sugar intake to what is now the WHO recommendations. Behind closed doors, with no right of reply or appeal, the goal posts shifted and I was investigated for the whole LCHF concept, for being disrespectful to health professionals (the Dietitians Association of Australia and the Heart Foundation, but never an individual) on social media and for failing to disclose a conflict of interest (COI) in our Nutrition for Life Centre, whilst on social media.

The good news is that AHPRA have decided NOT to argue the LCHF concept. I submitted enough material for a thesis and they have accepted that LCHF may be that the benefits of the LCHF lifestyle become the accepted best medical practice.

The central issue for my silencing has been that my primary medical degree and my further qualifications as an Orthopaedic Surgeon are not satisfactory to give nutritional advice. “The fundamental fact ‘is’ that you are not suitably trained or educated as a medical practitioner to be providing advice or recommendations on this topic as a medical practitioner.”

If it wasn’t so serious it would be farcical. This decision is non-appealable under National Law. The determination is life long and by its wording, does not allow me to even do research in the area or gain further qualification because that would involve me communicating in the area of nutrition. The only thing I have not clarified is if it affects international boundaries.

We have put up the post this morning re the AHPRA decision and the launch of our community fund to keep the LCHF message going

The web page is

http://www.nofructose.com/introduction/help-be-a-voice-for-lchf-after-gary-is-silenced/

and the Facebook one is off Belinda Fettke No Fructose

https://www.facebook.com/belindanofructose/posts/1175659919195124

The other parts of the AHPRA decision I can live with.

I will not force anyone to eat LCHF, not that I ever did or ever could.

I will show respect to the medical profession (doesn’t stop me from thinking otherwise).

The COI allegation is unproven as I do declare my vested interest for all patients that I send to Nutrition for Life. I admit guilt for not doing that in social media but the doctor/patient relationship is not defined in that context. I pointed out to AHPRA that they shouldn’t be applying jurisdiction in an area that is undefined. That went down like a lead balloon.

I also pointed out that AHPRA don’t govern nutritional advice in Australia. Another lead balloon.

I had a recent notification, again from an anonymous dietitian, and have been investigated for ‘inappropriate’ reversal of someone’s Type 2 Diabetes and was also reported for what I was ‘about to say’ at a hospital food national conference. AHPRA actually asked me for a copy of my speech BEFORE I gave the talk. I refused as it was an infringement of the right of free speech.

AHPRA have just this week decided to close that investigation but have warned me that they will be observing me to see if a ‘pattern of behaviour’ continues, presumably in relation to reversing more patients’ diabetes.

I hear rumours that I have ‘attacked’ health professionals at a personal level – that is simply unfounded and I think started by some naysayers. Alas, I am having some sh!t thrown at me at times. If you hear something, then let me know please.

If this sounds like a horror story, it is. I honestly thought that this would just fade away but strange things do happen when you upset the ‘industry’. Just see what’s happening with Tim Noakes. The only thing in Tim’s favour is that it has gone to court. Mine is a closed process with no right of appeal, unless I can continue to have politicians assist.

My next step is to challenge the process via more closed groups and that will be years of tying me up. I am going the public awareness path as the finding lacks the common-sense conclusion. We are liaising with some media channels and politicians. It’s all we can do.

Any support would be appreciated. Happy to liaise. Feel free to forward this email as it is.

Cheers.

Gary

Gary Fettke
Orthopaedic Surgeon
M.B.,B.S.(University NSW), F.R.A.C.S.(Orthopaedic Surgery), F.A.Orth.A.

Science evolves by being challenged. Not by being followed. @thegaryscience

If you think this is all completely ridiculous, then please circulate widely, and make as much noise as possible.

Tim Noakes Is the Subject of a Vendetta

Professor Tim Noakes is the subject of a vendetta by the Health Professions Council of South Africa, which wants to destroy his career, his lawyer has claimed.

This comes after the council issued a statement saying Noakes was guilty of unprofessional conduct. The statement was issued after conclusion of the council’s hearing this week on allegations Noakes gave “unconventional” and “dangerous” medical advice about breastfeeding on Twitter.

