Dr. Sean Wheatley, PhD – Science and Research Lead/17 January 2020
Last week we launched a new position statement, looking at the evidence for using low carb diets for the management of Type 2 diabetes. In this week’s blog I’ve broken down the key messages into plain and simple English (well, I’ve tried to…). If you want more detail, the full, referenced version can be found here – or you can get in touch using the contact details at the end.
It’s still a slightly longer read than our average blog (estimated reading time is about 25 minutes), but hopefully it’s worth it. If it’s not, you can always use the sub-headings to pick and choose the bits you’re interested in – or you can just skip to the summary at the end! Otherwise, grab yourself a coffee (other beverages are available), make yourself comfortable, and here we go…
Although carb restriction isn’t a new approach for managing Type 2 diabetes, interest in it has increased significantly in recent years. Based on this, we decided it was important to update our position statement (the last one was from 2015) to make it clear where we stood, and why.
NOTE: IF YOU HAVE TYPE 2 DIABETES, YOU SHOULD SPEAK TO YOUR HEALTHCARE TEAM BEFORE MAKING ANY MAJOR LIFESTYLE CHANGES – ESPECIALLY IF YOU ARE TAKING ANY MEDICATIONS.
What is “low carb”?
Although not everyone agrees with how to define a low carb dietary approach (LCD) the most common definitions, and those used by us, are that:
Low carb = less than 130g carbs, or less than 26% total energy from carbs, each day
Very low carb = less than 50g carbs, or less than 10% total energy from carbs, each day
How do LCDs work?
There are a number of ways LCDs can help improve Type 2 diabetes management, and these are listed below. That is not to say LCDs are the only ways to achieve these things, but they are all reasons a LCD might be the right option for some people. These possible benefits include:
Improved blood glucose control – Most people with Type 2 diabetes:
1. have a reduced ability to remove carbs from their blood effectively, because of insulin resistance, This is when insulin, which acts like a key to open up your body cells to let glucose in, doesn’t work as well as it should
2. aren’t able to properly control the amount of glucose the body creates itself, mostly within the liver. This glucose is then pushed out into the blood
3. don’t have a normal response in the body when carbs are eaten because the pancreas, the organ which produces and releases insulin, doesn’t function as effectively. This is related to issue number 2, as the first thing insulin released from the pancreas does when you eat carbs is to stop the liver producing and releasing more glucose. That way you only have one source of glucose to deal with (what you’ve eaten) instead of two (what you’ve eaten + what your body is making)
The result of these factors is that there is too much glucose entering the blood, and not enough leaving it. Reducing the amount of carbs you eat (which break down into glucose) can help to make it easier for your body to manage this. By doing this, Low carb diets can improve blood glucose levels rapidly – even before any weight is lost.
Improved weight management and reduced hunger
There are a number of ways LCDs can improve weight management, the most important perhaps being that people following LCDs often reduce the amount of food they eat naturally – simply because they feel less hungry. There are lots of reasons this might happen, including possible effects on how easily the body can access energy between meals and on the hormones that control hunger.
LCDs also naturally result in a reduced intake of ultra-processed foods, especially things like cakes and crisps. This is important, as ultra-processed foods are usually energy-dense and nutrient-poor. They also tend to be “hyper palatable”, meaning that we want to eat more and more of them once we start. The overall effect is that we tend to overeat these products, leading to weight gain. People follow a LCD also tend to eat more protein, which is good at helping us feel fuller for longer.
LCDs are effective for reducing insulin levels too. As well as helping glucose into the cells, insulin makes us store more fat. It also affects other things that influence weight management, including other hormones, how some of our nerves work, and our gut function. So there are multiple ways that reducing insulin, which is usually high in people with Type 2 diabetes, can help us lose weight.
In those following a very low carb diet, hunger may be further reduced due to raised ketone levels (when this is maintained it’s called nutritional ketosis). For more on ketones, and why they aren’t as bad as people think, see our previous blog on the subject
Reduced insulin resistance
Insulin resistance is the main underlying issue in most people with Type 2 diabetes. The main way to reduce insulin resistance appears to be through fat loss, particularly from the central organs. LCDs can be effective for achieving this. A second way is to reduce the body’s exposure to insulin – i.e. lowering insulin levels – which LCDs are very good at too.
