How Zoom calls with GPs are helping to end the epidemic of wounds that never heal

It is a hidden epidemic that has hit more than two million Britons and left them struggling through each day with debilitating pain.

Chronic wounds – ulcers and cuts, usually on the legs and feet, that fail to heal – cost the NHS £5 billion every year.

And they are far from a minor affliction, often leading to infections with thousands of patients ultimately facing limb amputations each year.

Zoom calls with GPs are helping medics manage problems such as chronic wounds on legs and feet which fail to heal and cost the NHS some £5bn a year

With the help of video-call appointments many patients are finally healed, quite possibly for good

With the help of video-call appointments many patients are finally healed, quite possibly for good

But, according to new figures, the tide may finally be turning as new home-management methods, adopted during lock-down, are rapidly revolutionising treatment for these stubborn injuries.

With the help of video-call appointments many patients are finally healed, quite possibly for good.

This week, the UK’s leading charity for leg and foot problems, Legs Matter UK, estimated that half a million sufferers are now treating themselves effectively at home, using guidance given via video or phone calls from specialist nurses.

Waiting times to speak to a nurse or doctor have dropped from eight weeks to just seven days in some areas.

Dr Leanne Atkin, vascular nurse consultant at the Mid-Yorkshire NHS Trust, says the pandemic has forced medics to try new approaches to patient care.

She said: ‘We receive photographs of wounds by email and phone messaging, which allows us to judge instantly if there’s an infection that needs treating – or if dressings need changing. Then we give step- by-step advice about how to do so over the phone or via video calls.

‘This frees up time in clinic for the more severe cases, which can be seen far quicker than ever before.’

This revolution is well-timed, given that the toll of chronic wounds is predicted to increase in the coming years.

The risk of developing a non-healing wound is worsened by illnesses that affect the circulation, including diabetes and heart disease, both of which are on the rise due to spiralling obesity levels and an ageing population.

Experts estimate that wounds become chronic in two-thirds of patients with these conditions. In diabetes, high blood sugar levels can also lead to nerve damage, which means patients are often unaware of a foot injury and will continue to walk on it, compounding problems.

Unless treatment is given rapidly, to both cover the wound and improve the circulation in the legs, the ulcer may not heal.

Such is the growing concern that, last year, an all-party parliamentary group commissioned a report on the crisis. In October, MPs on the committee for vascular and venous diseases warned that ‘organisational barriers’ within the NHS were hindering speedy treatment. Scores of patients were found to be waiting two months for an initial referral to a nurse specialist, by which time amputation may be the only option.

This is despite expert advice to stick within the 14-day ‘window of opportunity’ to save limbs.

Previously, once patients were referred by a GP, they’d visit a specialist nurse for compression therapy – tight bandages that squeeze the legs to encourage blood flow.

After that, face-to-face sessions with healthcare professionals were needed to change dressings frequently, possibly at a GP surgery or specialist clinic. But soaring patient numbers and staff shortages have left patients waiting for months on end, both for an initial appointment and check-ups.

When Covid-19 hit, clinicians rapidly redesigned services, leading to a dramatic improvement in treatment for patients. Now, after a referral is made from a GP, which can be done following a phone appointment, specialists can intervene within 48 hours.

After assessing photographs, clinicians decide how quickly each patient needs to be seen. If a visit isn’t needed straight away, patients are provided with video tutorials to guide the changing of dressings, or in-depth guidance over the phone.

Family members are involved too – partners and children are given step-by-step instructions for changing and cleaning dressings over the phone. Bureaucratic constraints have also been torn down, with specialists such as Dr Atkin able to prescribe pain medication or antibiotics to treat infections outside of a GP clinic. She says: ‘We had this the wrong way round. Covid has given us the opportunity to go back and see where we should be focusing things.’

One useful result of the pandemic is that many older people have become more familiar with technology, having used it to stay in touch with loved ones.

One patient to benefit from the new routine is retired lorry driver Peter Hilton, 78, who has suffered with leg ulcers for 30 years.

He also has type 2 diabetes and has been shielding with wife Pat, 77, at their home in Leeds. Despite being a ‘bit squeamish’, former dental nurse Pat admits she has excelled herself in changing the dressing on her husband’s left foot, where an ulcer had developed.

During lockdown, Pat underwent two hours of training by phone with Kate Williams, a wound clinical nurse specialist in Leeds, and has been able to clean and redress the wound more frequently than was possible at their busy GP surgery.

As a result, the wound that stretched from Peter’s heel to toes is healing rapidly. Pat sends weekly images via email to Kate to check on his progress. ‘At first, I wasn’t confident, but Kate told me what to do,’ Pat says. ‘At first, it needed daily dressing. But it’s healing well so it’s every other day now.’

And her grateful husband adds: ‘It only takes her 30 minutes. She’s absolutely first-class!’

DR ELLIE CANNON: Just what is a healthy level of cholesterol these days?  

I read in The Mail on Sunday that having very high HDL cholesterol is a worry, especially for middle-aged women like me.

My total cholesterol is 5.3 – and I have an HDL of 2.3. The ratio calculator online tells me this is healthy, but now I read that 2.3 is very high.

Also, could my high HDL be the reason for having a lipoma, and should I have it removed?

Our understanding about cholesterol has evolved over the past 20 years. Once, we were just concerned with total cholesterol, but now we are focused much more on sub-types of cholesterol, and how they contribute to increased risk of a heart attack.