Hours later, however, after releasing the guilty verdict statement, the council issued a retraction and an apology, but by then the “verdict” had gone viral. “The previous statement is retracted and we apologize for incorrectly stating that Prof Tim Noakes was found guilty by the professional conduct committee,” read the statement from the council. The Noakes inquiry is, in fact, set to conclude in April 2017.

Adam Pike, an attorney for Noakes, reacted angrily to the initial statement. “This is deliberate. It’s an intent to destroy the reputation of one of South Africa’s greatest scientists. “It’s symptomatic of how the matter has been run. This is so irregular and so incorrect on so many levels. There’s a personal vendetta and I don’t know where it comes from.”

Pike also attacked what he said was the council’s lack of professionalism. “The council is a regulator of the profession. They have failed in their duty.” The statutory body regulates health workers. If it finds Noakes guilty, his license could be revoked.

“Our feeling is that the hearing went very well in our favor but obviously we can’t say yet what the committee will decide.” Noakes referred all queries to Pike.

Council representative Daphney Chuma said the PR department was to blame for the “guilty” verdict on Friday. “The mistake is attributed to the PR department. It’s not our legal team.” It appeared from Chuma’s comments the council had prepared the guilty verdict statement and was prepared to send it out when the hearing concludes. “There was no communication breakdown. We sent a wrong statement. It was issued by myself,” said Chuma.

The initial statement opened with the line: “Professor Tim Noakes, a professor at the University of Cape Town, was found guilty of unprofessional conduct. This is after he provided unconventional advice on breastfeeding babies on social media, which was not in accordance with the norms and standards of his profession.

“Professor Noakes testified and called all of his witnesses in defense of his case. The witnesses were cross-examined.” The council said further it “now closed its case and there are no further witnesses to be called”. The council said proceedings had been adjourned until April 4 and 5.

“The only outstanding issue is that of argument of the matter. The matter will then be argued before the (professional conduct) committee, which will then deliberate on the issue and come to a decision between April 6 to 7. “A judgment/verdict on the matter will be issued on Friday, April 21, 2017 by the committee.”

Noakes was accused of giving “unconventional” and “dangerous” medical advice in February 2014 after a woman had asked him on social media whether he’d recommend a low-carb, high-fat diet to breast-feeding mothers.

Noakes said his answer - that the breast milk would be very healthy - had initially been deemed as potentially “deadly”.

Are You Short on These Nutrients?

Fully 90% of Americans are deficient in one or more key nutrients. Unfortunately, many Americans are not even meeting the government’s (flawed) recommended daily allowances of key nutrients. The chart below is from Precision Nutrition, and is based on USDA data.

I have some serious doubts in my mind about the accuracy of the data when it applies to people with diabetes. I would have thought vitamin B12 would have been a larger percentage because if the number I know that are B12 deficient it seems that the average would be closer to 55 percent instead of 30 percent. I guess I will just have to accept the estimate of the USDA.

One nutrient in particular to note is magnesium. Life Extension Foundation (LEF) points out in its most recent issue (December 2016) that magnesium could be the next vitamin D. It is a low-cost supplement that confers broad health benefits. Magnesium is associated with reduced risks of sudden cardiac death, stroke, type II diabetes, asthma, heart disease, hypertension, colon and pancreatic cancer, and more.

Depending on the type taken, it also helps the brain (magnesium-l-threonate is the most helpful) and bowel regularity. Ironically, magnesium oxide, the type most commonly sold, works best for regularity precisely because it is very poorly absorbed by the body and thus does not confer most of the other health benefits of this mineral! It is also important to have functioning stomach acid to absorb and utilize any mineral. Those on acid blockers are unlikely to be able to do so.

LEF also points out that food sources for magnesium can be unreliable. This is because plants take magnesium from the soil, and there can either be not enough magnesium or too much of something else, like potassium, that crowds out a plant’s absorption of magnesium. Studies show that the magnesium content of food has declined precipitously from pre-1950s levels.

The bottom line: to get enough of this vital nutrient, we probably need to supplement with it.

It’s ironic that the above chart data comes from the US Department of Agriculture. Meanwhile, the FDA continues its war against supplements, presumably intended to protect the drug companies that fund the agency.

