A STRICTLY BIOMEDICAL BLOG... WITH NO ANTHROPOLOGICAL COMMENTS...

Are All Type 2 Diabetes Medications Created Equal?

Daniel D. Dressler, MD, MSc, MHM, FACP reviewing Tsapas A et al. Ann Intern Med 2020 Jun 30

For high-risk patients, some drug classes should be considered preferentially to lower risk for mortality and other adverse outcomes.

Many therapeutic options exist for patients with type 2 diabetes, but we have few head-to-head trials in which newer glucose-lowering medications have been compared with each other and with older agents to guide clinical decision making. Now, researchers have compared the efficacy and safety of 21 antidiabetic agents (in 9 drug classes) with one another (and with placebos) in a meta-analysis that included 450 randomized trials and more than 320,000 patients.

Results were as follows:

• Among treatment-naive patients with low cardiovascular (CV) risk, all drugs and drug classes had similar efficacy in lowering glycosylated hemoglobin (HbA_1c) except for dipeptidyl peptidase-4 (DPP-4) inhibitors, which were less effective in glucose-lowering.
• Among all patients with low CV risk, no regimen differed from placebo in vascular or mortality outcomes.
• Among patients with high CV risk who received metformin therapy, all-cause mortality was significantly lowered by adding specific glucagon-like peptide-1 (GLP-1) agonists (i.e., exenatide, liraglutide, or semaglutide) or specific sodium-glucose cotransporter-2 (SGLT-2) inhibitors (i.e., dapagliflozin or empagliflozin). Risk for stroke was significantly lowered by adding specific GLP-1 agonists (i.e., dulaglutide or semaglutide); heart failure hospitalizations and end-stage renal disease were significantly lowered by adding SGLT-2 inhibitors.

COMMENT

Consistent with results of prior analyses, patients with low CV risk gain HbA_1c-lowering benefit from most glucose-lowering agents, and metformin should remain the first-line option due to its low cost and low side-effect profile. For patients with high CV risk who receive metformin-based therapy, some SGLT-2 inhibitors and GLP-1 agonists offer significant improvement in mortality and other outcomes and should be considered preferentially as add-on therapy. However, these new drugs are extremely expensive, and numbers needed to treat to prevent one adverse event are high.

Metformin. Glargine. Exenatide. Flozin.  But I wonder whether there would be CV and Renal protection if the Lifestyle does not bring the Blood Sugar down?

For developing world: Metformin. Insulin. Lifestyle. All other medications are beyond the purchasing power of most patients. We have to train Lifestyle coaches and Nutritionists and patient advocates. Medications account for 25% of the control of Type 2 Diabetes. 1/3 of the patients regardless of where they live: Beirut, Kabul or Cambodia will have A1c of 7.0.

TO PROBIOTICS OR NOT

july 7, 2020

Probiotics to Reduce Antibiotic Use in Nursing Home Patients?

Thomas L. Schwenk, MD reviewing Butler CC et al. JAMA 2020 Jul 7

In a randomized trial, probiotics conferred no benefits.

Probiotics are used widely for a range of purported benefits, including reduction of antibiotic use through various proposed mechanisms. In this randomized trial, researchers examined whether probiotics reduced antibiotic administration in 310 nursing home patients (mean age, 85) in the U.K. Each patient received a daily probiotic capsule containing Lactobacillus rhamnosus GG and Bifidobacterium animalis lactis BB-12 (≈10 billion cells in each capsule) or a matching placebo capsule. Patients who already were taking probiotics, or who were immunocompromised, were excluded.

During mean follow-up of ≈8 months, during which roughly one fifth of patients died, researchers found no significant difference between the two groups in the number of days of receiving antibiotics for all causes (mean, 12.9 days for intervention patients vs. 12.0 days for control patients). Antibiotic use for lower respiratory infections was significantly shorter in control patients than in intervention patients (4.0 vs. 6.2 days), but no difference was found for several other clinical conditions. Adverse events, hospitalizations, quality of life, antibiotic-associated diarrhea, and other secondary measures were not significantly different between groups.

COMMENT

These results, showing no reduction in antibiotic use and no benefit for other measures, do not support the practice of probiotic use in nursing home patients.

