Blood pressure difference between arms can be a risk factor for cognitive decline…as well as other things.

From Systolic inter-arm blood pressure difference and cognitive decline in older people, a cohort study. Christopher E Clark. BJGP July 2020


A prospective study was done in 1,113 Italians whose average age was 66.4 years. Even a difference of only 5 degrees between the arms was associated with a greater level of cognitive decline.

My comment: In UK GP practices, only one arm is used to check the blood pressure. In my case, it was the arm that was nearest to the desk. Perhaps we should check both ? Inter-arm BP differences are both associated with cardiovascular disease, and this in turn affects dementia. Then of course, is the question, what can you do about it? For a further discussion of the subject here is Pharmacist Antonio Bess from Diabetes in Control.

Cognitive Decline: Just Life, or a Preventable Disease?
Feb 22, 2020

Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Antonio Bess, Pharm D Candidate, Florida Agricultural & Mechanical University School of Pharmacy

Cognitive decline is associated with many diseases and medications, but the exact mechanisms are not clearly understood.
Diabetes, obesity, and declining cognitive function are all associated with increased prevalence with increasing age.

Diabetes is a known risk factor for eye, kidney, neurological and cardiovascular diseases, but its effect on declining cognitive function has been in question. Previous studies have found associations between patients who have diabetes and poor glycemic control and significantly faster cognitive decline. Other studies have demonstrated a pattern in which diabetes, high blood pressure, and high body mass index in midlife predict dementia in late life.

In this prospective study, individuals were followed for up to ten years to find associations between indices in diabetes, insulin resistance, obesity, inflammation, and blood pressure with cognitive decline. The indices of interest were measured separately among those with and without central obesity.
The Monongahela‐Youghiogheny Healthy Aging Team is a population‐based cohort of participants recruited randomly from 2006 to 2008, who were 65 and older, and were from a group of small towns in southwestern Pennsylvania. The study is focused on the epidemiology of cognitive decline and dementia in an area that still has not recovered economically from the collapse of the steel industry in the 1970s.

Participants were analyzed at study entry, and annual follow up. To measure cognitive function, participants were given a panel of neuropsychological tests tapping the domains of attention/processing speed, executive function, memory, language, and visuospatial function. At study entry and annually, BP, BMI, waist‐hip ratio, and depressive symptoms  were measured.
Key variables at the time of blood draw, including age, sex, race (white vs. nonwhite), education (high school [HS] or less vs. more than HS), APOE*4 allele carrier status, mCES‐D score, BMI, WHR, systolic BP (SBP), and the following laboratory assay variables: CRP, glucose, HbA1c, insulin, HOMA‐IR, resistin, adiponectin, and GLP‐1 were all reviewed to identify predictors of cognitive decline.
Among 1982 participants who were recruited and underwent full assessment at baseline from 2006 to 2008, only 478 individuals were able to provide fasting blood samples. Of this group of individuals, the median age was 82 years; 66.7% were women; 96.7% were white, and 49.0% had more than HS education.

Compared to the 1504 original participants without fasting blood data, at baseline, these 478 were significantly younger (74.6 vs. 78.6 years; P < .001); more likely to be women (66.7% vs. 59.2%; P = .004); more likely to be of European descent (96.7% vs. 94.1%; P < .001); more likely to have at least HS education (49.0% vs. 38.6%; P < .001); but about equally likely to be APOE*4 carriers (19.3% vs. 21.5%; P = .350).
In unadjusted analysis in the sample as a whole, faster cognitive decline was associated with greater age, less education, APOE*4 carriage, higher depression symptoms (mCES‐D score), and higher adiponectin level. HbA1c was significantly associated with cognitive decline.

After stratifying by the median waist-hip ratio, HbA1c remained related to cognitive decline in those with higher waist-hip ratios. Faster cognitive decline was associated, in lower waist-hip ratio participants younger than 87 years, with adiponectin of 11 or greater; and in higher waist-hip ratio participants younger than 88 years, with HbA1c of 6.2% or greater. Higher adiponectin levels predicted a steeper cognitive decline in the lower waist-hip ratio group.
Abdominal obesity plays a crucial role in cognitive decline in those with diabetes. The microvascular disease may play a more significant role than macrovascular disease. Midlife obesity contributes to cognitive decline but there was no midlife data in this study. Future studies should include a large minority, midlife population. Adiponectin levels need to be carefully assessed as well.

