Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
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Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

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Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

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The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

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‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

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Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

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Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

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Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

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I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

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Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June
http://aca.ninemsn.com.au/article/8863098/prescription-drug-warning

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Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

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Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

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Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

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Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

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Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

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Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

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Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

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Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

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Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

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Substituting Vitamins and Supplements for Pharmaceuticals in Type 2 Diabetes

Staff Researcher

articles by this author...

Editing and Researching news and stories about Australian and International Pharmacy Issues

Orthomolecular Medicine News Service, May 28, 2012
Commentary by Stuart Lindsey, PharmD

(OMNS May 28, 2012) Just when you thought it was safe to go back into the drugstore, we are going to question authority yet again. Readers may remember Dr. Stuart Lindsey as the Frustrated Pharmacist (http://orthomolecular.org/resources/omns/v08n05.shtml). He's back and at it once more, this time presenting an important supplement-based approach to type 2 diabetes. This essay presents ideas that are very possibly a large part of the solution. As with all OMNS releases, it is not meant to substitute for medical advice. Persons should consult their own doctor before making any health decision. - Andrew W. Saul, Editor

The current treatment of diabetes is among the least successful in medicine, despite billions of dollars spent on research. Many scientists make a career of studying diabetes. Medicine has succeeded in making diabetes very expensive for the patient while making the disease a cash cow for the numerous businesses that cater to the diabetic. We should expect to see some improvement in diabetic treatment, but in fact the basic protocols haven't changed much in twenty years. Is research getting close to a solution? In my opinion as a practicing pharmacist, the answer is no.

For fifteen years I was the pharmacy manager for an independent neighborhood drug store. I saw the results of many people over the long term as they were introduced to the "sugar-med treadmill." After prolonged consumption of their diabetic medications, their health did not improve. This was disturbing to me. The long term diabetics all seemed to have the same group of symptoms: they were overweight (due to hyper-insulinemia), edematous (having swelling under the skin), and they all suffered from poor exercise tolerance and had a generally unhealthy appearance. Many of them had peripheral neuropathy (malfunction of nerves), often associated with pain in their hands and feet. Only rarely did they believe their diabetes treatment was actually improving their health.

My interest in the lack of results from standard treatment of diabetes came into sharp focus when pain in my feet led to my being diagnosed with type 2 diabetes. From my observations at work, I already knew that the drug treatments for peripheral neuropathy were questionable. Introducing amitriptyline, gabapentin and Lyrica, which are sedatives and pain killers, made the people sleep a lot. Medically, it's obvious that sedating nerves doesn't solve anything. When such patients step up to daily long term narcotics and finally get some pain relief, they still haven't solved their problems.

Current medical practice relies on the HgbA1c (glycated hemoglobin) level as a measure of blood sugar over several months. The glycated hemoglobin is caused by high levels of sugar binding to hemoglobin inside red blood cells. When it builds up, this means that the body's biochemicals and organs are being damaged by too much sugar. It was interesting to note how many of the diabetic patients were in the normal range (i.e. HgbA1c < 6.5) but were still in agony over their feet. The problem was that seeing a normal value of HgbA1c, the doctor would hesitate to change the treatment. Apparently, severe foot pain wasn't a symptom that needed attention.

I decided to explore the whole HgbA1c issue. The biggest argument you see in diabetes is that diabetes is a 'disposal' issue. A high level of blood sugar is a type of metabolic malfunction that needs to be corrected. Blood sugar has a geography problem. The body seems driven to urinate the sugars out of the body instead of jamming the sugars across supposedly malfunctioning membranes and burning the sugars intracellularly. Medical practice can apply insulin and many types of drugs to insure that the body's tissues metabolize the sugars. Most current diabetic research is targeted at 'breaching the barrier' and making the supposedly malfunctioning membranes more permeable to carbohydrates. When those extra sugar calories are crammed into cells you get advanced glycation end-products (AGE's) that are a threat to the body.

