Doktor Dahlqvists blogg

080116

Jag har idag fått besked om beslutet avseende dietisternas anmälan av min kostråd.

Det var två dietister som anmälde mina kostråd dec -05. De menade att mina kostråd äventyrade patienternas säkerhet.

Torsten Mossberg, medicinalråd på socialstyrelsen, handlade ärendet och  anlitade professor Christian Berne, Uppsala, att utreda frågan.

Professor Berne skriver nu i sitt utlåtande att kolhydratfattig kost är i överensstämmelse med vetenskap och beprövad erfarenhet.

Med reservation för att behandlingen ännu ej är i omfattande utsträckning utvärderad.
Patienter man kostrådgiver bör förstås följas upp. Berne föreslår att behandlingen ska följas upp i nationellt kvalitetsregister av typen Nationella DiabetesRegistret. Han skriver att evidens för farlighet inte har framkommit i systematiska litteraturgenomgångar.

Socialstyrelsen har beslutat i enlighet med professor Bernes utlåtande.
SoS efterlyser att längre tids studier ska genomföras.

Som ljuv musik:
"Socialstyrelsen ansluter sig till professor Bernes yttrande och bedömer att dr. Dahlqvists rekommendationer av "lågkolhydratkost" till patienter med övervikt och patienter med diabetes typ 2 idag kan anses vara i överensstämmelse med vetenskap och beprövad erfarenhet."

Och till Bernes yttrande.

Erik Edlund har i sin MatFrisk blogg idag satt in hela texterna från Socialstyrelsen och Berne

Om detta även i Läkarforum.

---------------------------------------

Översättning till engelska

Anders Brandén      x_anbr@hotmail.com     har hjälpt mig med översättningen.
(Han meddelar att han gärna åtar sig översättningsuppdrag, engelska - svenska och svenska - engelska):

Bernes yttrande:

Akademiska sjukhuset Uppsala(The Academic Hospital)                                         2007-12-13

Torsten Mossberg
medicinalråd (medical adviser)
Enheten för behörighet och patientsäkerhet
(Department for licensing and patient safety)
SOCIALSTYRELSEN
(The Swedish Board of Health and Welfare)
106 30 Stockholm

Diarie(Journal) number: 44-112267/2005

Regarding licensed physician Annika Dahlqvist's advice concerning "Carbohydrate Tight" diet. In regard to weight reduction and "wellbeing" documented in a background material covering Low-Carbohydrate diet.

Question: Is this treatment in accordance with science and well-tried experience?

The answer to this question is yes, reserving the fact that the scientific basis in the form of randomized controlled trials is much narrower than it is regarding diets with a higher content of carbohydrates and that long time trials (> 1 year) is lacking.

Furthermore, considering the aforementioned reasoning, it's especially important that some of the practitioner's self-evident principles of the profession are met. Any kind of intervention, whether it be related to drugs or lifestyle changes such as dietary advice, should be followed by a thorough, regular follow-up and record keeping of the patient's healthiness and physical data(such as weight and waist measurement), how the patient has apprehended the advices given and the level of appliance thereof. Regarding patients with type 2 diabetes and/or overweight often combined with dyslipidemia or high blood pressure, surveilling HbA1c, blood lipids, blood pressure, P-creatinine and microalbuminuria is crucial. Since the longtime effects of this method are unknown there may be strong reason to recommend following-up over time using a national quality registry such as the National Diabetes Registry, that documents all of the above variables and can be used in local quality follow-up.

This advisory opinion is not the place for detailing the extensive literature research that I've used as a basis for my conclusions. Some relevant reviews are listed below. Substantially, they're briefing randomized controlled trials aimed at weight reduction for the obese and a sprinkling of trials using subjects with type 2 diabetes. One of the systematic reviews (2003) concluded that the evidence to support recommending a low-carbohydrate diet was insufficient but there was no evidence for it being harmful in the short run at least. It has been difficult to prove that the carbohydrate share alone has had an effect on the weight reduction since several trials has ascribed to a coincidental total energy reduction as an essential cause for the weight loss. One reservation has been that upon consuming a larger share of saturated fat in the diet one is liable to get a minor increase of LDL cholesterol, something that has been observed in longer trials, and emphasizes the responsibility to follow-up patients with relevant sample-taking over time.