Reduced liver fat
Having too much fat stored in the liver is a key cause of Type 2 diabetes. Having high insulin levels and consuming too much energy (particularly from refined or sugary carbs) are major causes of liver fat accumulation. LCDs are good ways to address both of these things.
Reduced pancreas fat
When the liver is too fatty it pushes some of this fat out into the blood, and a lot of this can end up in the pancreas. So, if you reduce liver fat (as discussed above) you can also reduce pancreas fat! Reducing pancreatic fat is key, as it helps the specialist cells in the pancreas to work better
Allow the pancreas to rest
Consuming fewer carbs reduces the need for the body to move glucose into the cells, so there is a decreased requirement for insulin. As a result, the workload of the pancreas is not as high when an individual adopts a LCD. This increased rest can help the specialist cells in the pancreas recover, which improves blood glucose control.
In excessive amounts glucose, like many things, can cause damage to the body. This toxic effect, “glucotoxicity”, can have a major impact on the pancreas – damaging the specialist cells and negatively affecting the production and release of insulin. LCDs can help reduce this, by reducing the amount of glucose the cells are exposed to.
Improved blood pressure
Weight loss is one way a LCD may help to reduce blood pressure, though, again, it seems LCDs can improve blood pressure in other ways too. For example, reduced insulin levels may play a role. This is because, as well as its impact on glucose and fat usage and storage, insulin causes sodium (which is found in table salt) to be retained in the body. This can lead to an increase in blood pressure. A LCD also typically results in a reduced intake of highly processed foods, which tend to have a high salt content. As a result, LCDs often lead to both a reduced intake and a reduced retention of sodium; and it can in fact be necessary for individuals following a LCD to add salt to their food to prevent sodium levels, and blood pressure, dropping too low!
Reduced blood fat (triglyceride) levels
LCDs consistently lead to a reduction in triglyceride levels, an effect that is likely linked to their ability to reduce liver fat (see above). This is because when liver fat is too high, excess fat is pushed back out into the blood. Reducing blood triglyceride levels can also have a positive effect on the size, structure and number of circulating lipoproteins (e.g. high-density lipoprotein, HDL, and low-density lipoprotein, LDL).
Available evidence: systematic reviews and meta-analyses
Meta-analyses, a way of statistically pooling results from multiple studies, of randomised controlled trials are considered to be the best type of evidence available, and 11 of them were identified that were relevant (see Appendix 1 in the full position statement for more on these). The general conclusion of many of these is that LCDs perform better for weight loss and improving diabetes control in the short-term, but over the longer-term (more than six months) there is often little difference between LCDs and the diet they are being compared to (usually low fat diets). The reasons for this reduced difference over time may be that people in the studies stop following the LCDs, that any superiority of LCDs is truly only short-term, or it may be influenced by limitations with these reviews or the studies included within them. Regardless of the reasons, these findings provide clear and consistent evidence that LCDs can be at least as effective as other dietary approaches. They therefore support the use of LCDs as a suitable option for people with Type 2 diabetes.
It is worth nothing though, that where there are differences between groups they almost always favour LCDs. This is particularly true in relation to body weight, blood glucose control, blood pressure, triglycerides, and HDL.
As mentioned before, there are lots of limitations with many reviews and studies in nutrition. One that is important here is that changes in medication use is often not considered. The reason this is important is that LCDs are consistently better at helping people to reduce their need for diabetes meds – something I covered in a previous blog. To demonstrate this, here’s a scenario:
Bill and Ben both have Type 2 diabetes. They both have a HbA1c (a measure of average blood glucose control over 2-3 months) of 60 mmol/mol, and they both take insulin. After one year, both Bill and Ben have reduced their HbA1c to 50 mmol/mol. Bill (who followed a low carb diet) is no longer taking any insulin, whilst Ben (who followed a different diet) still takes the same amount of insulin as he did at the start.
So, in this scenario, if we only consider the change in HbA1c it looks like Bill and Ben had equally effective diets. This is basically how most studies and reviews look at it. In reality though, Bill is achieving the same health results but without needing to take any medication anymore. This is, I’m sure almost everyone would agree, a better outcome! So, as most studies and reviews don’t properly consider medication changes, the benefits of LCDs are often underestimated.
