comment‘ We shouldn’t simply use anecdotes as the basis for changing practice, leaving ‘it to others to find actual evidence NO HOLDS BARRED Margaret McCartney Miracle diets aren't fair to anyone n the world of nutrition, “low carb and key foods or food vouchers. Both and high fat” diets are a growing groups lost weight, marginally more in trend. Big claims are made, the low carb group, but the difference in including from doctors, that these HbA1c between the groups did not reach can “save your life,” “reverse significance. Itype 2 diabetes,” and, of course, help A 2017 systematic review, meanwhile, you lose weight. So, should GPs start found no long term difference between recommending low carbohydrate diets to high and low carb diets in glycaemic people who want to lose weight or who control, weight, or low density have type 2 diabetes? lipoprotein cholesterol. The low carb Criticism of the status quo is diet did, however, allow for more people reasonable. By its nature, diet research to use less medication: the average contains many uncertainties, with few long term improvement was 0.34% lower HbA1c. randomised controlled trials. But doctors, researchers, None of this negates the experience of people who and guideline committees can surely aspire to do better. dedicate themselves to a major dietary change of the low Many in the low carb lobby have been highly critical of carb type and are successful in the long term. It does current government dietary guidance. Some legitimately mean, however, that there isn’t one big, miracle diet fix. criticise conflicting or weak evidence underpinning A 2013 systematic review found that low carb diets were some guidelines. But we should be just as critical of the as good as a Mediterranean diet. The authors concluded evidence for low carb diets, which should include clear that “there may be a range of beneficial dietary options definitions. We must prove that such diets lead to the for people with type 2 diabetes.” benefits their proponents claim. We shouldn’t simply use Surely this is the offer we should make to patients. We anecdotes as the basis for changing practice, leaving it to need light, not heat. While it’s long been known that others to find actual evidence. bariatric surgery may effectively halt type 2 diabetes, For long term weight loss, a 2015 systematic review the question is whether the same effect can be achieved published in the Lancet found that low carb diets were no with diet alone. A study of 11 patients who followed a better than low fat diets. The difference between the two very low calorie diet for eight weeks showed that fasting was statistically but surely not clinically significant—an glucose returned to non-diabetic levels, but a longer average of 1.15 kg after a year. For type 2 diabetes, a term, larger study is yet to report. And the environment, 2011 systematic review found no consistent differences poverty, inequality, and work all affect what (and how) in weight and glycated haemoglobin (HbA1c) between low we eat. fat and low carb diets. Promising an easy solution in the form of uncertain Several randomised controlled trials have been science isn’t fair on anyone. And replacing one set of reported since then. An Australian trial in 2015 flawed guidelines with another is not progress. compared low fat and low carb diets, containing the same Margaret McCartney is a general practitioner, Glasgow number of calories, in obese people with type 2 diabetes. [email protected] Participants were offered fortnightly individual meetings Follow Margaret on Twitter, @mgtmccartney with a dietitian, exercise classes three times a week, Cite this as: BMJ 2017;358:j4226 the bmj | 30 September 2017 485 PERSONAL VIEW Matt Morgan The ward round is broken; let's fix it Doctors’ way of working would not be accepted by businesses making decisions with far less impact ou are the director unstructured data. You are shown of a multi-million complex financial reports going back pound coffee business. over the past few years, followed by The working lives of masses of customer comment cards. your employees, not As you try to synthesise it all, you Yto mention your customers, are have frequent interruptions. You do dependent on your actions today. all of this standing in front of all the medicine seems crazy. First described Today, you will visit 10 of the shareholders, in the middle of the by the Dutch physician Herman lowest performing branches in your store. Then, 10 minutes later, you Boerhaave in the 1700s, the ward business. You will need to decide announce your decision to increase round was a great innovative concept what is wrong with each branch and, the strength of the coffee by 10% in at the time. With limited amounts more importantly, what to do about all drinks as part of the treatment. I stand in a of information to process and a it. You may even need to close a store You then move on to the next store. busy, noisy, small team to communicate with, if the causes of poor performance By the time you get to the tenth store critical it was just what patients needed. cannot be rectified. you are tired, having made at least care unit, Today, however, I stand in a busy, The method you have chosen 200 decisions already that morning. presented noisy, critical care unit, presented to conduct this process is novel. This is known to be the limit of with hundreds of pieces of data, You decide to drive from store to reasonable decision making. Then with hundreds surrounded by a multidisciplinary store throughout one morning with you do it all again the next day, and of pieces of team of 10 people. This is not what little or no prior knowledge of their the day after, and the day after that. data. This patients need. problems. When you arrive, you When viewed through this lens, the is not what Many doctors, including myself plunge into masses of unfiltered, way in which decisions are made in patients need and my colleagues, have recognised ACUTE PERSPECTIVE David Oliver Junior doctors’ working conditions are an urgent priority A health service is nothing without we are already failing to fill many and continue an NHS career. Plenty its clinical workforce. The biggest consultant posts in key specialties. will not. Others will decide against existential threat to the NHS is a Junior doctors suffer from being a joining the most hard pressed and failure to retain existing clinicians transient workforce—they are often short staffed specialties (often those or attract enough new ones. This only in one hospital or even town for the health service needs most) in damages morale, burns out those a year at a time—and their concerns favour of better training, work-life who stay, and compromises care all too easy to brush aside. We need balance, and work intensity. quality. to wake up and take those concerns We know plenty about what For junior doctors, the workforce Junior doctors’ more seriously. current junior doctors think crisis is becoming critical. We must intellect, At the end of the foundation about their own working lives, act now to tackle it or reap the skills, and UK programme only a half of doctors the problems they encounter, and consequences for years. The length are going straight into core or “run- the solutions they’d like to see of training means that there’s no training are through” training, including GP implemented—in their own words, reserve of ready replacements. eminently vocational training. Core training in official reports and surveys, and Juniors are a precious human exportable— places in much needed specialty from social media. In the wake of the resource that we shouldn’t casually right out of stems are increasingly unfilled. 2015-16 dispute over the (ultimately alienate or squander. Their intellect, the NHS There’s a knock-on effect of falling imposed) junior doctor contract, skills, and UK training are eminently recruitment into higher specialist there was a contractual commitment exportable—right out of the NHS. training. and multi-agency code of conduct Fewer trainees today means fewer Some doctors stepping out of to tackle a range of concerns about GPs or consultants tomorrow, and training programmes may rejoin later working conditions. 486 30 September 2017 | the bmj checklist, and spend time speaking to patients, examining them when BMJ OPINION Florence Wilcock appropriate, and communicating with them, family members, and Helping women navigate other members of the team. We uncertainty during pregnancy have time to teach, time to reflect, Recent reporting of a study on alcohol consumption in and time to talk. We finish on time pregnancy is typical of the changing instructions faced (mostly). by women. The old concept of the ward round From the moment a pregnancy test is positive, a is broken and needs to change. woman is besieged by advice: don’t eat or drink this, do This fact needs to be recognised, eat and drink that. Some of this advice may come from researched, and taught. It is health professionals, but frequently friends, family, surprising that, although I attend and even strangers have something to contribute. The a compulsory resuscitation update NHS website’s catalogue of foods to avoid is daunting. annually, I have never been taught Suddenly, everything a woman consumes is subjected how to conduct a better ward round. to what may feel like arbitrary rules. We need technology to support this The evolution of evidence means that advice this. I often arrive early for work, shift, and spaces where we can sit may change between generations or even from one sit down in a comfy chair, in a cool and review the complexity of patient pregnancy to the next.