Israel leads the world in Microbiome and Pro/Pre Biotic research. They have repeatedly shown that uncontrolled use of ProBiotics actually do harm. Await more work on this field. That has not stopped Americans and Westerners and some Asians spending money on Probiotics. There is an effect called Placebo Effect, so good luck to them.

STATIN STATIN STATIN what a great Sin not to put them on ?

uly 7, 2020

Statins for Primary CV Prevention in Older Adults

Thomas L. Schwenk, MD reviewing Orkaby AR et al. JAMA 2020 Jul 7

In a retrospective study, initiating statins in older patients was associated with lower mortality during 7 years of follow-up.

The relatively small number of older adults who have been enrolled in prior randomized, controlled trials (RCTs) of statins has led to uncertainty regarding their value in primary prevention of atherosclerotic cardiovascular disease. Investigators used the Veterans Health Affairs database to perform a retrospective cohort study of about 327,000 patients (age, ≥75; mean age, 81; mostly white men) without prior statin use; about 57,000 received new statin prescriptions during mean follow-up of 7 years. Patients with any form of cardiovascular disease at baseline and those who died within 150 days of enrollment were excluded. Patients with cancer, dementia, or paralysis were not excluded.

Crude cardiovascular-related mortality for statin users and nonusers was 22.6 and 25.7 per 1000 person-years, respectively. Corresponding all-cause mortality was 78.7 and 98.2 per 1000 person-years. In analyses adjusted for a wide range of clinical and demographic variables, statin initiation was associated with significantly lower cardiovascular-related and all-cause mortality (hazard ratios, 0.80 and 0.75, respectively).

COMMENT

Despite its retrospective nature, this study benefited from a large national database, robust adjustment, and inclusion of patients with underlying severe noncardiovascular conditions. Based on these results, some clinicians might decide to initiate statins for primary prevention in patients older than 75. However, at least some residual confounding is likely in this retrospective study, and other clinicians might prefer to wait until ongoing RCTs of statins for primary prevention in older patients are completed.

I personally think STATINs are great medications but I firmly believe that they do what they are supposed to do Lower Cholesterol. In fact, in our patients I check, on those on Statin, their TC and LDL cholesterol, if they are down, you know that they are taking Statins and as a logical extension, the other medications in their med-boxes.

In 2005, I was thinking why there had been an explosion of Hypercholesterolemia in the USA and in the western world to a lesser degree. The higher degrees of Cholesterol, could they indicate an INFLAMMATORY state of the body ? and that Statins are a wonderful anti-metbolic inflammatory preparation ?

Here is a review published in 2017

Curr Cardiol Rev. 2017 Aug; 13(3): 209–216.

Published online 2017 Aug. doi: 10.2174/1573403X13666170426104611

The Anti-Inflammatory Effects of Statins on Coronary Artery Disease: An Updated Review of the Literature

Evangelos Diamantis,^* George Kyriakos, Lourdes Victoria Quiles-Sanchez, Paraskevi Farmaki, and Theodoros Troupis

Background:

Statins have long been used for the protection against coronary artery disease (CAD). Their beneficial effect apart from cholesterol reduction lies in their pleiotropic properties. Emerging evidence from laboratory studies and clinical trials as well have pointed out the pivotal role of inflammation on the initiation and exacerbation of atherosclerosis; a major cause of CAD. Inflam-mation markers such as high sensitivity C-reactive protein and adhesion molecules are shown to in-crease in CAD patients and are used as prognostic tools. It is well known that statins can actually re-duce the circulating levels of these agents slowing therefore the inflammatory process; interestingly not all types have the same outcome.

Conclusion:The anti-inflammatory effect of statins on the formation of atherosclerotic plaque and the function of endothelial cells is thus of particular importance as these agents can actually ameliorate CAD prognosis

We use ACE Inhibitors in our patients with Diabetes even when they do not have Hypertension so that we can protect their kidneys. So we can use STATIN medications when there is a strong presence of Inflammation in the body.

Always remember NUTRITION can be used as an anti-inflammatory method as well.

THE MORNING HAS RISEN IN MIAMI.... IT IS NICE TO WAKE UP THE SUN ...