Available evidence: randomised controlled trials
As well as considering meta-analyses, it can be helpful to look at individual studies too. This allows us to consider how any issues with the studies or reviews might have affected the outcomes. One such issue is that in lots of studies, the “low carb” groups often consume a lot more carbs than we might consider to be truly “low”. These aren’t helpful if we really want to know if a LCD actually works!
So what we did, was narrow down the studies by getting rid of any that didn’t meet the definitions we’d set (less than 130g carbs, or less than 26% total energy from carbs, per day; these are now widely used, so it seems like a fair place to set the bar). We also added limits in line with those previously used by the National Institute of Health and Care Excellence (NICE), who set healthcare guidelines in the UK. These additional criteria were simply that there had to be at least 50 participants (studies that are too small often aren’t as reliable), and the studies had to be at least 3 months long (studies that are too short often don’t leave enough time to see any meaningful differences or changes).
In the 11 meta-analyses we used in the previous section, there were 61 “low carb” studies included. When we narrowed these down to only those that met the definitions of a LCD, there were only 21 left. Of these:
* eight had less than 50 participants (leaving 13 studies)
* one study wasn’t really a “proper” low carb study, because it was based on protein shakes (leaving 12)
* in one the reported carb intake was higher in the low carb group than the high carb one! (leaving 11)
* in two the average carb intake was too high, even though the amount of carbs they were supposed to have was low enough to count as a LCD (leaving 9)
We also found one more qualifying article (a follow up to one of the nine we had been left with), taking us to ten overall. Some of these were reporting results from the same trial though. To avoid considering the same study more than once we only included the results at the latest time point in each case, leaving us six studies for analysis (see Appendix 2 in the full position statement for additional details on these).Although there are more complex ways of outlining the findings of these studies, the headlines were:
* the HbA1c reduction was greater in the low carb group of all six of these trials; though the difference between groups was only statistically significant in two
* for other health markers, such as body weight or markers of cardiovascular disease risk, most studies found comparable improvements for LCD and the comparison diets. But where there were statistically significant improvements, they were consistently in favour of the LCD groups
* all five studies that reported on medication changes showed a greater reduction in diabetes medication requirements in those following LCDs. As highlighted before, this results in an underestimation of the benefits of LCDs
These findings, based only on studies where reported carb intake was actually low enough to be classed as “low” carb, clearly show that LCDs are at least as effective as low fat diets.
Available evidence: other sources
Research trials and systematic reviews/meta-analyses are considered to be the best type of evidence, but important information can also be found from alternative sources. Although they may not be as good in some ways, other types of evidence can also have their own strengths. One major one is that they often reflect a real world setting better than research trials do. They can therefore help to bridge the gap between research and practice. Examples include:
* Virta Health have demonstrated excellent outcomes that show LCDs are safe and effective Virta Health have demonstrated excellent outcomes that show LCDs are safe and effective, and that they can possibly lead to the remission of Type 2 diabetes too! Most of their participants were consuming less than 30g carbs per day, which is classed as a very low carb diet. After two years, over half had an HbA1c below the cut-point used to define diabetes, two-thirds of all diabetes medications were no longer required, average insulin dose was reduced by 81%, and more than six in every 10 of those using insulin at the start were able to omit it altogether. They also achieved meaningful reductions in cardiovascular disease risk, with a mean reduction in 10-year risk score of 12%.
* The Diabetes.co.uk Low Carb Programme The Diabetes.co.uk Low Carb Programme has had over 400,000 users, demonstrating the popularity of LCDs. Outcomes from a sample of 1,000 participants of the programme have been published in a peer reviewed journal, with the results showing it is effective. Of the 743 participants whose HbA1c was above the threshold for diagnosing Type 2 diabetes, 195 (26%) saw a reduction that took them below this level. Of the 714 who were taking at least one medication to manage their diabetes, 289 (40%) reduced one or more of these medications; and nearly half of participants lost at least 5% of their initial body weight.This programme is also included in the NHS App Library and is part of an NHS innovation accelerator, a programme designed to speed up the uptake of high influence interventions. This shows that it, and LCDs, are deemed acceptable by the NHS. The programme has also received approval from the British Dietetic Association (BDA).