Risk is a nuanced thing and many factors are at play – blood pressure, whether you’re overweight or smoke, your age and family history, as well as other illnesses you may suffer from, all contribute. Cholesterol isn’t the be-all-and-end-all but if you do have high overall cholesterol, and also raised levels of a sub-type called LDL cholesterol, sometimes called ‘bad’ cholesterol, you might be advised to take statins, which will lower it. HDL cholesterol was once thought to protect the heart, which is why it’s often called ‘good cholesterol’. And although it still does, it seems very high levels, above 1.4, are associated with a raised heart-attack risk.

Our understanding about cholesterol has evolved over the past 20 years. Once, we were just concerned with total cholesterol, but now we are focused much more on sub-types of cholesterol, and how they contribute to increased risk of a heart attack

This is based on new research and it’s not fully understood, but it is worth talking to your GP, showing them the article you mention. They might want to recalculate your risk, based on the new evidence.

Medication can’t lower HDL but there may be other steps worth taking, such as statins to lower LDL, tackling blood pressure, and lifestyle changes.

A lipoma is a benign, soft lump on the skin composed of fat – and this is unrelated to cholesterol. They are usually harmless, so doctors do not advise removing them unless they are unsightly or causing pain.

Life has left me utterly miserable. My GP suggested antidepressants but I don’t want to take them. Can you help?

It is not surprising that any of us would be feeling miserable right now. Not only has day-to-day life changed immeasurably, but the immense trauma, loss and uncertainty we have experienced nationally and individually since the start of the pandemic has, understandably, left huge emotional toll.

   

More from Dr Ellie Cannon for The Mail on Sunday…

Doctors are increasingly concerned about rising numbers of patients with symptoms of anxiety and depression – and those who actually make it as far as calling a doctor are probably just the tip of the iceberg.

It is vital that anyone feeling persistently low gets a proper assessment, so a diagnosis can be made. Depression is different to sadness or misery, and involves symptoms of mood or sadness but also changes in appetite, sleep, and thoughts. These things have an impact on daily life, work and relationships.

A GP can carry out initial consultation via video calls or phone.

Or you can cut out the middle man and refer yourself directly to a specialist in your area who offers psychological therapies.

If you search online for ‘IAPT services’ – IAPT stands for improving access to psychological therapies – the top hit should be the nhs.uk web page that allows you to refer.

Mental health treatment can involve medicine, but also psychotherapy and lifestyle changes. If medicine is not a choice for you, look at the two other options.

Free, NHS online therapy sessions for many areas of the country are available via iesohealth.com.

Doctors are increasingly concerned about rising numbers of patients with symptoms of anxiety and depression

Doctors are increasingly concerned about rising numbers of patients with symptoms of anxiety and depression

There are some incredibly helpful mental health apps that I routinely recommend to patients. These are available to look at on the NHS apps library and are targeted to specific issues – for example Big White Wall for stress and anxiety, or Silvercloud which is an eight-week course for depression. Lifestyle measures sound simple but shouldn’t be underestimated. Walking daily, pushing yourself to exercise or finding a hobby, yoga or just conversations with a friend can have a tremendous impact on mood and feelings, even when the mental health problem is quite significant.

I am 76, and relatively fit, and until February was going to the gym up to three times a week. But then my hip starting hurting. A lot. An X-ray showed nothing wrong. What could it be?

Anyone aged over 76 will have some arthritis in the hips and knees, which may or may not show up on an X-ray. Other common hip pain comes from bursitis which is swelling from the fluid around the hip – known as trochanteric bursitis.

Your GP can arrange access to physiotherapy which is helpful for bursitis and can be sought at the moment remotely. Bursitis of the hip can be part of greater trochanteric pain syndrome, when the top of the thigh bone becomes irritated.

Avoid sitting cross-legged and do not sleep on the affected side, and it might improve matters.

I told Boris Johnson to be a mask model… now he is

I was on the news again last week talking about my favourite subject, masks – and the fact that leading politicians, despite telling us we should wear them, seem not to want to practise what they preach. 

Boris Johnson, Matt Hancock and Rishi Sunak had all been seen over the past fortnight out and about meeting the public, sometimes in close contact, not once wearing a mask. It wasn’t a good look, I argued. They need to be role models, as mask-wearing is a huge culture change for us Britons. Well, it seemed Boris was listening as on Friday he appeared, right, for the first time wearing a face covering. I hope the Cabinet follow his lead.

In other news, people have been asking where I get my cloth face coverings. They’re from the charity Binti, at bintiperiod.org. I might buy one for Boris.

Boris Johnson, Matt Hancock and Rishi Sunak had all been seen over the past fortnight out and about meeting the public, sometimes in close contact, not once wearing a mask. It wasn’t a good look, I argued, but now the PM has a been spotted with a mask

Boris Johnson, Matt Hancock and Rishi Sunak had all been seen over the past fortnight out and about meeting the public, sometimes in close contact, not once wearing a mask. It wasn’t a good look, I argued, but now the PM has a been spotted with a mask

Has that mole changed? Get it checked now

I’ve been asked whether skin clinics are closed, by people worried about changes to a mole and have stressed that they should make a GP appointment without delay.

We are working differently, but are very much open, as are dermatology units. Most GP appointments will start on the phone and then, for a skin problem, we will either want to see photos or use a video consultation. If your GP is concerned, you can be referred. Many dermatology clinics are open for face- to-face appointments but it may be possible to have a more than adequate consultation remotely.

Signs of melanoma skin cancer include changes in shape, size or texture of a mole. One that looks very different to others around it can be a concern.

You are also more at risk over the age of 65, if you have fair skin and freckles, or if you have a member of your family with melanoma.