The last scene in a movie that I remember as an adolescent, Orfeo Negro, one boy persuading another to play the guitar so that the Sun will rise over the favelas of Rio de Janeiro. 
This morning before the sun came up, i was walking around a lake nearby and it was nice to see the sun coming up..

as I arrived, the full moon plus one day was fading into its daily oblivion.

The new lifestyle has tremendous drawbacks.. psychologial and also physical. 
Social isolation and the fear of the Other and lack of initiative in making new friends (reciprocal)..
Israelis had calculated the rule of 15 rule..
On the average, a person under this lockdown would gain 15 lbs.
the divorce rate would go up by 15%
15 % more babies born!

In Miami, even people who normally do not have a weight problem, like myself, are begining to notice certain bulges. It is the lack of physical activity and sedentariness in front of the computer for hours on end.

Felt good to walk around the lake, in the silence of the morning.

Fortunately, I am conscious of nutrition and not attracted to everyday food in America (considered by many as the least nutritious in the Western world!)

Green leaves, Genetic food (eastern meditarranean), protein was Chana Masala from Trader Joe's and of course a sauvignon Blanc from New Zealand (Aotearoa)..

KNOW YOUR GENES, KNOW YOUR CULTURE AND THAT IS YOUR NUTRITION .. NO ONE SINGLE NUTRITIONAL ADVICE FITS EVERY ONE

When I finished my training as an Endocrinologist, my knowledge about Nutrition was biblically minute, it could have been written down on a grain of rice! Very little training about nutrition, all through the years of medical training, I do not remember receiving detailed education about nutrition apart from some very quantitative information from Dieticians who were much more interested in hospital kitchens. Also at that time, “peripheral practitioners” were looked down upon in academic circles, such as Podiatrists or Nutritionists.

I am happy to say that the environment has changed and because of my association with some excellent Dieticians and Medical Nutritionists, and independent readings in Microbiome and Nutrigenomics, I no longer feel ignorant. It is not education that opened my mind but association with excellent nutritionists. Becoming an anthropologist helped immensely as it placed FOOD in the context of our societies rather than micro molecules and ingredients and calorie centrism.

Published: May 3, 2018

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How much does your doctor actually know about nutrition?

By American Heart Association News

Eat more fresh fruits and vegetables. Cut down on sweets and processed foods. Increase consumption of fish, nuts and legumes.

This rudimentary advice has been dished out to the public for decades, yet soaring rates of diabetes, obesity, high blood pressure and other chronic illnesses linked to poor diet – and which increase risks for stroke and heart disease – fail to reverse.

Part of the problem stems from the fact that doctors don’t know how to provide information beyond the basics.

(below roadside eating in Phnom Penh Cambodia)

(KFC in Phnom Penh, opened in 2008 by 2010 they had 10 outlets)

The cultural aspects of nutrition was brought to my attention in Cambodia which has its share of Type 2 DM, defying all the western notions of aetiology. Cambodians were thin, they ate rice and fish and steamed vegetables. At that time, it was known that Indians from India had a high rate of Diabetes, so the western reductionists pointed a racial connection to India. Khmer people are not racially related to people from South India, even though Hinduism was the state religion when the construction of Angkor Wat began 1100 years ago.

Kentucky Fried Chicken had recently arrived in Phnom Penh and of course, the local people were educated on the “benefits” of KFC and paid peons from Australia educating the doctors about avoiding RICE..

Recently I asked a Jamaican friend of mine, what if your doctor said, do not use Coconut Oil, what would you say. My friend replied, he would inform the doctor gently that he does not know much about Jamaican cooking and that he rather change the doctor than the Oil ..

A good Lesson in Culture and Nutrition.

I am a Physician-Anthropologist who travels (will resume my trips when I can be vaccinated for Covid-19). I have been in remote islands, Tokelau in the Pacific,  where people had lived on fish, coconut and root vegetables and they were quite healthy until New Zealanders arrived with their tinned spam and highly processed food and visitors visas to Wellington. Now one in three living in Tokelau Islands have Type 2 Diabetes, Fakafetai Aotearoa (Merci, Nouvelle Zelande).