* Evidence of the safety and effectiveness of LCDs for the management of Type 2 diabetes has been shown within primary care in the UK, for example in Dr David Unwin’s GP practice in Southport. Complete remission of Type 2 diabetes has now been recorded in approximately half of the patients who have adopted a LCD within this practice. Dr Unwin’s approach has also resulted in considerable financial benefits, with the overall diabetes drug spend approximately £45,000 less per year than the regional average.
* We (X-PERT Health) ran a pilot project in partnership with Modality GP partnerships, supporting patients in reducing their carbohydrate intake to 20g per day using structured education. Of the 35 participants who began the programme, 27 (77%) completed it. Clinically meaningful improvements were seen at three months for body mass (mean change = -7kg), HbA1c (-15.6mmol/mol), systolic blood pressure (-7mmHg), diastolic blood pressure (-5mmHg) and triglycerides (-0.4mmol/l). 85% of participants who were taking medication at the onset of the pilot reduced their requirement, with 25% of them omitting their medication entirely. Half (3/6) of insulin users were able to omit it.
Position of other organisations
Perhaps even more so than what the evidence says, the position of bodies who produce relevant policy and guidelines is highly significant. This is because many people (including healthcare professionals) who are not specialists within a certain area will have little choice but to follow these recommendations; as they do not have the time to look into any emerging research, and often won’t have the skills to appraise it even if they do. Importantly, there are a number of influential organisations that now support the use of LCDs for the management of Type 2 diabetes:
* Diabetes UK (DUK) guidance says that there is no diet that is superior to the others, so people should be supported in adopting an approach that works for them. LCDs are included amongst the possible options
* The BDA released a position statement in 2018 supporting carb restriction as a suitable option
* The Scottish Intercollegiate Guidelines Network (SIGN) national clinical guidelines recommend that people with Type 2 diabetes be given dietary choices for achieving weight loss that may also improve blood glucose control. The listed options for achieving this include restricting the total amount of carbohydrate
* A 2018 joint position statement from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) reached conclusions similar to DUK (see above), promoting individualised approaches, with LCDs being included as a suitable option
* A 2019 report from the Legislative Assembly of Western Australia’s Education and Health Standing Committee reached conclusions supportive of LCDs for the management of Type 2 diabetes
* A 2019 consensus report from the ADA concluded that “a variety of eating patterns are acceptable for the management of diabetes” supporting the need to individualise approaches. In relation to carbohydrate restriction specifically, the report says:
“Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycaemia and may be applied in a variety of eating patterns that meet individual needs and preferences”
“For select adults with type 2 diabetes not meeting glycaemic targets or where anti-glycemic medications is a priority, reducing overall carbohydrate intake with low- or very low-carbohydrate eating plans is a viable approach”
“…from the current evidence, this eating pattern does not appear to increase overall cardiovascular risk…”, with the authors noting that this was the case even though most of the included trials did not restrict saturated fat
This position was also included in the 2020 update to the ADA Standards of Medical Care in Diabetes, which represent the ADA’s current official recommendations.
Although the current guidance provided by NICE is not fully consistent with these other organisations, elements of it are. For example, it includes recommendations to favour lower glycaemic index carbohydrates (carbs that don’t affect blood glucose levels as quickly) and to individualise carbohydrate intake. NICE have also stated (in this document) that the guideline “…already advises individualising recommendations for carbohydrate intake, and meal patterns, which could include low carbohydrate and low calorie diets.” It was however disappointing that NICE decided not to update their guidelines to be more specific around which approaches can work (in line with the position of most other relevant bodies), a decision they made despite multiple stakeholders (including DUK, the BDA and X-PERT Health) challenging their position.
Long-term effects of LCDs
Although the positions outlined in the previous section acknowledge the potential use of LCDs for people with Type 2 diabetes, the position of X-PERT Health is that there are still unnecessary caveats regarding the longer-term effects in some of them. The two main reasons we believe this are that:
1. there isn’t high quality, long-term evidence for ANY dietary approach – so it isn’t fair to hold LCDs to a standard that other ways of eating can’t meet either. This is largely due to the fact it is difficult, and expensive, to carry out good long-term studies. Even a low fat diet does not have high quality long-term evidence showing it works well and reduces risk compared to other ways of eating, and this is widely promoted without any suggestion people should be cautious about the long-term influence
2. the evidence we do have doesn’t suggest there needs to be any special concern with LCDs, with safety (including a reduced risk of cardiovascular disease) demonstrated in a number of studies than are longer than 12 months. This belief is supported by the ADA, who concluded in their 2019 consensus statement that “…from the current evidence, this eating pattern does not appear to increase overall cardiovascular risk…”
Another criticism of LCDs is that people can’t stick to them. However, the available evidence does not support the suggestion that LCDs are more difficult to follow than other approaches. In the Virta trial mentioned before, for example, adherence was 83% at one year and 75% at two years. These values were for a very low carb diet too (most individuals were required to consume less than 30g carbohydrate per day), which may be more difficult for many people to stick to than a more moderate LCD.