You can save a fortune buying braces online, but they might not give you the smile you’re after… 

A body that represents British dentists has called for a crackdown on DIY braces sold online which promise to straighten teeth in just six weeks but could, in some cases, lead to irreparable damage, including the loss of teeth.

The braces being offered are known as aligners – removable moulds that fit over the teeth to gently move them into new positions, and highly effective when used under the supervision of a dentist or orthodontist.

However, some experts warn that some patients may have underlying dental problems, often without knowing, that can make the devices more likely to cause loosening of the teeth, bleeding and bone damage.

The braces being offered are known as aligners – removable moulds that fit over the teeth to gently move them into new positions, and highly effective when used under the supervision of a dentist or orthodontist

These patients need regular monitoring to minimise risks, they say.

Our investigation has discovered companies selling aligners directly to the public via Instagram and Facebook – sometimes promoted by social-media stars to their millions of followers. Treatment costs up to £1,500 less than it would if purchased from a clinic. While this is legal, customers are not always given enough medical support or supervision, say worried dental chiefs.

The firms argue passionately that, for many patients, the treatment can be completed safely at home without a visit to the dentist. They consider themselves ‘disruptors’ to the orthodontics industry, arguing that their remote methods are in fact superior – and even safer – than traditional methods involving x-rays which, they say, could put patients at risk of cancer. They dispute the warnings of top British dentists – suggesting the concern is rooted in their desire to protect their financial interests.

Experts are adamant that this hands-off service is indeed a risk to patients – as a number of those with dental problems, which render them unsuitable for braces, may be exposed to complications. One concerned professional is Dr Saaqib Ali, dentist and owner of Sherwood Dental Practice in Birmingham.

He said: ‘Increasingly we are seeing patients reporting problems with loose teeth, bleeding gums and difficulty getting advice from a clinician after undergoing DIY braces treatment.

‘I rejected a patient for braces two years ago, because he had ongoing gum disease and bone loss. He was then treated by an online aligner company – I was amazed. When he came back to see me afterwards, he had bleeding gums and had lost further bone from around his teeth. The pressure that aligners put on the teeth can further accelerate gum disease, causing teeth to become wobbly and, in worst cases, premature tooth loss.’

The Mail on Sunday had planned to name all three companies investigated, yet the threat of legal action from one firm prohibited us from doing so. The same company has asked at least three patients seeking a refund and compensation to sign a general release form, including a non-disclosure clause preventing them discussing their treatment. When approached, the company said this is ‘standard practice’ when customers request a refund outside of the published refund policy.

Another customer alleged an attempt to censor his feedback, writing on a review website that the company had tried to remove his negative review.

The General Dental Council, which regulates dentists and orthodontists in the UK, is ‘gathering evidence about the potential risk of harm to patients from direct-to-consumer orthodontics’.

One social media user complained that she lost a tooth while using dental aligners

One social media user complained that she lost a tooth while using dental aligners 

Dentist Mick Armstrong, chairman of the British Dental Association, is another who has warned that DIY braces could leave patients with ‘irreparably damaged mouths… resulting in lost teeth or worse’. And Peter McCallum, from the British Orthodontic Society, said: ‘Many of our members are already seeing patients who’ve had problems after DIY braces treatment. If a tooth is moved to an unstable position, the damage can be permanent.’

Aligners, when offered by a dentist, can cost upwards of £3,000. Treatment includes X-rays, other scans and numerous face-to-face consultations over the course of six to 12 months. All the DIY companies investigated say they employ qualified dentists or dental assistants who provide support for patients. However, most patients are not routinely offered physical checks or examinations, with most interactions via email or phone.

One unhappy customer is Paula Keirnan, a personal assistant from Birmingham. The 31-year-old claims to have suffered ‘severe bleeding’ and ‘scarily loose teeth’ while wearing aligners sent to her in January by the same company threatening legal action against this newspaper.

Paula says that, despite raising concerns with the firm via emails in April and then June, asking for a refund, she never spoke to or heard from a dentist.

The first time she spoke with ‘her’ nominated dentist was last Sunday, after the MoS approached the company for comment. Days later, the company offered Paula compensation and a full refund, and asked her to sign a legal document containing a non-disclosure agreement – also referred to as a ‘gagging clause’.

Paula was attracted to the braces, which cost about £1,500, after seeing adverts on Instagram. She hoped one receding tooth beside her front teeth would be straightened. She said: ‘Six months on my tooth is still not straight, and I’m in agonising pain when I eat anything that isn’t soft and often spurt blood into the sink when I brush. One night I burst into tears, convinced that all my teeth would fall out.’

Paula Keirnan, pictured, claims she suffered severe damage using dental aligners

Paula Keirnan, pictured, claims she suffered severe damage using dental aligners 

The companies’ websites claim to have transformed the smiles of millions – providing links to thousands of rave customer reviews. Scores of young customers can be seen documenting their success stories on social media sites such as YouTube and Facebook. But The Mail on Sunday has also seen more than 200 online reviews by unhappy customers. Alleged complications range from mouth ulcers and pain to snapped, cracked teeth and, in one case, a crown falling out.

Two customers who contacted The Mail on Sunday, but cannot be named for legal reasons, claim to have required root-canal procedures after wearing aligners sold to them by the company threatening legal action.

Writing on the consumer review website Trust Pilot, one customer said: ‘I had a very badly cut mouth, which bled and ulcerated and took nearly a month to heal fully.’ Another reviewer wrote that his front teeth were left ‘visibly crooked’. Other reports online include patients complaining of ‘loose teeth’, and ‘gaps’.

