June 12, 2022 · 7:00 AM

Dr Hall Reviews Weight-Loss Pill Plenity

Dr Harriet Hall wrote a brief review of the new weight-loss drug Plenity at Science-Based Medicine. Her conclusion:

So far, effectiveness has been shown in only one placebo-controlled trial. Diet and exercise must be continued. It doesn’t work well for everyone: 6 out of 10 users lost at least 5% of their body weight; the other 4 didn’t. It appears to have fewer side effects than other weight loss products. Not a way to achieve ideal weight, but probably worth trying for patients who understand that it is only an aid and not a final solution. I hope they will be encouraged enough by a 22-pound weight loss to continue losing weight with or without Plenity.

Overweight and obese folks with diabetes also tend to lose weight with the new once-weekly injection therapy called tirzepatide, brand name Moujaro. (Where do they get these names?!) And remember that bariatric surgery is often very effective at weight loss and controlling diabetes…if you survive the operation.

Steve Parker, M.D.

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June 9, 2022 · 4:55 PM

Keto Versus Mediterranean Diet: Which Is Best for T2 Diabetics and Prediabetics?

Use the search box to find the recipe for this LCHF avocado chicken soup

Effect of a Ketogenic Diet versus Mediterranean Diet on HbA1c in Individuals with Prediabetes and Type 2 Diabetes Mellitus: the Interventional Keto-Med Randomized Crossover Trial

Right off the bat, I don’t like that they studied both diabetics and prediabetics. There were only 40 original study participants, with complete data on only 33. Why lump the two together?

Participants followed each diet for 12 weeks then lab data and body weight were assessed.

The researchers conclusions:

HbA1c [a measure of blood sugar control] was not different between diet phases after 12-weeks, but improved from baseline on both diets, likely due to several shared dietary aspects. WFKD [ketogenic diet] was beneficial for greater decrease in triglycerides, but also had potential untoward risks from elevated LDL-C, and lower nutrient intakes from avoiding legumes, fruits, and whole intact grains, as well as being less sustainable.

Triglycerides dropped more on the keto diet, no surprise. Body weight dropped the same for both diets, 7-8%. HDL-cholesterol (the “good cholesterol”) rose 11% on keto and 7% on Mediterranean diet. HgbA1c dropped the same on both diets, about 8% from baseline. Both diets lead to eating ~300 calories less per day than baseline consumption.

Dr Bret Scher addressed the increased LDL-cholesteral (aka “bad cholesterol”) over at DietDoctor.com:

The authors reported that LDL “dangerously” rose 10% on the keto diet. But was it really a dangerous change? Triglycerides went down on the keto diet, as we would expect. And as we saw in 2018 with the Virta Health trial, on average, LDL went up 10%. However, the calculated cardiac risk score went down 12%.

In terms of answering the headline question, Keto Versus Mediterranean Diet: Which Is Best for T2 Diabetics and Prediabetics?, the answer really depends on long-term data concerning longevity and various diseases. This study doesn’t answer the question.

What say you?

Steve Parker, M.D.

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June 8, 2022 · 2:04 AM

High-Volume Versus High-Value Doctors

In your ideal world, would you prefer your physician’s income reflect:

  • number of patients seen and procedures performed, or
  • high quality of care, reflected in ready accessibility, lowering cost without compromising care, compliance with science-based guidelines, and patient satisfaction/experience, or
  • combination of the above

In other words, do you want your physician incentivized by volume or value?

It doesn’t matter what you want anyway, peon.

A recent study looked at salary arrangements for doctors in system-affiliated physician organizations in four states. The main conclusion:

The study results suggest that despite growth in value-based payment arrangements from payers, health systems currently incentivize physicians to maximize volume, thereby maximizing health system revenues.

This in-depth multimodal cross-sectional assessment of compensation and incentives among health system–affiliated POs [physician organizations] for which there is greater exposure to VBP [value-based payment] and APM [alternative payment model] arrangements compared with independent practices found that volume was the most common form of base compensation by a wide margin, being included by more than 80% and 90% of POs for PCPs [primary care physicians] and specialists, respectively, and representing more than two-thirds of compensation when included. Similarly, actions to increase volume were the most commonly cited means for physicians to increase their compensation. Base compensation incentives for physicians were not dominated by population or value-oriented payments, with only a third of POs reporting inclusion of capitation with PCPs and averaging only about a third of total compensation when included. Performance-based financial incentives for value-oriented goals, such as clinical quality, cost, patient experience, and access, were commonly included in compensation but represented a small fraction of total compensation for PCPs and specialists in health systems, operating at the margins to affect physician behavior. Taken together, these findings suggest that despite growth in APMs and VBP arrangements, these value-based incentives were not commonly translated into health system physician compensation, which was dominated by volume-oriented incentives.

The problem is that it’s a lot easier to measure volume than value. Easy wins.

Steve Parker, M.D.

Ref: Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems in JAMA Network

PS: Avoid the medical-industrial complex as much as is safely possible. Let me help.