In the RCTs mentioned before, the completion rates (in the studies which reported them) were almost identical in the low carb (73% completion) and control (72%) groups of the studies. These aren’t perfect markers of adherence (completing the study doesn’t always mean people stuck to the diet, and sticking to a diet in a study doesn’t mean you would in the “real world”), but it outlines that the evidence we do have available doesn’t back up the idea that people can’t stick to a LCD.
In the “real world” there are still practical barriers to adopting LCDs; including, in the UK, that:
* the reference intakes and traffic light colour coding on food labels are designed to support a low fat diet
* many people are not supportive of their friends/family if they try to follow a LCD, in part because a general “fat-phobia” still exists through much of society
* most readily available food is geared towards a low fat way of eating; for example, sandwiches are still the most common lunch option in most places
These factors may make it more difficult for someone to adopt a LCD, but that does not mean that it is not possible. Indeed, anecdotal evidence supports that many people are able to sustain a LCD long-term; and in a survey of dietitians in the UK the majority responded that they felt a LCD was achievable for the “right individuals” as long as they received appropriate support. Ensuring individuals are well informed regarding what barriers they may face and what their options include, and are provided with appropriate support where possible, is important. Practical advice is available through a number of channels, including:
* structured education programmes – such as the X-PERT Diabetes and X-PERT Insulin Programmes
* mobile Apps – such as the diabetes.co.uk Low Carb Programme and X-PERT Diabetes Digital
* websites – such as Diet Doctor
* books – such as the X-PERT Eat Fat Handbook
Support for healthcare professionals, to help them learn about LCDs and how they can support their patients in adopting them, is also available; more information in relation to this can be found in the full position statement.
Beyond those discussed above, other concerns sometimes raised include:
* LCDs cause low blood glucose levels (hypoglycaemia, or “hypos”): although minor hypos can be experienced by anyone, severe hypos are only a danger for individuals taking certain medications (particularly insulin or sulphonylureas). This is because these medications continue to remove glucose from the blood even if blood glucose levels are already low. When someone starts following a LCD though these medications are reduced or omitted, meaning there is actually a reduced risk of hypoglycaemia – as long as they have a medication review before they begin.
* LCDs are nutrient deficient: any way of eating can result in people not getting everything their body needs, particularly if it is not well planned or if it is based on highly processed foods. In relation to LCDs, concerns are often raised in relation to fibre in particular. However, there are a wide variety of foods that can provide fibre without contributing large quantities of carbohydrate to the diet, e.g. nuts, seeds and dark chocolate; whilst the staple foods often recommended when individuals adopt LCDs are usually nutrient ones, including non-starchy vegetables, eggs, cheese and oily fish.
* LCDs are more expensive: it has been suggested that LCDs are not suitable for lower income households, but that is based on false assumptions about the types of food an individual might regularly eat. As with any way of eating there are more expensive options which may not be suitable for everyone, but there are also multiple ways an LCD can be adapted to be more cost-effective. For example, staple ingredients such as eggs or tinned oily fish need not be expensive; whilst purchasing frozen vegetables, for example, can reduce waste and help save money.
It should also be considered, as discussed previously, that LCDs have been demonstrated to reduce hunger for many people. This naturally reduces food intake, so less money spent on food!
It is important that financial factors are not ignored though, and people should be supported to adopt the best quality diet that they can afford, regardless of which dietary approach they wish to follow
Should all people with Type 2 diabetes follow LCDs?
The overall ethos of X-PERT Health is that “one size doesn’t fit all”, as there is evidence that a number of different dietary approaches can be effective. There is no value in a person trying to adopt a dietary approach that they cannot sustain, and/or in trying to change their way of eating if what they’re currently doing is allowing them to meet their health goals.