Although we were unable to further verify the accuracy of these reviews, they remain online.

On the video-sharing app TikTok, one DIY braces customer is seen holding an aligner that appears to have pulled out a tooth. The woman, posting under the username @nelliesmilees, says: ‘I have been using smile aligners… and I’ve just taken out my aligners and… my tooth just fell out.’

In a later post, she clarifies that it was a crown. The content cannot be verified as the video has now been removed.

Dr Ali said: ‘A crown that is bonded properly shouldn’t come off with an aligner. It’s a risk if aligners are poorly fitted, or if a dentist hasn’t inspected the quality of the crown to begin with.’

Plastic aligners have surged in popularity as a cheaper and less visible alternative to traditional ‘train-track’ orthodontic braces.

The most popular brand, Invisalign, involves dentists taking scans and X-rays of the mouth which are used to create a bespoke series of aligners. They differ slightly in shape and each is worn for a number of weeks before it’s swapped for the next in the series, gradually coaxing the teeth into new positions.

FACT BOX TITLE

Q: I heard that coronavirus might be airborne. What does that mean?

A: Airborne transmission is when a virus is spread in tiny particles, exhaled by someone, which can stay suspended in the air before coming into contact with other people.

This is thought to occur with some types of viral infection, for example measles.

At the moment, the evidence suggests coronavirus is primarily spread by droplets expelled when an infected person coughs, sneezes, shouts or sings. These droplets may land on surfaces, where other people come into contact with them, or may land directly on other people nearby.

However, the World Health Organisation has said there is ‘emerging evidence’ of airborne transmission of coronavirus.

An official added that the possibility of this happening in crowded or poorly ventilated spaces should not be ruled out.

If confirmed, it could affect social-distancing guidelines for indoor spaces – and make the argument for wearing masks inside much stronger.

And, if airborne transmission of coronavirus is found to take place, scientists will need to work out if it is a major contributor to infection, or a rare one.

Q: Is it really safe to go back to my gym or swimming pool?

A: The opening of gyms and pools has had to be done carefully, because of the increased risk of Covid-19 spreading indoors.

Indoor facilities will be able to open from July 25, while outdoor pools reopened yesterday.

Leisure facilities have the ideal conditions for the virus to pass from person to person. They are usually filled with lots of people in close proximity to one another, often breathing heavily while exercising, and equipment is shared.

To limit these risks, strict new social-distancing guidelines will be introduced. These include limits on the number of people able to use facilities at any one time, reduced class sizes, one-way systems and more space between equipment. Customers will be encouraged to shower and change at home.

Gym-goers do not have to wear masks, but, Government advice is that they should be worn in enclosed public spaces where social distancing is not possible.

Indoor gyms in Northern Ireland reopened on Friday, but no date has been set for Wales or Scotland.

Companies offering DIY braces design them using a 3D image of the teeth, based on a dental mould made at home by the patient or specialist scans taken by an assistant at one of the companies’ stores to create a computer model of the teeth. A dentist or orthodontist then designs a custom treatment plan, before the set of aligners is posted to the customer. It is standard, when aligners are prescribed by a dentist at a regular clinic, for a physical examination and dental X-rays to be carried out. However, these are not always offered by the DIY firms.

Dentist Dr Keshvi Patel, of Smiledent Dental Practice in North London, said: ‘X-rays are essential. You need to check how much bone, or root, is under the gum, as too little can cause teeth to become loose when they move.

‘Many people, even in their 30s and 40s, have lost a significant amount of bone due to gum disease, and don’t realise it. It is impossible to detect this with 3D scans.’

According to DIY firms, a patient can be deemed appropriate for aligner treatment based on digital photographs, scan results, a complete medical and dental history and, in the case of one company, a patient’s mould of their teeth. Dr Ali said: ‘Teeth might look perfect in photographs, but you wouldn’t be able to detect rot inside. Equally, scans and moulds won’t show the telltale sign of gum disease – pockets between the gum and the teeth which can trap bacteria, causing bleeding and pain. You need a specialist probe to do this, in person.’

Before beginning treatment, customers purchasing online braces must sign a form to confirm they have had a full dental check-up, including X-rays, within the past six months. According to the company that treated Paula, its registered dentists and orthodontists provide regular virtual check-ins, guiding treatment remotely throughout.

The firm promised her that a dentist would make contact after 90 days of treatment, in April. She claims this never came, despite her complaining to the customer care team. The company say that Paula had contact with dental assistants on multiple occasions, and the dentist overseeing Paula’s case completed a ‘progress check-up’ in mid-April, based on photographs emailed to him by Paula.

He concluded that ‘progress was being made’. Paula was not aware of this assessment.

Dr Patel says: ‘Dentists need to physically examine the patient at least every month to check if the aligners are too tight, which can cause ulcers and painful cuts. It’s also common for patients to need filing down of tooth enamel, to prevent overcrowding. They also need to check for evidence of gum disease, which three-quarters of us have but don’t know it.’

Aligners can trap bacteria that can cause or worsen gum disease. Infection can spread to the bone, increasing the risk of tooth loss or a poor cosmetic result.

A review of Paula’s oral health, carried out by an independent dentist last week, identified severe gum disease, including an abscess and infection spreading from the gum to one of her back teeth. It is not clear if the disease existed prior to wearing her aligners. The independent dentist said: ‘It’s unlikely Paula’s problems would have been detectable via scans, both at the outset and in follow-up photographs.’

In an email on June 16, the company told Paula she would benefit from ‘more time in aligners’. However, the independent dentist said: ‘I would not deem this patient appropriate for aligner treatment at present – she would need significant treatment to restore the health of the gums and teeth first.’

