Abbott / Apple Librelink SNAFU

 Abbott have updated their Librelink software for the Libre 2 sensor in the UK and the new version 2.10.x has the advantage of streaming glucose values every 60s to the app screen. It works well on Android. https://www.freestyle.abbott/uk-en/home.html

Not much else changed, there's no watch integration or lock screen / notification area display of blood glucose data. But it does work quite well, and the values are pushed through to the Libreview.com cloud and hence on to LibreLinkUp followers continuously.

Unfortunately there were many problems with iPhone / iOS users experiencing white screens when the app updated. This was solvable by deleting the app (and losing up to 90 days data off the phone) and reinstalling. The data is still held at Libreview.com. This problem led Abbott to pull the 2.10.x update from the app store, but not replace it with the old one, leaving no Librelink-GB app on the App Store.

For some reason the Ireland app store still carries their updated version, perhaps the white screen problem didn't arise. https://apps.apple.com/ie/app/freestyle-librelink-ie/id1307010255

So many iPhone Libre users were suddenly left in the lurch with no working app, and no app in the App Store to download.

Abbott released a video https://www.youtube.com/watch?v=LfIbDA8ciSg explaining how to delete the app and then recover it from "Purchased apps" in the user's App Store profile. This seemed to work for the majority, the loss of recent history on the phone was collateral damage. There is now a web page too https://www.freestyle.abbott/uk-en/iphone.html

It seems strange that Abbott did not rewind the update process and just put v2.8.x back on the app store. This would have restored the status quo and given them time to resolve the issue. There are some questions to be answered about the testing regime as after all there's a very limited set of hardware using iOS and an even more limited OS/user interface - surely a beta test by 50 end users would have revealed this problem in advance of messing up thousands of users.

The iOS version 2.10.x does work once installed, although some users were struggling to adapt to the movement of the "Scan" button to a more subtle RFID icon top right as shown below. With the new streaming data feature you only really need to scan to start the sensor and if it won't reconnect.

Type 2 Diabetes Remission - UK Direct Trial update.

Diabetes UK have been publicising unpublished results from a 5 year follow-up of the DiRECT trial where a harsh calorie restriction diet ((825–853 kcal/day formula diet for 3–5 months)) was used to attempt remission of Type 2 diabetes in obese and overweight adults. 85 subjects from the initial intervention group of 149 were included in the follow-up.

After 5 years, 11 people were still in remission with a mean weight loss of 6.1 kg. This compares to an average 5-year weight loss of 4.6kg, with 3.4% in remission, for those in the control group.

At the 3 year point 48 of the 85 had been in remission, so only 23% had sustained remission from years 2-5. The percentage in remission in this group fell from 56.5% to 13%.

After the first year of DiRECT, remission was seen in 68 out of 149 subjects, or 46%. Follow up after the second year reported that 53 of the original 149 were still in remission, or 36%.

This suggests that the 85 people in the extension study had a higher success rate at the outset than the whole intervention group. Even if we scale up the 13% in remission at year 5 from 85 to the original 149 it would suggest 19 long term successes in total.

The other primary goal of DiRECT was to achieve a 15 kg weight loss, not least because remission is much higher if this level of loss is achieved. Despite the severity of the calorie restriction and the amount of support provided only 36 (24%) of original participants achieved this at one year, falling to 17 (11%) after 2 years. The Diabetes UK press release does not appear to clarify how many of the 85 had sustained a 15 kg weight loss at year 5, but reports a mean weight loss in the group of 6.1 kg at year 5 compared to 10 kg in the whole intervention group at the end of the first year.

Dr Nicola Guess has written an article suggesting that there is merit in looking at the macronutrient content of the diet beyond the energy balance, as studies show that liver and pancreas fat can be reduced by carbohydrate reduction without weight loss due to the change in fat use for energy and reducing denovo lipogenesis from high carbohydrate intake. This could improve the success rate and reduce the regression seen in DiRECT where weight loss proves hard to achieve and harder to sustain.

Testing Mosley's Fast 800 Keto diet

Dr Michael Mosley has published a Keto version of his "Fast" diet series in book form, serialised in the Daily Mail for the January "dieting season" and online on his web site.

I decided to give it a try, as it's written in British English with familiar foods and takes the interesting approach of targetting a calorie reduction explicitly, alongside carbohydrate restriction. In the first phase it presents meal plans of 2 or 3 meals per day broadly designed around keeping daily protein at 50g or more, carbs below 50g and calories around 800-1000. None of the meal plan days are actually as low as the stated 800 kcal/day. For our Transatlantic friends the 50g of carbs is digestible carbohydrate excluding fibre, what the US would call "net carbs".

After one week I am writing this and can report a weight loss of 4.6 lbs / 2.1 kg. Blood glucose this morning was 4.6 mmol/l (83 mg/dl) and ketones 1.5 mmol/litre, so the approach certainly works for me. My wife has a smaller weight loss of 3.8 lbs, eating approximately the same as me.

We have prepared and cooked all the food for the recipes and not used any of the shakes or soups that are available for the "Fast 800" series of diets. Generally speaking we eat the three meals between 9 or 10 am and try to finish by 6pm, in part to avoid any hunger issues around 5pm.

I have tracked the meals using Cronometer to see how the macro and micronutrient intake looks on this restricted calorie intake. The macros are broadly in line with the recipe values in the boook, which are wriiten by Mosley's wife Dr Clare Bailey. There were a number of shortfalls in the micronutrients though, with tpyically 85% of daily targets being met. I shall discuss these individually below. At this stage I think some of it may be missing data, but some of it is a deficiency in the diet which would probably also apply to my standard diet. Here's what the Cronometer web site shows for one of the days (ignore the water intake, I don't reliably log water or black coffee intake) :-

Starting with the lipids, the Omega-3 value above includes a fish oil based supplement I take which has 360 mg of EPA and 240 mg of DHA. This accounts for ~38% of the omega 3 value and avoids a deficit.

Omega-6 typically runs low on this diet as there is a little olive oil used but no sunflower or other high PUFA oils. I don't feel it necessary to increase the 3-6 g/day intake.

Moving on to protein the list of amino acids is generally filled out to at least 100% with the inclusion of eggs, salmon, chicken and similar foods that contain high quality protein.

In the Vitamins we start to see some gaps occur regularly. Vitamins D & K are taken as a supplement and without that D would always be deficient and K often so. The B vitamins often show deficiency which I have chose to correct with a daily teaspoon of nutritional yeast flakes reinforced with B12. Vitamin E is persistently low, and not easy to find in foods. While some rapeseed or sunflower oils appear to contain an amount of E it is at a level that would involve too many calories or too much omega-6 intake. We have added some nuts and seeds to help with this, but it's a work in progress.

When it comes to minerals the Calcium and Potassium are persistently low. As my wife has a broken wrist she is now supplementing with calcium to offset this. I am a little unsure if the actual intake is low, or if we have a data problem with minerals in the food databases. More investigation required. Marnesium would be low if I wasn't supplementing with 300 mg of magnesium as citrate. The sodium intake is good and I beleive this will help offset any potassium issues based on what Dr Stephen Phinney has said about the action of the kidneys on a keto diet.

So overall we have had initial success with 3 meals a day of 1000 +/- 150 kcal/day following the book's eating plan. We haven't looked at switching to two (larger) meals per day and it is later in the diet that we may switch to 4 days of higher calorie intake and 3 days at the above restricted intake.