Practice Pearls:
In individuals younger than 88 years old, central obesity can lead to faster cognitive declines.
Obesity, diabetes, and aging contribute to cognitive decline, so it’s hard to distinguish the most significant risk.
Adiponectin may be a novel independent risk factor for cognitive decline and should be reviewed.

Ganguli, Mary, et al. “Aging, Diabetes, Obesity, and Cognitive Decline: A Population‐Based Study.” Journal of the American Geriatrics Society, John Wiley & Sons, Ltd, Feb. 2020, p. jgs.16321, doi:10.1111/jgs.16321.
Ganguli, Mary, et al. Aging, Diabetes, Obesity, and Cognitive Decline: A Population-Based Study. 2020, pp. 1–8, doi:10.1111/jgs.16321.
Tuligenga, Richard H., et al. “Midlife Type 2 Diabetes and Poor Glycaemic Control as Risk Factors for Cognitive Decline in Early Old Age: A Post-Hoc Analysis of the Whitehall II Cohort Study.” The Lancet Diabetes and Endocrinology, vol. 2, no. 3, Elsevier Limited, Mar. 2014, pp. 228–35, doi:10.1016/S2213-8587(13)70192-X.
Cukierman, T., et al. “Cognitive Decline and Dementia in Diabetes – Systematic Overview of Prospective Observational Studies.” Diabetologia, vol. 48, no. 12, Springer, 8 Dec. 2005, pp. 2460–69, doi:10.1007/s00125-005-0023-4.

Antonio Bess, Florida Agricultural and Mechanical University College of Pharmacy

Low carb kitchen: cheese crackers


100g almond flour

1 egg

40g unsalted butter

250g extra strong cheddar cheese grated

half a teaspoon of oregano


pre-heat the oven to 180 degrees and line a baking sheet with parchment paper

In a large bowl mix the almond flour with the egg, butter and oregano

Add the cheese and combine to form a dough using your hands if you need to

split the dough into two rough balls and place between two pieces of parchment paper one at a time

flatten with the palm of your hand and then a rolling pin till they are about 4mm thick

Place these flat in the fridge or freezer to allow the dough to cool and harden a bit

When ready, say 30 mins, use a cutter or shaped container eg egg cup to form your biscuits and put them on the prepared baking sheets

bake in the oven for 10 -12 minutes till golden

allow to cool on the sheet before removing and eating.

Some symptoms are more predictive of long Covid than others

Adapted from Sudre CR et al medRxiv 19 Dec 2020

This paper has not been finalised for peer review yet and could change. I decided to publish this because many of us are wondering why some people, especially younger people, seem more prone to long Covid than others. This paper does not yet tell us why, but gives some information on the pattern of symptoms that seems more linked to prolonged symptoms.

The findings were that if you have six or more symptoms during the first week of Covid-19 there tends to be a higher risk of long Covid. The 5 most predictive symptoms are: fatigue, headache, breathlessness, hoarseness and muscle pain. In adults over the age of 70, loss of smell was most predictive.

Of 4182 patients who were interviewed prospectively about their symptoms using a phone app from the UK, Sweden and the USA:

13.3% had symptoms for a month. 4.5% for two months. 2.6% for three months. 38% had “short-Covid”.

Factors that increased the possibility that recovery would be prolonged were: being a woman, having pre-existing asthma and having five or more symptoms.

In the over 70s, loss of sense of smell, fever and hoarseness were most predictive.

Low carb kitchen: Almond pancakes


125g ground almonds

1 egg

90mls milk

1tbs inulin powder or granular sugar substitute

half a teaspoon of gluten free baking powder

half a teaspoon of vanilla extract

pinch of salt

4 strawberries and 12 blueberries

20g dark chocolate melted

butter or coconut oil


whisk the egg, milk and vanilla in a bowl

add the ground almonds, salt and baking powder and inulin powder and beat till smooth

heat a large frying pan on a medium heat and put enough butter or coconut oil in the bottom to coat it.

spoon the mixture into the pan to make four pancakes

when the pancakes bubble on top and firm a the edges and then flip and cook till golden brown

transfer to a warm plate

add the berries to the frying pan and reduce the heat to low

melt the chocolate in the microwave

add the berries to the pancakes and drizzle over the warm chocolate sauce

It’s not usual to have perfect mental health

A study of children from birth until they were well into middle age showed that 86% of them met the criteria for a psychiatric disorder at least once during nine assessments undertaken by a psychiatrist from the age of 11 to 45.