After it was approached by The Mail on Sunday, the company offered, with no admission of liability, a full refund to Paula – and £7,500 in compensation, as well as payment for an appointment with an independent dentist.

Paula says: ‘I’m miserable, uncomfortable and self-conscious when I go out of the house.

People need to realise that investing in braces is not like buying a pair of jeans.’

In a statement, the General Dental Council said it is ¿concerned about a number of consumer reviews brought to our attention¿. A spokesman added: ¿Should anyone suspect a cause for concern, we would urge them to bring this to our attention¿

In a statement, the General Dental Council said it is ‘concerned about a number of consumer reviews brought to our attention’. A spokesman added: ‘Should anyone suspect a cause for concern, we would urge them to bring this to our attention’

In a statement, the General Dental Council said it is ‘concerned about a number of consumer reviews brought to our attention’. A spokesman added: ‘Should anyone suspect a cause for concern, we would urge them to bring this to our attention.’

In a statement, the company that treated Paula said: ‘Ms Paula Keirnan, has made representations about her treatment that are false. [The company] notified the Daily Mail [sic] that the third-party dental “experts” the producers consulted for their story have no experience with [the company’s] platform and therefore have no authority to comment as to the safety and efficaciousness.

‘The claims presented by third-party dentists around teledentistry and bone imaging are not supported by any clinical evidence. In fact, it is the exact opposite.

‘Ample evidence exists as to the efficaciousness of bone imaging and oral exams via a remote platform to diagnose suitability for low-risk orthodontic procedures such as clear aligner therapy, and there are plenty of studies as to the harmful health effects of unnecessary radiation exposure. The feedback from our customers is overwhelmingly positive (more than 99 per cent) and the conclusions being offered in this report are inaccurate.’

Jab that lets you stay awake for complex hand surgery

It might sound daunting – particularly for the more squeamish – but NHS patients are now routinely being offered complex hand surgery while wide awake, with doctors claiming the method is faster and safer than operating with a general anaesthetic.

Instead of being put to sleep, injections containing a numbing local anaesthetic and adrenaline, which temporarily reduces blood flow, are used.

During the procedure, patients are conscious, able to talk and, if they wish, can even watch what is going on.

During the procedure, patients are conscious, able to talk and, if they wish, can even watch what is going on

And, unlike with general anaesthetics, which carry risks of their own and require hours of recovery time, patients can be free to go home within an hour.

The technique is well established and commonly used in A&E departments, where patients may need to be operated on without delay.

Minimal staff are required, and it can be carried out outside of main operating theatres.

During the pandemic, a lot of hand surgery has been carried out like this, as it has allowed surgeons to continue operating while faced with staff shortages and reduced theatre capacity.

Matthew Gardiner, consultant plastic surgeon at Wexham Park Hospital in Slough, says: ‘The coronavirus pandemic accelerated use of the technique overnight.

‘Surgeons who were only comfortable operating the traditional way have embraced it. The great thing is it doesn’t require any specific training beyond what we already know and it is, after all, just like injecting local anaesthetic, which we routinely do anyway.’

The traditional method for hand and arm surgery, using general anaesthetic, also involves the use of a tourniquet strapped around limbs to apply pressure and cut off the flow of blood.

This keeps any bleeding to a minimum, enabling surgeons to carry out repairs without disruption.

However, the tourniquet can put strain on healthy tissue and in some cases causes damage to nerves and muscle. ‘It crushes the muscle and there is a limited time you can use it for – normally about two hours,’ says Mr Gardiner, who is a Royal College of Surgeons of England surgical speciality lead for plastic and hand surgery.

The new technique is known as Wide-Awake Local Anaesthesia, No Tourniquet, or WALANT.

Patients are given the anaesthetic and adrenaline injection at the site of the injury on their arm or hand. The anaesthetic quickly numbs the area so they can’t feel anything, while the adrenaline acts in a similar way to a tourniquet, closing off blood vessels – the tiny tubes that transport blood around the body – to minimise bleeding.

Patients are given the anaesthetic and adrenaline injection at the site of the injury on their arm or hand. The anaesthetic quickly numbs the area so they can¿t feel anything, while the adrenaline acts in a similar way to a tourniquet, closing off blood vessels ¿ the tiny tubes that transport blood around the body ¿ to minimise bleeding

Patients are given the anaesthetic and adrenaline injection at the site of the injury on their arm or hand. The anaesthetic quickly numbs the area so they can’t feel anything, while the adrenaline acts in a similar way to a tourniquet, closing off blood vessels – the tiny tubes that transport blood around the body – to minimise bleeding

It takes about 30 minutes to take effect, and causes the area to turn white and cold. After the procedure, blood flow naturally returns after a few hours, and there is no damage to tissues. The technique is suitable for operations to repair tendons and hand fractures or other injuries but can also be used for common hand problems, such as carpal tunnel syndrome, caused by undue pressure on a nerve in the wrist.

Although some patients are apprehensive about staying awake during their surgery, Mr Gardiner says it can be a very relaxing experience. ‘Some patients are a bit squeamish and they don’t want to watch but many just listen to music and fall asleep,’ he adds.

Christopher Stone, 50, from Lymington in Hampshire, had surgery to repair three tendons in his left hand earlier this month after severing them with an angle-grinder in a DIY accident.

The married father-of-four says: ‘With my right hand, I managed to put pressure on the opening – because it was really gaping open and squirting blood – which held it together.’ He was taken by ambulance to A&E and referred to Mr Gardiner at Wexham Park, who recommended he had surgery under local anaesthetic.