However, there may be an upper limit of carbohydrate intake that many people with Type 2 diabetes can tolerate before they have difficulties managing their blood glucose levels and other markers of health. An element of carbohydrate restriction may therefore be necessary, though that does not necessarily mean individuals will be required to follow a true “low carb” diet to meet their goals. This suggestion is supported by a recent survey of dietitians, with the majority of respondents believing that the Public Health England guidance of a 50% energy intake from carbohydrates was inappropriate for people with Type 2 diabetes.
Current evidence also suggests that a LCD may be better than other dietary approaches for helping people achieve remission of Type 2 diabetes. Until recently it was not known or accepted that Type 2 diabetes remission was possible at all, suggesting that standard dietary management approaches are not effective for achieving this. Although there is now evidence that Type 2 diabetes remission is possible with a number of approaches (including Mediterranean and low fat diets), the evidence is strongest for very low energy diets and very low carb diets. Very low energy diets are only a short-term option though, meaning that a long-term, sustainable dietary approach still needs to be adopted after the weight loss phase. This doesn’t mean they’re not a suitable option for some people, but when we talk about “dietary approaches” we mean a way of eating that someone can keep following – hopefully for the rest of their life.
Are LCDs suitable for people who do not have diagnosed Type 2 diabetes?
As the focus is on Type 2 diabetes here I won’t go into detail, but briefly:
* For people with prediabetes it could be argued that much of the evidence discussed so far is still relevant, as prediabetes and Type 2 diabetes are typically as a result of the same underlying mechanisms (insulin resistance in particular). There are clear pathways as to how a LCD may help to prevent Type 2 diabetes, and it is logical that any approach that can be suitable for the management of Type 2 diabetes is suitable for those with prediabetes too. Beyond this, most attempts to prevent prediabetes developing into Type 2 diabetes are based on weight loss, so as LCDs can be effective for achieving this they should be considered a suitable option.
* In the general population, a high proportion of people who are overweight or obese have some element of insulin resistance – and changes in how their body produces and releases insulin that are not dissimilar to those seen in Type 2 diabetes. It is therefore possible that many people who are overweight may benefit from a LCD, for the same reasons this approach can be effective for those with Type 2 diabetes. Furthermore, and as with the management of Type 2 diabetes, weight maintenance (or the maintenance of weight loss) is heavily influenced by how well an individual can adhere to a particular diet. Therefore, the “one size doesn’t fit all message” applies here too. Evidence shows that a LCD can be safe and effective for individuals without diagnosed health conditions, with LCDs resulting in similar, or potentially superior, weight loss compared to control diets. Based on this, there appears to be no reason that individuals should not be supported in adopting a LCD if it is the approach that they think is best for them.
* There is evidence that a LCD is safe and can be effective for individuals with Type 1 diabetes. This is logical, as people with Type 1 diabetes have an inability to metabolise carbs (because the specialist cells in the pancreas don’t work properly). So, reducing the amount of carbs that the body needs to deal with reduces the impact of the underlying cause. Reducing carb intake reduces the requirement for insulin to be taken too, which, as long as adjustments are made appropriately, reduces the risk of hypos, can improve weight management, and can have a positive effect on quality of life.
Available evidence shows that LCDS are safe and effective for the management of Type 2 diabetes. In particular, they appear to be better than other dietary approaches for reducing the requirement for diabetic medications and for placing Type 2 diabetes into remission. LCDs should therefore be promoted as a possible option, and patients should be supported in following one if they choose to do so.
Despite claims to the contrary, adherence to LCDs is possible if an individual adopts, and adapts, it in a way that suits their preferences and lifestyle. Education and support may be necessary to facilitate this.
There are also other dietary and lifestyle approaches that can be safe and effective, so individuals should be supported to identify the approach that is right for them. However, as Type 2 diabetes is a condition of carbohydrate intolerance, some level of carbohydrate restriction (whether this is a “low carb” diet or not) may be the most effective method for achieving significant health improvements for many people in this population.
As with all our blogs and other work we’d love to hear your thoughts and feedback, so feel free to leave a comment on one of our social media accounts, drop me an e-mail at email@example.com, or tweet us/me at @XPERTHealth or @SWheatley88. If you have attended an X-PERT Programme or are an X-PERT Educator you can also register for our online forum.