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June 4, 2022 · 10:15 AM

It’s True: Olive Garden Won’t Necessarily Blow Your Ketogenic Diet

Steve Parker MD, low-carb diet, diabetic diet
Olives, olive oil, and vinegar: classic Mediterranean foods

Lisa MarcAurele authored an article about eating at Olive Garden even though you’re on a ketogenic diet:

Whether you are traveling and can’t cook or you are celebrating something special with people you love, Olive Garden has some low-carb options that are simply delicious!

They might be known for their endless breadsticks and overflowing plates of pasta, but there are some keto-friendly choices on the menu, too. You just have to know where to look. 

Olive Garden is also known for its large portions, so you will have to think ahead before eating everything on your plate. 

When you don’t have time to cook or just want to dine out, Olive Garden can be an appealing option for people on a ketogenic diet. Thankfully, there are ways to eat a keto meal at Olive Garden – you just have to be a little creative with a custom order!

Thank you, Lisa.

Steve Parker, M.D.

PS: Conquer Diabetes and Prediabetes includes a ketogenic option.

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May 30, 2022 · 7:00 AM

Leafy Greens Can Kill You!

Not sure if this is chicken or tuna salad with walnuts and grapes

Periodically there are outbreaks of illness caused by eating contaminated leafy greens. The contaminants are usually bacteria such as E coli and Salmonella. The illness is typically diarrhea, sometimes with belly cramps, nausea, and vomiting. And rare deaths.

Cathe Friedrich published an interesting article about this phenomenon. Here are a few bullet points (I haven’t independently verified):

  • Leafy greens such as lettuce are linked to 22% of food poisoning outbreaks over over the last 10 years
  • The riskiest leafy green is bagged, ready-to-serve lettuce

A few ways to avoid foodborne illness:

  • Avoid pre-packaged leafy greens
  • Avoid sprouts
  • Keep the produce refrigerated and dry
  • Consume before the expiration date

Click for leafy green food safety tips from the Canadian government.

Click for a harrowing story at Consumer Reports about E coli poisoning from romaine lettuce.

Consumer Reports article on the safest ways to eat salad.

Steve Parker, M.D.

h/t Jan at The Low Carb Diabetic

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May 26, 2022 · 7:00 AM

Stable Chest Pain: CT Angiography Versus Standard Angiography

Heart attacks and chest pains are linked to blocked arteries in the heart

We’re all gonna die of something.

The #1 cause of death in the U.S. is coronary artery disease (CAD), which causes heart attacks, sudden cardiac death, and some cases of congestive heart failure. Folks with diabetes have a higher-than-average risk of CAD. Blockage in the heart arteries typically develops over years and many people are walking around not knowing it’s there. The lucky ones develop warning signs like transient chest pain or shortness of breath on exertion. After consulting a physician, the next step may be a “stress test” or some sort or imaging of the arteries of the heart.

Angiography refers to imaging of arteries or veins. Angiography of the heart arteries is helpful in diagnosing blockage of arteries that may cause heart attacks or sudden cardiac death in the future.

CT stands for computerized tomography: x-rays obtain images that are then manipulated by computer technology to provide more information than plain x-ray technology alone. CT angiography of the heart arteries is done with iodinated contrast injected into the low-pressure venous system of circulation. In contrast, standard arterial angiography involves introduction of a needle (and catheter) into the high-pressure arterial system, usually the femoral artery in the groin or the smaller radial artery in the wrist. Standard arterial angiography is associated with a higher risk of complications such as leakage of blood from the artery. Another potential complication is embolization of arterial plaque or clots downstream from the arterial puncture. Because of the higher complication rate in the arterial system, standard angiography is considered “invasive.”

The study at hand asks which is a better way to image heart arteries in a patient with stable chest pain: CT versus standard arterial angiography. The article abstract doesn’t define “stable” chest pain. I assume the researchers did not include acute myocardial infarctions (heart attacks) and unstable angina.

European researchers concluded that:

Among patients referred for invasive coronary angiography (ICA) because of stable chest pain and intermediate pretest probability of coronary artery disease, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy.

I bet the non-invasive CT is also less expensive than standard arterial angiography.

Steve Parker, M.D.

PS: You now what else help prevent heart attacks and cardiac death? The Mediterranean diet.

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May 19, 2022 · 11:41 PM

FDA Approves Tirzepatide for Type 2 Diabetes

From the U.S. Food and Drug Administration May 13, 2022:

Today, the U.S. Food and Drug Administration approved Mounjaro (tirzepatide) injection to improve blood sugar control in adults with type 2 diabetes, as an addition to diet and exercise. Mounjaro was effective at improving blood sugar and was more effective than the other diabetes therapies with which it was compared in clinical studies.

“Given the challenges many patients experience in achieving their target blood sugar goals, today’s approval of Mounjaro is an important advance in the treatment of type 2 diabetes,” said Patrick Archdeacon, M.D., associate director of the Division of Diabetes, Lipid Disorders, and Obesity in the FDA’s Center for Drug Evaluation and Research.

Type 2 diabetes, the most common form of diabetes, is a chronic and progressive condition in which the body does not make or use insulin normally, leading to high levels of glucose (sugar) in the blood. More than 30 million Americans have type 2 diabetes. Despite the availability of many medications to treat diabetes, many patients do not achieve the recommended blood sugar goals.

Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are hormones involved in blood sugar control. Mounjaro is a first-in-class medicine that activates both the GLP-1 and GIP receptors, which leads to improved blood sugar control. Mounjaro is administered by injection under the skin once weekly, with the dose adjusted as tolerated to meet blood sugar goals.

Three different doses of Mounjaro (5 milligrams, 10 milligrams and 15 milligrams) were evaluated in five clinical trials as either a stand-alone therapy or as an add-on to other diabetes medicines. The efficacy of Mounjaro was compared to placebo, a GLP-1 receptor agonist (semaglutide) and two long-acting insulin analogs.

On average, patients randomized to receive the maximum recommended dose of Mounjaro (15 milligrams) had lowering of their hemoglobin A1c (HbA1c) level (a measure of blood sugar control) by 1.6% more than placebo when used as stand-alone therapy, and 1.5% more than placebo when used in combination with a long-acting insulin. In trials comparing Mounjaro to other diabetes medications, patients who received the maximum recommended dose of Mounjaro had lowering of their HbA1c by 0.5% more than semaglutide, 0.9% more than insulin degludec and 1.0% more than insulin glargine.

Obesity was common among study participants, with an average body mass index of 32 to 34 kilograms/height in meters squared reported at the time of enrollment. Among patients randomized to the maximum recommended dose, the average weight loss with Mounjaro was 15 pounds more than placebo when neither were used with insulin and 23 pounds more than placebo when both were used with insulin. The average weight loss with the maximum recommended dose of Mounjaro was 12 pounds more than semaglutide, 29 pounds more than insulin degludec and 27 pounds more than insulin glargine. Those patients receiving insulin without Mounjaro tended to gain weight during the study.

Mounjaro can cause nausea, vomiting, diarrhea, decreased appetite, constipation, upper abdominal discomfort and abdominal pain.

Mounjaro causes thyroid C-cell tumors in rats. It is unknown whether Mounjaro causes such tumors, including medullary thyroid cancer, in humans. Mounjaro should not be used in patients with a personal or family history of medullary thyroid cancer or in patients with Multiple Endocrine Neoplasia syndrome type 2.

Mounjaro has not been studied in patients with a history of pancreas inflammation (pancreatitis), and it is not indicated for use in patients with type 1 diabetes.

Mounjaro received priority review designation for this indication. A priority review designation directs overall attention and resources to the evaluation of applications for drugs that, if approved, would be significant improvements in the safety or effectiveness of the treatment, diagnosis or prevention of serious conditions.

Click for full prescribing information.

The starting dose is 2.5 mg subcutaneously once weekly. After four weeks dose can be increased to 5 mg once weekly. Dose can be increased every four weeks to a maximum of 15 mg once weekly.

Steve Parker, M.D.

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May 17, 2022 · 9:59 PM

Consider the Paleo Diet for Diabetes

Photo by Vanessa Ray on Pexels.com

Some of you may know that I’ve designed a paleo diet for folks with diabetes. If interested, check out the Paleo Diabetic blog. Feedspot in February placed it on their Top 80 Paleo Diet Blogs and Websites list.

Steve Parker, M.D.

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May 1, 2022 · 7:00 AM

Got COVID-19? You May Not Need That Pulse Oximeter After All

…per a letter to the editor at New England Journal of Medicine.

Study participants were enrolled from Nov 2020 to Feb 2021. So probably before the delta and omicron variants. Outpatients were assigned either to a “standard program” of home monitoring or the standard program + pulse oximetry. There was no difference between groups in terms of “number of days alive and out of the hospital.” For the 30-day trial, that number was 29.4-29.5. In other words, very few of the ~1000 enrolees got very sick.

Pulse oximeters are readily available in the U.S. for ~$40.

The standard program was “COVID Watch, a 2-week program involving twice-daily automated text messages inquiring about dyspnea and offering rapid callbacks from nurses when appropriate. This program has been associated with improved survival as compared with no remote monitoring.5“

I spent about 10 mins trying to find the age of these patients. No luck. I don’t even now if they were adults. Thanks, NEJM. I’m not totally convinced that outpatient oximetry has no role in home treatment of COVID-19. But clearly not every patient needs it. Perhaps just those at high risk of hospitalization and death.

Steve Parker, M.D.

PS: Obesity is a risk factor for severe disease from COVID-19. Let me help you do something about it.

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April 25, 2022 · 11:43 PM

Recipe: Japanese-Style Salmon and Avocado Salad

If image owner (who?) objects to me posting the image, let me know and I’ll delete it.

This looks and sounds intriguing but I haven’t tried it yet. I’ve never combined avocado and salmon in an entree. I never imagined I’d like avocado in chicken soup, but it’s become a Parker Compound favorite.

Click for recipe at Tesco Real Food.

Steve Parker, M.D.

h/t/ Jan at The Low Carb Diabetic

PS: I couldn’t find the nutrition breakdown at Tesco Real Food, but Jan came up with this:

Nutrition Per Serving (1/4 of the total): Carbohydrate 4.3g Protein 28.7g Fibre 1.4g Fat 41g

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