‘I’m not very good with blood, so I was initially a little bit worried,’ Mr Stone says. ‘But during the procedure the doctors were fantastic, talking me through everything they were doing. When the surgeon had stitched my tendons together, he asked if I wanted to have a look. He moved my fingers and you could see my tendons, now stitched together, moving.’

Ten minutes after the two-hour operation, Mr Stone was walking around, and left hospital within an hour. He says: ‘It was really quick and although I didn’t feel on top of the world, I was surprised by how generally well I felt afterwards.’

Is a banana as bad for type 2 diabetes as SIX spoons of sugar?

Is eating a banana the same as swallowing six teaspoons of sugar? It would seem intuitive to say no, of course not – a banana is a fruit, and sugar is, well, just sugar. But a while back I came across a set of detailed charts on Twitter that made this claim. And it wasn’t the usual clickbait.

It had been written by Dr David Unwin, a well-known GP at an NHS practice in Southport, Merseyside – who has advised Parliament on diabetes care and obesity. The charts were endorsed by NHS watchdog the National Institute for Health and Care Excellence (NICE) and have been backed by Health Secretary Matt Hancock.

It’s understandable then that Dr Unwin has been called one of the most influential GPs in Britain by doctors’ magazine Pulse. His diagrams, shared thousands of times across various social-media platforms, show a wide range of foods, from breakfast cereals and brown bread to potatoes and fruit and veg. Each is given a teaspoon-of-sugar count, to show that eating them is – in Dr Unwin’s words – ‘the same as’ eating that much pure sugar.

Barney Calman, pictured with former Olympic triple jumper Michelle Robinson ahead of testing the theory

The rationale is that, because carbohydrate in food is broken down into single sugar molecules during digestion, both food and ‘neat’ sugar have the same effect on blood sugar levels.

According to Dr Unwin, an average-sized banana is the equivalent to almost six teaspoons of sugar. A small 150g portion of basmati rice has the same effect on blood sugar as ten teaspoons of sugar – a whopping 40g. When this was posted on Twitter, the ex Labour Party deputy leader Tom Watson, who recently published a book about his eight-stone weight loss thanks to a low-carb diet, commented: ‘That white rice one gets me every time. Why didn’t I know this 25 years ago!’

Indeed, it’s startling stuff, particularly for the 3.5 million Britons who, like Mr Watson, have type 2 diabetes. For them, high blood sugar over a lifetime means a raised risk of strokes, heart attacks, blindness, kidney failure, limb amputation and premature death.

It’s this group that Dr Unwin’s message is aimed at. He designed the graphs himself, based on his own research with colleagues, to simplify conversations about diet with patients.

‘If you have type 2 diabetes, sugar becomes a sort of metabolic poison,’ he said in a recent lecture. Dr Unwin points out that the ‘quality of diet’ is the most important thing, when it comes to healthy eating, whether it’s low-carb, low fat or otherwise. However scores of his patients have reversed their type 2 diabetes after following his low-carb advice and cutting down on sugar, starchy foods such as bread, potatoes and rice, and fruit such as bananas.

This is one of the charts used by Dr Unwin to support his theory about blood sugar levels

This is one of the charts used by Dr Unwin to support his theory about blood sugar levels 

Dr Unwin, who goes by the handle @lowcarbGP on Twitter, where he has almost 50,000 followers, says: ‘At an average of 30 months low-carb, 49 per cent of our patients have achieved drug-free type 2 diabetes remission – this is in 82 individuals.’

With the Government urging Britons to slim down, after obesity and diabetes were linked to the worst Covid-19 outcomes, low-carb advocates suggest the approach could offer hope.

But is it really the answer? Although proven to aid weight loss initially, studies show few people stick to low-carb plans in the long term.

A recent report from the Scientific Advisory Committee on Nutrition concluded there was no difference between low and high carbohydrate diets when it came to weight loss beyond 12 months.

And despite high-level political approval, some experts robustly reject Dr Unwin’s statements about teaspoons of sugar, calling them misleading and unscientific.

When we asked NICE, in light of these findings, on what basis it had endorsed his infographics, it said it had decided to remove them from its website ‘as a precautionary measure… while we conduct our own assessment of the competing evidence claims’. It added: ‘In the meantime, we will ask Dr Unwin not to promote his resource using NICE’s endorsement.’

We spoke to some of Britain’s leading names in diabetes medicine and food science, who told us that carbohydrates, far from being ‘metabolic poison’, are essential for human life, and effectively demonising foods such as bananas, which contain lots of nutrients, raises the risk of deficiencies. And a growing body of evidence suggests some cause for concern: long-term low-carb diets may actually be associated with serious illness.

Those hidden sugar claims tested 

If current trends continue, within five years the number of diabetes sufferers in Britain will top five million, with most affected by type 2 diabetes, which is linked to obesity. The disease costs the NHS roughly £1.5 million every hour – ten per cent of its total budget – so politicians are keen to find new approaches to treatment.

Dr Unwin’s methods appear to have been a huge success: his practice reports it saves the NHS £48,000 in medication every year. But is what he says about carbohydrates right? I put his eye-catching claims about foods being ‘the same as’ teaspoons of sugar to the test. And what I discovered left me wondering why, exactly, health chiefs and politicians alike had lined up to back them.

With the help of Professor Gary Frost, Head of the Section for Nutrition Research at Imperial College London, and his team, I set about finding out what would happen to my blood sugar if I ate a banana and a portion of rice compared with the ‘equivalents’ – based on Dr Unwin’s diagrams – in pure sugar. A continuous blood glucose monitor – a stick-on patch worn on the upper arm or abdomen – would track my blood sugar level.