{Fish and shellfish are an important part of the Tokelauan diet. Chicken and pork are also eaten. Breadfruit, sweet potatoes and taro are traditional foods. Coconuts, bananas, 

pandanus fruit and papayas are grown.

A traditional garden in Nukanonou Atoll, Tokelau Islands)

(Ultraprocessed food being loaded in Apia, Samoa and offloaded in Nukanonou Atoll)

.So, please don’t come to Cambodia and tell them they have Diabetes because they are related to Hindus a millennium ago; please do not tell Polynesian people that Coconut Oil is not good for them…

My ancestry is strictly east of Jerusalem (No Arab, African or Chinese blood so please do not ask me not to eat RICE, give Coconut Oil a miss..

Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations: JACC State-of -the-Art

Review

ArneAstrupMD, DMSc^aFaidonMagkosPhD^aDennis M.BierMD^bJ. ThomasBrennaPhD^cMarcia C.de Oliveira OttoPhD^dJames O.HillPhD^eJanet C.KingPhD^fAndrewMentePhD^gJose M.OrdovasPhD^hJeff S.VolekPhD, RDⁱSalimYusufDPhil^gRonald M.KraussMD^j

Show more

Abstract:

The recommendation to limit dietary saturated fatty acid (SFA) intake has persisted despite mounting evidence to the contrary. Most recent meta-analyses of randomized trials and observational studies found no beneficial effects of reducing SFA intake on cardiovascular disease (CVD) and total mortality, and instead found protective effects against stroke. Although SFAs increase low-density lipoprotein (LDL)-cholesterol, in most individuals, this is not due to increasing levels of small, dense LDL particles, but rather larger LDL which are much less strongly related to CVD risk. It is also apparent that the health effects of foods cannot be predicted by their content in any nutrient group, without considering the overall macronutrient distribution. Whole-fat dairy, unprocessed meat, eggs and dark chocolate are SFA-rich foods with a complex matrix that are not associated with increased risk of CVD. The totality of available evidence does not support further limiting the intake of such foods.

I was anxious to return to Melbourne to do my Housemanship when I qualified in Medicine in London. I mentally calculated, it would take me three years of being a Junior doctor and there are 250 vineyards in my state (province). I have to get to know as many as possible.

I a proud to say I did.

Such delicious Australian wines..

(Seppelt wines, Victoria, Australia)

RESVERATROL. Is the active ingredient in the skin of red grapes that protects your heart.

Another important nutritional lesson.. No amount of Resveratrol in a pill is going to help you .. If you want the body to benefit from an ingredient please take it in the natural form. If the body is lacking in Selenium or Magnesium for various medical reasons, you may need to supplement it with pills but otherwise eat nuts and get your selenium (one brazil nut a day would give you all the selenium you need!).  No Probiotics from your favourite (not so favourite) Vitamin Store, toda rabah, Eran Elianav and Eran Segal from Weizmann!

Eat Food Please .. A colleague of mine takes ProBiotic tablets specially “formulated” for women and she claims her bowel actions have become regular, and looking at the ingredients I see there are at least three digestive enzymes included in the pill!

June 29, 2020

Association of Low to Moderate Alcohol Drinking With Cognitive Functions From Middle to Older Age Among US Adults

Ruiyuan Zhang, MD, MS¹; Luqi Shen, MS¹; Toni Miles, MD, PhD¹; et alYe Shen, PhD¹; Jose Cordero, MD, MPH¹; Yanling Qi, PhD²; Lirong Liang, PhD³; Changwei Li, MD, PhD, MPH¹

JAMA Netw Open. 2020;3(6):e207922.

Key Points

Question  Does an association exist between current low to moderate alcohol drinking and cognitive function trajectories or rates of cognitive decline from middle to older age among US adults?

Findings  In this cohort study of 19 887 participants from the Health and Retirement Study, with a mean follow-up of 9.1 years, when compared with never drinking, low to moderate drinking was associated with significantly better trajectories of higher cognition scores for mental status, word recall, and vocabulary and with lower rates of decline in each of these cognition domains.

Meaning  Current low to moderate alcohol consumption among middle-aged or older adults may be associated with better total cognitive function.

Please bring me a glass of Luigi Bosca Malbec from Argentina or a Sauvignon Blanc from Marlborough valley!

