Dr Ford Brewer - PrevMed

The VA Diabetes Trial was criticized in a letter to the editor for being underpowered. Dr. Banerer made the appropriate point that " A negative finding in an underpowered study should not change the way we think about the importance of glucose control in the prevention of diabetes-related complications."

Both the study and the editorial are available at the links below.

They actually did get adequate study power through additional recruitment and follow-up. So, why didn't they describe this in the original study?

There has been a major reaction to an article published by Lancet on August 16, 2018. Dietary carbohydrate intake and mortality: a prospective cohort and meta-analysis.

There are rants of criticism toward the Journal, the methods of the study, and even Harvard. (One of the authors is from Harvard.) There is actually a lot of good dietary epidemiological methodology demonstrated by the study.

Light chain disease and Amyloid are unusual types cancer. They consist of clone cell lines of plasma cells or b cells. Often they create unusual amounts of antibodies. Sometimes there are just small parts of antibodies. Light chains (usually either lambda or kappa ) are the light chain component of the antibodies. These light chains can at least clog up the filter mechanisms of the kidney (glomerulae). If the light chain stimulates immune cells, (like neutrophils), they can create inflammatory responses (involving chemicals such as the interleukins). Therefore, inflammation can be a big issue in this unusual disease process as well.

This video is part 4 in a series on Heart Failure - Diastolic Dysfunction. Stage 1 diastolic dysfunction is indicated by an echocardiogram showing an inverted E/A wave ratio (less than 1). The E wave shows the rate of flow past the mitral valve ring during diastole-filling the ventricle. Usually, the majority of filling occurs in the E wave period ( Early diastole). The A wave (atrial kick) happens at the end of the diastole. It usually adds about 20% of the volume. But the if ventricles are stiff ( hypertension is the most common cause), they don't relax well. The filling during Early diastole is decreased. Since there is a lot of volume remaining in the atria during the late (A wave) phase, the Atrial kick is increased in early-stage diastolic dysfunction.

ACCORD was a large (over 10,000 subjects, 71 centers) trial of lower A1c levels in people with advanced diabetes and pre-existing cardiovascular disease. Over 32% were already on insulin; their mean BMIs were over 30.

The intensive study group (goal A1c less than 6) had fewer nonfatal MIs. However, they had a greater overall death rate. Deaths occurred in cardiovascular categories as well as others. The intensive study group had far more people gaining over 10kg. In other words, the attempts at lowering A1c were made with medication, not lifestyle.

This has lead to a fear of lower A1c goals for everyone, and even using lifestyle. What it really meant was you shouldn't try lowering the A1c of advanced diabetics using meds alone.

The VADT or VA Diabetes Trial is reviewed. There was a series of trials in the years 2005 - 2009 that showed that improved glucose control did NOT slow down heart attacks and strokes.

Here's why: there were 11.5 years since the diagnosis of diabetes in this population. And each of us typically has a decade - or more- of hyperglycemia and hyper-insulinemia prior to the actual diagnosis of type 2 diabetes.

These studies ( ACCORD, VADT, EDIC, and others) showed no improvement in lifespan due to "tighter" control. One of the studies even had to stop early.

Why? the time for prevention of heart attack and stroke is the decades of prediabetes, or insulin resistance, or metabolic syndrome. So, find insulin resistance early. Hit it hard, control it as tightly as possible. THAT will prevent heart attack, stroke, and dementia decades later. We do fail to acknowledge this is our culture. Both doctors and patients are guilty of neglect. And so is the government and standards bodies.

Another study has come out implicating Vit D levels and risk for Type 2 diabetes. The links above cover the article in PlosOne. And the UC San Diego press release. Is it conclusive? No. Is it another brisk in the wall? Might be.