Guidelines for CGM and CSII in Diabetes

Continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) represent 2 of the recent technological advances in diabetes care that aim to improve glucose control and quality of life and minimize hypoglycemia. Reliable data on such technology are scarce, however, due to the rapid pace of advancement in such products and the less stringent US Food and Drug Administration (FDA) regulation, and thus less demand for clinical trials, of medical devices compared with pharmaceuticals.

In September 2016, a task force appointed by the Clinical Guidelines Subcommittee of the Endocrine Society published a practice guideline pertaining to the use of CSII and CGM technologies in adult patients with type 1 diabetes and type 2 diabetes, based on a thorough review of relevant studies. The guideline is co-sponsored by the American Association for Clinical Chemistry, the American Association of Diabetes Educators, and the European Society of Endocrinology. The fact that type 2 is even mentioned should be an encouragement that there may be hope for us to obtain this equipment.

“I think the guideline is making more clinicians aware of the established role of technology in the treatment of diabetes,” said Task Force Chair Anne L. Peters, MD, director of the clinical diabetes program and professor at the Keck School of Medicine at the University of Southern California in Los Angeles.

“It is a good starting point for a field that is rapidly advancing,” she told Endocrinology Advisor.

The task force made recommendations that they considered either strong or weak based on the quality of the evidence available. For the former, they used the term “recommend,” and for the latter, they used the term “suggest.” They denoted the quality of evidence for each area reviewed, which ranged from very low quality to high quality. “The Task Force has confidence that persons who receive care according to the strong recommendations will derive, on average, more good than harm,” they stated in the document. “Weak recommendations require more careful consideration of the person's circumstances, values, and preferences to determine the best course of action.”

Throughout the 6 covered areas below, the guideline authors emphasize the importance of patient and caregiver training and education, as well as capability and willingness to use the devices.

“Educating our patients on the use of these technologies is vitally important,” Matthew Freeby, MD, director of the Gonda Diabetes Center and associate director of diabetes clinical programs in endocrinology at the David Geffen UCLA School of Medicine, said in an interview. “Providing education increases the chances of using them well and ensuring safety.”

#1. Insulin pump therapy without sensor augmentation. The authors recommend CSII vs analog-based basal-bolus multiple daily injections in patients with type 1 diabetes who have not achieved their HbA1c goal, as well as those who, despite having achieved their HbA1c goal, continue to have severe hypoglycemia or high glucose variability.

They also suggest CSII for patients with type 1 diabetes in need of more insulin delivery flexibility or improved satisfaction. “The flexibility provided by CSII with rapid-acting analog insulin could be an advantage for those who exercise and potentially those with gastroparesis because the basal delivery dose and pattern can be modified,” they explained in the paper. The guideline offers a detailed description of how to select candidates for insulin pump therapy.

#2. Insulin pump therapy in type 2 diabetes. The task force suggests CSII for patients with type 2 diabetes who have poor glycemic control despite all reasonable efforts with insulin or other injectable therapy, oral agents, and lifestyle modifications.

#3. Insulin pump use in the hospital. The guideline authors suggest continuation of CSII in patients with type 1 diabetes or type 2 diabetes who are admitted to the hospital, as long as the hospital has established protocols for evaluating and monitoring the use of CSII in such patients. This approach is supported by both the American Diabetes Association and the American Association of Clinical Endocrinologists.

#4. Selection of candidates for insulin pump therapy. Before prescribing CSII, the authors recommend that clinicians conduct a comprehensive assessment of the patient's mental and psychological status, history of adherence to other self-care measures pertaining to the disease (such as carbohydrate counting and sick-day rules), availability for necessary follow-up visits, and willingness to use the device.

#5. Use of bolus calculators in insulin pump therapy. The task force suggests that clinicians encourage “patients to use appropriately adjusted embedded bolus calculators in CSII and have appropriate education regarding their use and limitations.” They do not recommend the use of non-CSII insulin calculators, such as those available via smartphone apps, which are not FDA-approved.

#6. Real-time continuous glucose monitors in adult outpatients. The authors recommend real-time CGM devices for patients with type 1 diabetes and above-target HbA1c levels, as well as those with well-controlled type 1 diabetes, who are capable of using such devices almost daily. They suggest short-term, intermittent real-time CGM use in adults with type 2 diabetes who are not on prandial insulin and have HbA1c levels ≥7%.