Each ‘challenge’ – consuming 120g of banana, the ‘equivalent’ 24g of sugar, 150g of basmati rice, and ‘equivalent’ 40g of sugar – was carried out on a different morning after I had fasted since dinner the night before. An empty stomach meant no other foods could have affected my readings.

I consumed exactly the same meal the night before each challenge and avoided strenuous exercise and alcohol, again, to make sure nothing distorted the result.

During each challenge, I moved around as little as possible for two hours as I digested the food, as physical activity ‘burns’ blood sugar.

With the Government urging Britons to slim down, after obesity and diabetes were linked to the worst Covid-19 outcomes, low-carb advocates suggest the approach could offer hope

With the Government urging Britons to slim down, after obesity and diabetes were linked to the worst Covid-19 outcomes, low-carb advocates suggest the approach could offer hope

As I’m not diabetic, I asked former Olympic triple-jumper Michelle Griffith-Robinson, 48, to do the experiment alongside me. In 2018, Michelle was diagnosed by her GP with prediabetes – abnormally raised blood sugar levels that indicate a person is at risk of developing type 2 diabetes.

Now a lifestyle coach and personal trainer, living in Devon with her husband, former Welsh rugby player Matthew Robinson, and their three sporty children, Michelle says: ‘I was devastated. I was a small size 12, so not big – but having had three children, and being in my 40s, my weight had crept up a bit.’

Diabetes runs in her family, and Michelle, not wanting to follow the same fate, embarked on a strict low-carb diet.

In six months, she lost half a stone – and her blood sugar is now almost within the normal range.

‘I was strict,’ she explains. ‘I stopped eating rice, bread, potatoes and pasta, and upped my veg and protein, so I never went hungry. I was probably a bit too thin, almost a size eight for a while.’

‘Today, I’ve eased up a bit,’ she says. ‘I’ll have a portion of rice once a week, or a mouthful of pudding. It’s about moderation.

‘But I still worry about how much carbs will affect me. I don’t want to get diabetes – it just can’t happen.’

Once eaten, carbs can behave differently 

At the end of the week, we collected our results – seen on the graphs, far right. They show, clearly, that for both of us, eating a banana wasn’t the same as eating six teaspoons of sugar.

Nor was eating 150g of rice the same as consuming ten teaspoons of sugar. More glucose ended up in my blood when I consumed pure sugar than whole foods.

Michelle’s results were similar. None of this surprised the experts at Imperial: this experiment has been done before. What we ‘discovered’ is already well known to scientists.

So, how did Dr Unwin come up with his infographics? He has written that the teaspoon count is ‘a reinterpretation’ of something called glycaemic load – a scientific term to describe how much a serving of food affects blood glucose. Researchers have previously worked this out for a vast array of ingredients. Unwin says he simplified this by working out the equivalent in teaspoons of sugar to the glycaemic load of each food.

Carbohydrates are broken down at different rates in the digestive system

Carbohydrates are broken down at different rates in the digestive system 

Imperial College researcher Dr Katerina Petropoulou, who ran our study, says: ‘On paper, the calculation is correct. But it doesn’t take into account how food is digested and absorbed by the body.’

Prof Frost, a dietician who studies carbohydrates, says that to equate bananas or rice to teaspoons of sugar is ‘very misleading, and unscientific’. He says: ‘You can measure the amount of a nutrient in a food, but that doesn’t tell us how it will behave in the body.

‘Different types of carbohydrate are broken down at different rates by the digestive system.

‘That’s why you’d see a different blood glucose response if you ate the same amount of carbs in pasta and bread – because pasta has more hard-to-digest carbs.’

Some types of carbohydrate are indigestible. And cooking, cooling, then cooking foods such as potatoes, rice and pasta can turn digestible carbs into so-called resistant starch, which can’t be digested.

That impact of carbs varies hugely between individuals, and even in the same person, from day to day. Foods are often eaten in combination – bread with butter, for instance – which affects things further. Prof Frost adds: ‘Carbohydrates have been part of the human diet since the beginning of man – the body is well adapted to consuming them.’

Could low-carb diets raise risks?  

Low-carb diets have helped thousands lose weight, at least in the short term. The worry, explains dietician Douglas Twenefour, is that if potentially nutritious foods are labelled ‘the same as’ teaspoons of sugar, suggesting they should be avoided, means people risk missing out on essential nutrients.

Dr Unwin’s says his sugar graphs are intented to be used as a general guide, used in conjunction with other detailed diet advice, which he provides his patients.

Yet, in isolation, equating nutritious foods to pure sugar could be counterproductive, says Twenefour.

‘Four teaspoons of sugar will give you about 15g of carbs, the same as a medium apple. The apple provides vitamins and fibre, which are important for overall health.’ Mr Twenefour, an advisor to Diabetes UK and co-author of the recent Scientific Advisory Committee on Nutrition report on low-carb diets added: ‘Implying all of these foods are “the same as” pure sugar is not only unhelpful – it’s also potentially dangerous. You are diverting patients away from nutritious foods. Besides, we all need carbs for energy,’ he says.

Last November, Professor Michael Lean, chair of human nutrition at the University of Glasgow, published findings suggesting low-carb diets may not be a good way to prevent diabetes. The research analysed food questionnaires from more than 12,000 volunteers to calculate their fat, protein, carbohydrate and other nutrient intakes.