Observing the swedish diet debate can lead to the comprehension that the scientific basis is found in the evening papers, debate articles by laymen and in popular books on so-called fashion-diets. A research into scientific medical literature (see references) however indicates that a number of randomized controlled trials and reviews of low-carbohydrate diets are found in leading journals with a high impact such as New England Journal of Medicine, Diabetes, Annals of Internal Medicine, JAMA and American Journal of Clinical Nutrition. Even if the literature so far is much more scarce than the one documenting the effects of todays commonly recommended diet it shows that there is a serious scientific evaluation and debate going on about the possible positioning of carbohydrate restriction in the treatment of overweight and type 2 diabetes.

To sum up, with reservation for a narrow scientific basis, a lack of long time trials and trials that evaluates the effects on patient related effect measurements (cardiovascular diseases and for diabetes microvascular diabetic complications), a carbohydrate tight diet can today be said to be in accordance with science and well-tried experience for reducing an overweight and type 2 diabetes the motivation being that a number of trials has shown effects in a shorter run and that no evidence for it being harmful has emerged in systematic literature researches performed so far. There's no scientific support yet for treatments in excess of 1 year. A thorough evaluation of long time treatment results is therefore an important demand on the practitioner.

Christian Berne, professor, överläkare (senior physician)

Sektionen för endokrinologi och diabetesvård

(The section for endocrinology and diabetic care)

Specialmedicin (Specialized medicine)

OTM-divisionen (The OTM division)

Akademiska Sjukhuset (The Academic Hospital)

751 85 Uppsala

e-mail: christian.berne@akademiska.se

mobile: 070-668 4419

Systematic and other reviews

Nield L, Moore HJ, Hooper L, Cruickshank JK, Vyas A, Whittaker V, Summerbell CD. Dietary advice for treatment of type 2 diabetes mellitus in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004097.

Westman EC et al. Low-carbohydrate nutrition and metabolism. Am J Clin Nutr 2007;86:276-84.

Nordmann AJ et al. Effects of Low-Carbohydrate vs Low-Fat Diets on Weight Loss and Cardiovascular Risk Factors A Meta-analysis of Randomized Controlled Trials. Arch Intern Med. 2006;166:285-293.

Parikh P et al. Diets and Cardiovascular Disease. An Evidence-Based Assessment. J Am Coll Cardiol 2005;45:1379-87

Kennedy RL et al. Nutrition in patients with Type 2 diabetes: are low carbohydrate diets effective, safe or desirable? Diabet. Med. 22, 821-832 (2005).

Bravata DM. Efficacy and safety of low-carbohydrate diets. A systematic review. JAMA 2003;289:1837-1850.

Quote from briefing: "There is insufficient evidence to make recommendations for or against the use of low-carbohydrate diets, particularly among participants older than age 50 years, for use longer than 90 days, or for diets of 20 g/d or less of carbohydrates."

 ------------------------------------------

The document is to the most part translated to English by Anders Brandén

------------------------------------------------------------------------------------------------

Översättning av SoS-dokumentet till engelska :

Det är en hjärtläkare i Sundsvall, Eva Andersson, som har startat upp en privat mottagning: Hjärtdiagnostik i Sundsvall AB. Där utför hon hjärtundersökningar. Jag var dit idag. Jag har ätit LCHF i mer än tre år nu och tyckte att det kunde vara dags för en hjärtundersökning. (Kostnad 2000 kr)

Hjärta och lungor avlyssnades utan anmärkning. Blodtryck 112/70. Ekg normalt för en ung person (Jag är 59 år). Puls 60.
Hjärtultraljud var helt normalt. Halskärl och aorta hade gracila förhållanden utan tecken på plack. Intiman, endotelet (det innersta lagret i kärlet, det som vätter mot blodet. Intiman blir förtjockad vid kärlförkalkning), hade en tjocklek på 0,6 mm. Normalt räknas upp till 1,2 mm.

Eva bedömde att jag har ett utmärkt hjärtkärl-status för åldern.