They suggest that both patients with type 1 diabetes and type 2 diabetes using CSII and CGM receive appropriate education, training, and support to achieve and maintain their glycemic goals. They note that data showing improved long-term glycemic control using GCM underscores the importance of the patient's skill in using the new technology.

Final Thoughts

“The authors of this guideline did an excellent job reviewing the recommendations based on the current available data,” said Dr Freeby. “As stated in the guideline, there are plenty of data to support the benefits of pump therapy and continuous glucose monitoring in type 1 diabetes, and anecdotally, these therapies really work in day-to-day practice.”

Dr Peters hopes clinicians will be excited about data analysis and how the new devices can help patients. “I don't think they should be oversold—type 1 diabetes is still a challenge, but these are all steps on the way to more fully automated systems,” she said.

Smart Phone Apps May Be Self-Management Savior

Smart phone apps could offer patients with type 2 diabetes a highly effective method of self-managing their condition, concludes a study by Cardiff University.

Yes, this may help some people, but in talking to members of our support group, of the 25 members, only two members were using apps and even they were not happy with the apps they had or were using. Both stated they could do better without the apps.

A systematic review of 14 previous studies found that all had reported a reduction in average blood glucose levels in patients that used an app, compared to those who did not, with an approximate reduction in HbA1c (glycated hemoglobin) of about 0.5%. The analysis also found that younger patients were more likely to report a benefit. No evidence was found to support the use of apps in type 1 diabetes, but further research is needed to substantiate this.

Dr Ben Carter from Cardiff University's School of Medicine said: "With the number of patients globally with diabetes expected to rise to over 500m by 2030, there is an urgent need for better self-management tools. Both of the members agreed that there is a great need for better tools, but until app developers start listening to customers, apps will not improve much to fulfill the needs of users.

As we enter an era where portable technology is increasingly used to improve our lifestyles, as can already be seen with physical activity technology, apps can offer a large percentage of the world's population a low cost and dynamic solution to type 2 diabetes management.

Diabetes management includes monitoring and managing blood glucose levels. This is done by controlling diet and knowing how foods affect blood sugar. For many people with diabetes, it also involves taking medications that help manage blood sugar levels. Current diabetes apps allow patients to enter data and provide feedback on improved management. They can provide low cost, interactive and dynamic health promotion by allowing patients to track medications, set reminders, plan meals, find recipes and plan for doctor's appointments and blood tests.

Dr Carter added, "By the end of the decade it is predicted that global usage of mobile phones will exceed 5 billion, so apps, used in combination with other self-management strategies, could form the basis of diabetes education and self-management."

The study comprised of a systematic review of 14 diabetes type 2 randomized controlled trials, involving 1,360 patients. This type of research provides the strongest evidence for drawing causal conclusions because it draws together all of the best evidence.

"Do Mobile Phone Applications Improve Glycemic Control (HbA1c) in the Self-management of Diabetes: A Systematic Review, Meta-analysis, and GRADE of 14 Randomized Trials," is published in Diabetes Care.

Weight-Loss Education Missing for Low Income Adults

A new study finds clinicians less likely to counsel less educated, and younger and older patients. According to a study in Preventing Chronic Disease, low-income adults who are overweight or obese are less likely to be counseled to lose weight than adults with higher incomes.

High-risk patients, such as those who are extremely obese or have comorbidities, are most likely to receive weight-loss advice. However, demographic factors also appear to determine who receives advice. Patients who have high levels of education are more likely to receive advice than those who have low levels of education and those who are middle-aged are more likely to receive advice than younger or older patients. Study results are unclear about whether health insurance plays a role in determining who receives weight-loss advice; some studies found that insurance is not associated with receiving weight-loss advice, whereas one study found that patients who had private insurance were more likely than uninsured patients to receive weight-loss advice. Income also appears to play a role; those who have high incomes are more likely to receive weight-loss advice than those who have low incomes.

This study is the first to explore the determinants of receiving weight-loss advice in a sample of overweight or obese individuals from communities with a high proportion of low-income, racial/ethnic minority populations in a multivariate analysis of race/ethnicity, age, sex, health status, income, health insurance status, and education.

Over 1,100 overweight or obese adults from New Jersey were surveyed about whether their healthcare provider had advised them in the past year about weight loss. A substantial proportion of participants had low incomes and were of a racial or ethnic minority.