The study was undertaken in the South island of New Zealand. Most of them had multiple diagnoses.

The conclusion was that sustained good mental health is the exception rather than the rule and that people often manifest their mental health difficulties in different ways over their life span.

JAMA Netw Open doi:10.1001/jamanetworkopen.20203221.

Using a ketogenic diet to treat binge eating and food addiction

Adapted from : Treating binge eating and food addiction symptoms with low-carbohydrate
Ketogenic diets: a case series

Matthew Carmen1 , Debra Lynn Safer2, Laura R. Saslow1, Tro Kalayjian3 , Ashley E. Mason4 , Eric C. Westman5 and Shebani Sethi Dalai2*

Many patients with obesity and comorbid binge eating symptoms present with the desire to lose weight. Although some studies suggest that dietary restriction can exacerbate binge eating, others show dietary restriction is associated with significant reductions in binge eating. The effect of a particular type of dieting on binge eating, the ketogenic diet (a high fat, moderate protein, very low carbohydrate diet), is not known.

We report on the feasibility of a low-carbohydrate ketogenic diet initiated by three patients
(age 54, 34, and 63) with obesity (average BMI 43.5 kg/m2 ) with comorbid binge eating and food addiction symptoms.

All patients tolerated following the ketogenic diet (macronutrient proportion 10% carbohydrate, 30% protein, and 60% fat; at least 5040 kJ) for the prescribed period (e.g., 6–7 months) and none reported any major adverse effects.

Patients reported significant reductions in binge eating episodes and food addiction symptoms including cravings and lack of control as measured by the Binge-Eating Scale, Yale Food Addiction Scale, or YaleBrown Obsessive-Compulsive Scale modified for Binge Eating, depending on the case.

Additionally, the patients lost a range of 10–24% of their body weight. Participants reported maintenance of treatment gains (with respect to weight, binge eating, and food addiction symptoms) to date of up to 9–17 months after initiation and continued adherence to diet.

This is the first report to demonstrate the feasibility of prescribing a ketogenic diet for patients with obesity who report binge eating and food addiction symptoms. Further research should seek to reproduce the observed effects in controlled trials as well as to explore potential etiologies.

Natural and Low Carb Kitchen: Easy lemon pots


2 tbsp extra thick double cream
2 tbsp mascarpone
2 tbsp inulin or other sweetener
Juice of 1 lemon
Pinch of sea salt


1. Put the cream and mascarpone into a bowl – whisk a little to thicken to desired consistency.
2. Stir in the lemon juice.
3. Add the salt and inulin, and gently combine.
4. Divide into two glass ramekins, top with a little lemon peel to decorate and place in the fridge until ready to eat.

Diabetes complications start at pre-diabetes blood sugar levels

Adapted from Steve Freed’s article in Diabetes in Control Spring 2020

Elevated blood glucose levels indicative of prediabetes appear to be associated with increased risks for retinopathy, peripheral neuropathy, and also diabetic nephropathy, according to Emanuelsson et al. (p.894).

As a result, they suggest that screening for micro- and macrovascular complications should be recommended for individuals with raised blood glucose or prediabetes.

In total, about 820,000 individuals were considered in the analysis. The authors found that, on an observational level, increasing glucose levels were associated with higher risks for both micro and macrovascular complications. Validation in the cohorts further confirmed the associations with retinopathy, neuropathy, nephropathy, and myocardial infarction but not peripheral arterial disease or kidney disease. This risk is present at glucose levels within what is currently considered the normal or prediabetic range.  

The American Diabetes Association recommends screening for prediabetes in adults with obesity or overweight and with risk factors for diabetes. However, this screening does not include examinations for microvascular complications.

Screening for retinopathy, neuropathy, diabetic nephropathy and additional risk factors such as obesity, hyperlipidemia, and hypertension might be indicated in individuals with prediabetes. 