Those with the lowest carb intake actually had higher blood sugar than those with normal carb intake. Those who had seemingly compensated for their low-carb intake by upping the fat in their diet, had the highest risk.

Low carb advocates claim glucose can be made by the body from proteins and fat

Low carb advocates claim glucose can be made by the body from proteins and fat

This change, they said, could have affected the way the body processed sugar, leading to higher levels in the blood. Other studies have found low-carb diets are associated with a range of life-shortening illnesses, such as heart disease.

‘It’s hard to unpick why this might be,’ admits Prof Frost. ‘Some of it will undoubtedly be increased fat intake, and reduced fibre. It is possible to eat a balanced, yet low-carb diet, but it’s not easy. In practice when people cut out carbs they eat less healthily.’

Some low-carb advocates claim that we don’t need carbs and the body can make glucose, needed for energy, from proteins and fat.

Prof Frost agrees this is technically true, but warns: ‘The body has the capacity to make glucose in this way to supply vital organs such as the brain in times of starvation. But this is a short-term survival pathway. We have no idea of the long-term health consequences.’

Cut the calories, not the carbs 

When we contacted Dr Unwin, and put the concerns of other experts to him, he said: ‘It’s the quality of the diet, whether low-carb, or low fat, that is most important.’ He explained that a properly formulated low-carb diet could be healthy, and pointed out that NHS advice to diabetics encourages ‘low-glycaemic index [slow-burn] sources of carbohydrate in the diet.’ He added: ‘The American Diabetes Association this January concluded that reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving blood sugar.’

Dr Unwin says the low-carb approach to type 2 diabetes treatment is evidence based and was the main method used before effective drugs were invented.

While agreeing it is true, diabetes control before drugs did rely on avoiding carbs, Prof Frost makes the point that: ‘Patients’ quality of life was horrendous. They suffered ill health, and died rapidly.’ By far the biggest cause of death in diabetics, today, is heart disease, he adds: ‘To avoid heart disease, being a healthy weight and having a diet that’s lower in saturated fat is best, not low-carb but high fat.’

Professor Partha Kar, NHS England’s chief diabetes expert, argues that the only scientifically proven way to get type 2 diabetes under control, with diet, is to shed excess pounds: ‘The evidence, as far as trials go, sits with low calorie diets,’ he said.

Dr Unwin’s patients undoubtedly lost weight. This will be, Prof Kar says, because they were consuming fewer calories than they burned – not specifically because they’d cut out carbs. And it’s because they lost weight that their type 2 diabetes went into remission.

‘Some low-carb evangelists say it’s all about sugar, but this isn’t backed up by science,’ he adds.

While people on low-carb diets can shift weight fast and reduce blood sugar, the benefits rarely last after 12 months

While people on low-carb diets can shift weight fast and reduce blood sugar, the benefits rarely last after 12 months

So does sugar become a poison to type 2 diabetics? ‘That’s not supported by the evidence,’ answers Prof Kar.

All the professors agree that low-carb diets show no long-term advantage over other weight- loss methods.

While people on low-carb diets can shift weight fast and reduce blood sugar, the benefits rarely last after 12 months. Most people on a low-carb diet end up eating more carbs than those on other types of diet, according to studies. ‘Individual doctors may have success with helping their patients stick to a low-carb diet, but that’s not what we see when we look at the bigger picture,’ says Prof Frost.

Despite the concerns about long-term low-carb diets, Prof Lean adds that in the short term, any risk would be outweighed by the benefits of weight loss. ‘If patients say they want to go low-carb, we support them. But these diets are no better than any other,’ he says.

As for those contemplating a low-carb diet in the long term, he adds: ‘Every bodily cell depends on getting glucose. Low-carb is not a natural way for humans to eat. Luckily, most soon give it up.’

Prof Naveed Sattar, an obesity expert at the University of Glasgow agrees, saying: ‘Instead of low-carb, we advise patients to make small changes like cutting out sugary drinks, not putting sugar in coffee or tea, or always having a salad with a meal.’

Prof Sattar points out that eating fruit and vegetables is well known to reduce the risk of a wide range of illnesses, including type 2 diabetes. He adds: ‘Yes, lots of refined sugar is bad, and by all means have smaller portions of potatoes, but to say eating a banana is the same as eating pure sugar is just rubbish.’

Dr Unwin says: ‘Sixteen randomised controlled trials, with an average duration of nine months, compare low-carb diets to low-fat diets for people living with type 2 diabetes, the majority of which confirm the low-carb diet to be superior.

‘The low carbohydrate approach to type 2 diabetes now has growing worldwide support. My teaspoon of sugar infographics are based on research by Dr Geoffrey Livesey, an international expert on carbohydrates, and were published in a peer reviewed journal.

‘Last year our infographics were shortlisted for a prize by NICE, and they remain endorsed by them to this day. I have positive feedback from hundreds of doctors worldwide who have found them to be very useful and effective. They are a general guide to eating less sugar and refined starchy carbs while consuming more green veg. I believe, given a choice, people with type 2 diabetes should avoid not just sugar but the starchy carbs that digest down into surprisingly large amounts of sugar, as I illustrate in my infographics.

‘If diabetes is about weight not dietary sugar, why is it that every drug for diabetes finds a way to get rid of excess sugar? Perhaps it is sugar you would have been better not to eat in the first place?’

Michelle, meanwhile, is adding more carbs into her diet. ‘I noticed, while wearing the glucose monitor for a week, I often had very low blood sugar. I’m probably not eating enough. And I wasn’t getting my fibre intake right, even though I was eating loads of green veg. It’s about finding that balance – and I’m getting there, I hope.’