Comments on: Richard Lehman’s journal blog, 19 April 2009

By: Kathy Grant

Kathy Grant — Sun, 26 Apr 2009 09:03:55 +0000

How about polycystic ovary syndrome for the easily missed series?

By: Mikael Rabaeus MD

Mikael Rabaeus MD — Wed, 22 Apr 2009 17:47:19 +0000

Thank you for a refreshingly critical view on all the “science” that is published these days. I particularly liked and agreed with your comment on the polypill trial which has given rise to quite a hype here in Switzerland.
Clearly we would all benefit and like to keep you around for long. So you might still consider exercising and eating.
A previous study (Turning Back the Clock: Adopting a Healthy Lifestyle in Middle Age The American Journal of Medicine (2007) 120, 598-603) showed rather convincingly the benefit from changing your lifestyle.
As for the diet, I totally agree with you that forbidding a lot of different food items is not going to bring you anywhere. You can eat whatever you like for as long as you ensure eating the correct things in majority. Which leads us back to the so-called mediterranean diet variations, which in my opinion is clearly the only ony to have shown convincingly that you can influence prognosis. In addition, after 25 years in clinical practice in Switzerland, I notice that the only diet that the patients stick to WITH PLEASURE once they have succeeded to make the change, is the regional variation of the Mediterranean diet. Swiss mediterranean diet is not the same as the Italian or the Swedish one.

By: Prof. Enrique J. Sánchez-Delgado, MD

Prof. Enrique J. Sánchez-Delgado, MD — Wed, 22 Apr 2009 17:30:26 +0000

Dear Dr. Lehman,

Thank you for your efforts to clear up the picture on type 2 Diabetes and the concept of tight glycemic control. It is not so obvious or intuitive to conciliate the real world of evidence and clinical results, with the theory.

As you also explained, in their Editorial comparing the trials ACCORD versus ADVANCE (1), Dluhy and Mc Mahon pointed to the fact that in ACCORD there were significantly more deaths and adverse effects like severe hypoglycaemia and weight gain than in ADVANCE.

The use of insulin and glitazones was also much more intense, which helps to explain hypoglycaemias (usually accompanied by adrenergic reactions like tachycardia) and weight gain. Both drugs have been recently associated with more cardiovascular adverse effects (2, 3).

I consider that the increased risk can be explained by an increase in the Pulse Mass Index (Resting Heart Rate by Body Mass Index divided by 1730), which I reported years ago to correlate strongly with the global cardiovascular risk calculated by the Framingham Risk Score (4).

Drugs like metformin, in opposition to insulin and glitazones do not provoke weight gain or hypoglycaemia, nor increase the Pulse Mass Index, and is well known to reduce mortality and cardiovascular complications.

The effects of used and studied drugs on the Pulse Mass Index should be carefully observed, as also the concept and consequences of tight glycemic control.

Prof. Enrique Sánchez-Delgado, M.D.
Internist-Clinical Pharmacologist
Director of Medical Education
Hospital Metropolitano Vivian Pellas
Managua, Nicaragua

References:

1. Dluhy RG and McMahon GT. Intensive Glycemic Control in the ACCORD and ADVANCE Trials. N Engl J Med. 2008;358:2630-2633

2. Mellbin LG et. al. The impact of glucose lowering treatment on long-term prognosis in patients with type 2 diabetes and myocardial infarction: a report from the DIGAMI 2 trial. European Heart Journal.2008;29(2):166-176

3. Choy CK et. al. Type 2 diabetes mellitus and heart failure. Pharmacotherapy. 2008 Feb;28(2):170-92.

4. Sanchez-Delgado E. and Liechti H. Lifetime risk of developing coronary heart disease. Lancet 1999;353:924-925

Competing interests: None declared

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