Only 35% said they had recently been advised by a clinician to lose weight. After adjustment for health insurance status and other variables, participants whose household incomes were above 400% of the federal poverty level had a 64% increased odds of receiving weight loss advice, compared with those at or below the federal poverty level. Participants at 200–399% of that level had 56% higher odds.

The US Preventive Services Task Force recommends that all patients be screened for obesity and, if needed, be provided weight-loss advice. This study aimed to describe the determinants of receiving weight-loss advice among a sample with a high proportion of low-income, racial/ethnic minority individuals.

The finding that individuals in the lowest income group had significantly lower odds than individuals in higher income groups of receiving weight-loss advice from their health care provider is similar to the findings of previous studies. Patients who have risk factors such as obesity, poor health status, diabetes, and asthma would warrant special attention to weight. The finding that these risk factors increased the odds of receiving weight-loss advice aligns with the findings of other studies.

From the results of the study, it was concluded that income is a significant predictor of whether or not overweight or obese adults receive weight-loss advice after adjustment for demographic variables, health status, and insurance status. Further work is needed to examine why disparities exist in who receives weight-loss advice. Physicians should provide weight-loss advice to all patients, regardless of income.

Our November Meeting

On November 12, we met for our meeting. This happened to be the same evening as our competing group. Brenda brought the group to order and asked if there was discussion about new members. Barry said there should be as he has had four people talk to him about becoming members. One of the new members, B.J, said he had three people approach him about joining our group.

Julie said she had two people ask her about membership and Rose said she had been asked by three people. Allen said we should have a discussion then. He said that the number felt good with the present number of 25 and we had agreed on accepting new members at the October meeting only. Sue commented that maybe we should have them start a new group, as the group Glen led had stopped membership, Dr. Tom's group was now about 30 members, and the group that we separated from also had over 30 members.

Jason moved that we work with them to form a new group. Sue seconded the motion and Brenda introduced Glen to speak to the issue. Glen said the group he presently led had capped their membership at 25 and had eight more wanting membership so he could agree with the need for a new group. He continued that the twelve wanting membership and the eight from his group would make 20 members for a new group.

Brenda asked if there would be more discussion, and with no hand being raised, she asked for a vote. The vote was unanimous and she asked Barry and Allen if they would work with Glen or someone from his group to help form the group. Both agreed and Brenda thanked them. Allen stopped and told everyone that this is the first he has been thanked by a leader of the group and he said he wanted everyone to know why he would support Brenda. This brought a hearty round of applause.

Glen stated that he wanted to thank Brenda for helping keep members of the separated group out of his group, as three had tried to join his group. Brenda said we will need to work together in the future to avoid other problems. We will also be having a few meetings and inviting other groups. We hope you will find interest in some of them. We had planned this to be one of them, but the membership issue became important. In talking with you and finding out the numbers of potential members, we felt this required our joint attention, so thank you for your input.

Barry asked to speak and said a few potential members may back away from a new group, but this should be expected. Glen said this may happen, and these people should be told that the membership in our groups is capped at present and we don't anticipate any member changes in the near future. Allen said this is correct and Glen has explained this very well.

Brenda then asked if any one disagreed. No one disagreed and Brenda asked Julie, Rose, and B.J if they would work with Glen, Barry, and Allen to support the formation of the new group. All three said they would and B.J asked if he could be part of the group with Glen, Barry, and Allen as he wanted to learn from them, as he felt several could be in need of VA assistance like he was.

Allen said this was something Barry and he had discussed and this needed to be accomplished. Brenda asked Allen if he would work with the new members.  Allen said Barry and he should have done this in October and now this meeting was all but over, and it had not been done.

Brenda asked B.J if he needed the information now or later. He said there are three other new members and three in those he knew that wanted to join. Julie said both of her potential new members need this information. Rose said two of her three were also veterans.

Barry said this means about 14 are veterans and he asked Glen if he knew about those wanting VA information. Glen said he was not sure, but he would ask. Allen said there was a lot to be done to start the new group, but felt it might help start the new group.

Brenda asked if there was any other business. None was forthcoming and Brenda said cleanup is in order. She concluded by saying she would suggest those working on the new group stay in contact with her and each other. She said she would forward any information that she receives. The meeting is over.