In 2005, a UK researcher named Paul Thornalley wrote a paper detailing how many diabetic symptoms are due to a deficiency of thiamine (B-1).[1] Elevated blood sugar promotes a type of toxicity in the kidneys that causes thiamine to be excreted by the kidney at a rate much higher (sixteen to twenty-five times higher) than normal, leading to an acute deficiency of thiamine. From other studies, it is known that deficiencies in all B vitamins, as well as vitamin C and D are common in diabetics.[2] This can cause most of the symptoms of type 2 diabetes, which include: polyneuropathy, nephropathy (kidney damage), retinopathy (eye damage) and eventually heart failure. This raises the question of whether the symptoms are from diabetes or acute beriberi?

When I was diagnosed with type II diabetes, I immediately balked at taking the standard diabetic drugs. My doctor wanted to place me on statins, metformin and Byetta, all of which I refused to take. Having researched Dr. Thornalley's theory of diabetes being an acute thiamine deficiency, I started a regimen of vitamin and mineral supplements. Although the pain in my feet was quite severe, I wanted to avoid the regular drug regimen because it relied upon taking lots of pain killers that don't cure the problem. I reasoned that when the body's B vitamin levels are depleted due to high blood sugar, replenishing body stores through diet alone is difficult, so supplementation will be necessary.

I started taking a dietary supplement of thiamine (benfotiamine, 250mg 4x/day). I also added of vitamin B-6 (250mg/day) and pyridoxal 5 phosphate (P5P, 100mg/day) magnesium (aspartate, citrate, malate, or chloride) and acetyl-l-carnitine (1000 mg/day) depending on the severity of my peripheral neuropathy symptoms. More recently I've learned of the importance of taking vitamin C to reduce inflammation and prevent oxidation from high blood sugar levels.[2] My doctor did not approve of my self-treatment but was curious. I told him that I was willing to go back to the standard of care if this didn't work.

"Positive factors for treating type 2 diabetes are magnesium, exercise, weight control, chromium, dietary fiber, the B-vitamins, vitamin E, vanadium, vitamin C, and complex carbohydrates. I have been using the positive factors for the past 40 years. When patients followed such a program, the results are very good." Abram Hoffer, MD, PhD [3]

The most overt of the neuropathy symptoms started to subside rapidly. Within a week, the shooting pains in my ankles were mostly gone. All of the other symptoms of numbness of the toes and overall pain of the feet including the "boot effect" (the feeling that you have your boots or socks on) were mostly gone in three weeks. Now I know this treatment may not be a cure for diabetes. But it is a valid and reasonably inexpensive way to control the symptoms, which are held at bay as long as you keep your thiamine levels high. If you quit taking thiamine and the other B vitamins, the symptoms come roaring back.

I looked for the inevitable deterioration of my health that had been predicted. Ignore your blood sugar levels at your peril I was told. I was going to have kidney problems, my pancreas would stop cooperating and my vision would become blurry as the elevated sugars damaged my retinas. But the only sign of an active problem was the neuropathies in my feet which were quite painful at times: numbness of my toe area and shooting pains in my foot joints. I also had the feeling that the circulation of my feet was poor as my feet were always cold.

After two years I finally got blood tests. I still felt very good having lost some weight, with no vision problems, and my energy level and psychological attitude were all fine.I was actually afraid to look at the results and finding out that I had finally outsmarted myself and got hurt. There is a quite a propaganda machine built around the treatment of diabetes. As I drove over to retrieve my blood tests I did a mental check of how I felt. I decided I couldn't have a lot wrong with me as I just felt too good. My blood tests were amazingly free of problems related to elevated blood sugar, and I had few other related discernible health defects. This thiamine treatment did not change my HgbA1c (which is currently 9.1, and that is high) or my resting blood sugars (fasting blood sugars still between 180-190, and those also are high). Values like these are supposed to indicate a poor quality of health. My recent blood tests indicated:

Creatinine, urine 86.7mg/dl. Scale 20-370; low normal.
Microalbumin/Creatinine ratio 9.2mg/GCr. Scale 0-30; low normal.