The finding of a stepwise increase in the risk of vascular disease with increasing glucose levels within the normoglycemic range or higher support the idea that an elevated glucose level has a causal role in the pathogenesis of the microvascular disease, as do levels below the diabetes cut off. This is in line with the general understanding of the natural history of type 2 diabetes as a continuous process of declining β-cell function and increasing relative insulin deficiency, leading to a continuous increase in glucose that is initiated years before the diabetes threshold is reached.

Randomized controlled trials have shown that lifestyle changes and treatment with glucose-lowering drugs can reduce the progression from prediabetes to diabetes.

Recent 30-year follow-up data from a study of 577 Chinese individuals showed that lifestyle interventions in individuals with prediabetes reduce long-term risks of diabetes, a composite of microvascular complications, cardiovascular disease, cardiovascular mortality, and all-cause mortality.

The effects of lifestyle intervention are not likely to be due to glucose-lowering alone but to several beneficial metabolic effects. The findings highlight the importance of early detection of glycemia and screening for prediabetes in asymptomatic individuals through the use of risk assessment tools—such as the one currently provided by the American Diabetes Association  


  • Having blood glucose in the prediabetes range considered normal has shown to begin the complications of diabetes much earlier than thought. 
  • We need to be more proactive at the first signs of prediabetes. That means any fasting glucose reading above 100mg (5.5 mmol/l) or a random reading of above 139mg/dL(7.8 mmol/l). 
  • These findings suggest that elevated glucose levels should be identified as an essential risk factor for micro- and macrovascular disease in the general population and that screening for microvascular disease may be recommended, along with screening for additional cardiovascular risk factors, in individuals with prediabetes. 
  • Maybe it is time to just call prediabetes, diabetes, which would provide for much earlier treatment. 

Reference for “Prediabetes Equals Diabetes”:

Diabetes Care 2020 Apr; 43(4): 894-902. 

UK study shows you can cut BP on a low carb diet by 10 units

Photo by cottonbro on

Adapted from Substantial and sustained improvements in blood pressure, weight, and lipid profiles from a carbohydrate restricted diet: an observational study of insulin resistant patients in primary care. David J Unwin. Simon D Tobin et al. Int J Environ Res Public Health 2019 Jul 26;16(15);2680

Hypertension is the second biggest known global risk factor for disease after poor diet. Perhaps lifestyle interventions are underutilised? This study was undertaken in 154 patients with type two diabetes or impaired glucose tolerance in a general practice. This was an observational study that lasted an average of two years.

The average systolic blood pressure reduction was 10.9 mmHg. The mean diastolic reduction was 6.3 mmHg and the mean weight loss was 9.5 Kg. Lipid profiles were markedly improved. Medication was meanwhile reduced by an average of 20%.

Talk about “Time in Range”

Freestyle Libre

Adapted from Miriam E. Tucker Medscape 3 Nov 2020

The Freestyle Libre is now the most popular continuous blood sugar monitoring device used in the UK. Clinicians want both patients and doctors to move away from simple discussions about the HbA1C and embrace the next best metric to determine potential complication rate which is TIME IN RANGE.

Dr Emma Wilmot of the Royal Derby Hospital wrote about this new guidance in Time in Range: a best practice guide for UK diabetes healthcare professionals in the context of the COVID-19 global pandemic published Oct 19 2020.

The paper reviews and provides the rationale for international guidelines which recommend that more than 70% of a persons glucose readings should fall between 3.9 and 10 mmol/L with modifications for children, older adults and pregnant women.

Freestyle Libre users have been found to experience significant improvements in their HbA1c, have fewer hospital admissions, and lower levels of diabetes related distress in patients with type one diabetes.

They suggest that discussion about the information retrieved from the Freestyle Libre can be particularly useful now that face to face consulting at clinics has largely been replaced by telephone and video calls. Both the Freestyle Libre and the Clarity for Dexcom provide time in range and HbA1C estimates.

One UK doctor, Professor Choudhary has seen none of his 1300 patients who use the Freestyle Libre at his clinic since March and has found the device indispensible. He says, ” It is important for doctors and patients to be speaking the same language. Otherwise consultations are ineffective. Time in range is the new language”.

DTN’s education page has videos about the devices that monitor time in range and more will be posted in the next few months.