If you do not know who Michael Pollen is, you need to know him..

Here is a comment on his three pronged dictum:

Michael Pollan doesn’t expect you to be perfect, and he’s not judging you. He can't even see you. I promise. Just try to eat as much real food as you can, and try not to eat too much of it, and try to eat mostly plants. It’s easier than you think and the more you do it, the easier it gets.

FULL MOON OVER MIAMI. ... MY GOOD WISHES TO MY FRIENDS IN CUBA, BRASIL, IRAN, MALAYSIA, INDIA, FRANCE AMONG OTHERS

photos taken from the backyard of my sister's house in Miami.

The sun sets later at this time of this year in Miami, around 8 15 pm and it is nice to see the almost Full moon coming out at the same time.

Today is a special FULL MOON.

On this full moon day/night, may all of us, look for what is common between us, rather than stressing what is different about us.

We are living through a period of time unlike anything the living humans have experienced.. Every single country is affected and most importantly almost all human beings are affected psychologically by an invisible fear and threat.

Please take time today to look at the moon and think of the people who love you and whom you love.

All of a sudden the world looks much smaller.

Before we seek freedom outside, we have to be free inside, cleanse ourselves of the conflicting forces in our hearts.

Enjoy this day whether you are in Rio de Janeiro or Rio Muni.

PS. Where is RIO MUNI. If you are a stamp collector, you would know.

A CONFERENCE? A CONGREGATION? A PARLIAMENT? COLLECTIVE NAMES FOR ANIMALS

https://www.wanderlust.co.uk/content/animal-group-names-quiz/?utm_campaign=Fri%2003%2F07%2F2020&utm_medium=Friday%20Club&utm_source=email&uid=ea0fddd89ecf8aa3615e67b1197088b4

GOOD USEFUL MEDICAL RESEARCH COMING OUT OF CHINA, ZIE ZIE. THANK YOU

This morning I read just two articles both with great feasibility of immediate clinical implementation.

I have noticed the deterioration in the quality of research coming out of USA because of its heavily promoted pharmaceutical leaning. Many of the articles are about new drugs or like their politiicians, putting down the drugs of their competitors or new technology, all related to making money. Of course excellent research still comes out of USA but the direction is towards less science and more commerce. Also it is disheartening to see prominent clinicians all with so much Pharma affiliations.. but I would leave that to their conscience.

The two articles I read this morning , both are:

Useful

Not promoting any new technology

It is inexpensive in that it is already available to all, CBC complete blood count for example to calculate the Inflammation Ratio

Not promoting one drug or another

Simple to put into practice, even in places where there are not much resources, CBC is available all over the world .

I am grateful to these Chinese doctors and scientists

Association between neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and diabetic retinopathy among diabetic patients without a related family history

Jin-Rui Wang, Zhongli Chen, Ke Yang, Hui-Jun Yang, Wen-Yu Tao, Yi-Ping Li, Ze-Jia Jiang, Chao-Fang Bai, Yue-Chuan Yin, Jian-Mei Duan, Yuan-Yuan Zhou, Xin-Qian Geng and Ying Yang

Diabetology & Metabolic Syndrome 2020, 12:55 | Published on: 2 July 2020 Effect of metabolically healthy obesity on the development of arterial stiffness: a prospective cohort study Yue Yuan, Jian-Jun Mu, Chao Chu, Wen-Ling Zheng, Yang Wang, Jia-Wen Hu, Qiong Ma, Yu Yan, Yue-Yuan Liao and Chen Chen Nutrition & Metabolism 2020, 17:50 | Published on: 2 July 2020

BLACK LIVS MATTER AND RACISM TOWARDS JEWS IN THE UK

I AM TRULY SAD TO SEE THIS TURN OF EVENTS AT A TIME WHEN THE WORLD HAS A CHANCE TO HEAL

Spurs and BBC distance themselves from BLM after ‘gagged on Zionism’ tweet BY JEWISH NEWS REPORTER According to reports in the Telegraph, they will drop public displays of support for the movement in wake of controversial comment that was branded antisemitic.

OPINION: BLM is fighting racism with racism BY JEREMY HAVARDI a wonderful opportunity for the long oppressed people to live together in reconciliation I am sad...