Creatinine and microalbumineria values are the so called "Canary in the Coal Mine" indicators. The kidneys are supposed to go first when Advanced Glycation Endproducts (AGEs) have started your march to health failure because you didn't keep your HgbA1c values within range. I think my two-plus years is long enough for this to play out. I had my eyes checked for sugar damage to my retinas. I have no sugar damage to my eyes whatsoever. I am 61 years old and have 20-25 vision in both eyes. Jonathan Wright, MD, is among those who have noted that skin tags may be connected to diabetes; interestingly enough the skin tags on my arms have all disappeared.

However, my health hasn't failed due to hyperglycemia, although it is still a problem. In my case, the unusual positive results are evidently due to my nutritional approach. I substituted supplements of several essential nutrients for pharmaceuticals and stayed in relatively good health. And I continue to try supplementing with other nutrients such as antioxidants which are known to help prevent diabetes. [2] This suggests that the health issues are actually caused by nutritional deficiencies that can be easily prevented.

I am hoping this simple (and non-toxic) experiment on myself will lead the field to discussing the validity of substituting vitamins in diabetes treatment. The treatment of diabetes as it now stands is complicated and expensive. I am spending about $130/month on supplements, and during this two year experiment I have not given my doctor a single dime for advice on how to regulate my HgbA1c value. I imagine I've saved more than twice that amount by avoiding paying for drugs and doctor visits. Is this justified? If my health remains good and I have no other serious problems, I believe it is.

If all diabetics would supplement with B vitamins and vitamins C, D, and E, and minerals such as calcium and magnesium, they would lessen their problems with insulin and blood sugar, and the other serious symptoms of diabetes.[2] The reason is that most people in our society, especially including diabetics, have deficiencies of these essential nutrients that are known to be related to diabetes. But this essay is also an attempt to unseat some basic tenets of the medical fiasco known as diabetes. The prevalence in 2011 of type II world-wide according to the World Health Organization (WHO) is 346 million, and some 3.4 million people dies in 2004 as a consequence of the disease. The WHO predicts that the deaths attributable to diabetes will double between 2005 and 2030. [4] With this kind of projection a "Manhattan Project" kind of response seems necessary.

So what is the intellectual problem that seems so intractable to the medical research community? The standard treatments to lower blood sugar and HgbA1c were recently tested in medical trials. The ACCORD trials were meant to validate once and for all that the closer a patient got to a HgbA1c level of 6% the healthier a person became. Instead there was 22% increase in mortality from heart failure.[5] This unexpected value caused the FDA to terminate the trial midstream. Is it possible that the HgbA1c value should not be a primary goal in evaluating diabetes treatments?

If you go to PubMed and enter the keywords "thiamine deficiency" and "diabetes" you will get dozens of references that describe how many symptoms of diabetes are caused by a thiamine deficiency it generates. Deficiencies of B vitamins and other essential nutrients are important in diabetes.[2] This should be required reading for all doctors who treat or research diabetes. Currently in conventional management of diabetes, supplement based nutrition therapy is utterly neglected. The National Diabetes Fact Sheet reported that in 2007, the direct medical costs of diabetes nationally was estimated at $116 billion (USD). [6]

Diabetic patients can feel overwhelmed by a diagnosis of hyperglycemia, but are often comforted by the complicated explanations and sudden increase in activity and attention directed at them. The possibility that they are being misled just doesn't come up. Even if patients decide to do their own research it can be confusing. The cause of diabetes is basically unknown, but they are told that with some major alterations to one's lifestyle and lots of drugs liberally applied they can lead a relatively normal life. However for the truly curious, a large block of mainstream nutrition ideas of which the doctors are mostly ignorant can be freely accessed on the internet. When a patient presents this alternative information to the doctor today, they are comforted and told that they are already getting the cutting edge treatment. But even three years after the revelations of the ACCORD trials there has been no major correction of the type II treatment protocols that addresses the unexplained mortality issues revealed by the trials.

Even if my vitamin arguments are only partially correct, the implications for mainstream medicine are staggering. These ideas need wide discussion the field, because patients with diabetes need some new ideas.

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