Michael Marre, a French physician who
heads the diabetes department at a Paris hospital, gave an oral presentation at
the 2014 American Diabetes Association 74th Scientific Sessions in
San Francisco. It was reported on in Medscape Medical News, an aggregator of
medical news for physicians. The title of his talk: “Multifactorial Approach to
Prevent Cardiovascular Disease in Type 2 Diabetes,” subtitled “Identifying
Diabetes and Cardiovascular Risks.” The risk part was okay, the multifactorial
approach to prevent CVD ho-hum, and the comment section priceless. Here’s my
précis.
Dr. Marre’s definitions: “Diabetes
mellitus is a metabolic disorder caused by both a defect in insulin secretion
and in insulin action. It is an important contributor to vascular damage.
Remember that, by definition, diabetes induces microvascular complications, and
it is also a huge risk factor for macrovascular complications.” I might quibble
with “caused by” and argue that it is diabetes controlled to the ADA Standard
of Care that induces microvascular complications, but still, his view conforms
to the medical establishment’s, so you can’t blame him for their
dereliction.
To his credit, Dr. Marre
states that “you can take some prevention measures, which include lifestyle
interventions that can reduce the risk for diabetes by 50%.” He adds, though,
“If that’s not enough, you can add some pharmacotherapy” and then launches into
a litany of meds that can possibly “delay or postpone the progression to
diabetes mellitus.” His primer continues: “In fact, an individual evaluation
must include an assessment of the classic risk factors, the glycemic status,
the macrovascular disease, and the microvascular disease:
●
The classic risk
factors are family history, lifestyle, smoking, hypertension and dyslipidemia
(cholesterol issues).
●
Macrovascular
disease: coronary status, cerebral vascular disease, peripheral arterial
disease, and heart failure.
●
Microvascular
disease: retinopathy, nephropathy, and neuropathy, and
●
Don’t forget
arrhythmias, especially atrial fibrillation
To his credit, Dr. Marre says
“Cardiovascular risk requires multifactorial management, with an emphasis on lifestyle intervention. Look at what the patient
eats and drinks.” He advocates “a Mediterranean diet from your birth
date.” Okay, I’ll admit a Mediterranean diet would be a better choice of what
to eat and drink than the Standard American Diet (SAD), but hey, so would
almost any way of eating. And Dr. Marre says, he is “from the
Mediterranean area.”
Summarizing, Dr. Marre’s
management and control recommendations are pretty much pro forma “establishment”:
●
Maintain blood
pressure below 140/85 mm Hg. This is the objective for patients without any
renal impairment. If the patient has a slight increase in microalbuminuria,
then the blood pressure objective must be below 130/80.
●
Look at the low-density
lipoprotein (LDL) cholesterol level, which must be below 1.8 mmol/L (70
mg/dL).
●
Glycemic control,
as assessed by A1c, must be below 7%.
Dr. Marre cautions, “For blood
pressure lowering, do not forget to prescribe as first-line
therapy a rennin-angiotensin-aldosterone inhibitor. This is mandatory.”
That’s an ACE inhibitor, like Enalapril. Whew! I take one.
For lipid control, use a statin
for first-line therapy, and prescribe an appropriate dose. [another pill]. Antiplatelet
therapy [low-dose aspirin] is recommended for secondary prevention of
cardiovascular disease. “Often,” he said, “you have to combine several
antidiabetic agents [more pills or injections] to achieve good glycemic
control, but as most of our patients are overweight or obese, use Metformin
as much as possible in first-line therapy.” Again, whew!
But wait a minute! What happened to
those lifestyle interventions? To “looking at what the patient eats and
drinks”? Here is a doctor lecturing on the basics of clinical
care for the overweight or obese Type 2 diabetic patient, to avoid the
co-morbidities of micro and macrovascular disease, and all he has to offer, except
lip service, is a cocktail of pills?
There were just five comments. The first four were “the usual”; the
fifth, most unusual:
“This
is rubbish and when I open it, I am struck by several ads for Victoza I cannot
get rid of. What can I expect from a site that is financed by industry? Oh,
Eric Topol, how can you possibly work here and look yourself in the mirror
every morning.” Signed: Anders Hernborg, Swedish GP. Anders
Hernborg is a mostly retired, MD, “independent researcher” and “activist.” Of
the 22 published scientific papers which he has co-authored, one is titled
“Advertising or Science?” Being “mostly retired” makes time for research and
writing. Telling the truth may also be a certain way to become
“mostly retired.”
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