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Research and reports relating to diabetes.

After cardiac arrest, medium term outcomes are no different between specialist and local centres

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Adapted from 28 Oct 2023

There is a strong international drive to establish networks of cardiac arrest centres. After a cardiac arrest, is it better to transfer the patient to a specialist cardiac centre or to the nearest A and E facility?

The prospective, randomised ARREST trial took place in Greater London, so results may not be applicable to rural areas, areas which are poorly served by hospitals or ambulances, or areas with even worse traffic congestion.

They found that it took on average seven minutes longer to get a patient to a specialist cardiac centre compared to the nearest A and E. (84 v 77 minutes). My comment: note the long transfer time for both!

Once in the specialist hospital, patients got more interventions such as angiography and admission to intensive care. (56% v 37%) A marked difference.

However the chance of survival after a presumed cardiac arrest without ST elevation was exactly the same in both groups. The 30 day all cause mortality was 63%. Neurological outcomes were also similar.

Given that at least half of patients who have a cardiac arrest die within minutes, I would have to assume that only patients who were alive when the ambulance arrived were included in the trial. I was interested in whether the outlook after cardiac arrest had changed since I was working as a hospital doctor and GP and I tracked down the ARREST trial which was funded by the British Heart Foundation.

The clinical question

In the UK there are over 30,000 out-of-hospital cardiac arrests (OHCA) a year, where the heart stops beating suddenly. Less than one in 10 people in the UK survive an OHCA. 

Currently, cardiac arrest patients are taken by emergency ambulance to the closest Accident and Emergency (A&E) department for treatment. But some evidence suggests that people may have a better chance of survival if they are taken straight to a specialist hospital, called a cardiac arrest centre. These centres have a team of doctors and nurses experienced in treating cardiac arrest, and facilities like on-site heart imaging services and cardiac intensive care. Often, a cardiac arrest is caused by a heart attack, and specialist centres also have catheterisation laboratories open 24 hours a day, 7 days a week, with the equipment and expertise needed to unblock an obstructed coronary artery causing a heart attack as soon as possible. 

It seemed intuitive that people who’ve had a cardiac arrest out of hospital would benefit from being taken directly to a cardiac arrest centre for treatment compared with A&E. The ARREST trial was funded by the BHF to find out if this was the case.

What did the study involve?

ARREST was conducted across 35 hospitals served by the London Ambulance Service from 2018 to 2022. Seven of these hospitals were cardiac arrest centres. The trial was paused twice during the COVID-19 pandemic (from March 2020 through to November 2020, and from January 2021 through to August 2021).

Adults who’d had a cardiac arrest out of hospital were judged as eligible for the trial if they had:

  • no obvious non-cardiac cause of the cardiac arrest.
  • no obvious signs on their ECG trace of the heart of a major STEMI heart attack — in the case of a STEMI heart attack, patients would automatically be transferred to a specialist centre for treatment. 

In total, 862 participants were recruited into the trial from across London. Patients were resuscitated by London Ambulance staff until their heart was beating again. They were then randomly assigned to one of two groups by the paramedic crew:

  • Half the participants (431 patients) were transported to a cardiac arrest centre for treatment.
  • The other half (431 patients) were transferred to the closest hospital emergency department in London.

If the nearest hospital emergency department was a cardiac arrest centre, then the patient was taken to the cardiac arrest centre as it was not deemed ethical to delay their trip to an emergency department for the sake of the trial. At the cardiac arrest centre or emergency department, treatment was left to the discretion of the doctors and the clinical team.

Participants were followed up for 3 months to record how many in each group had died. The trial team also recorded how well people could function at discharge from hospital and after 3 months, for example how good their memory was, if they were able to live independently, and their quality of life. 

What did the study show?

  • The two trial groups were similar in terms of age (average age was 63 years), gender (a third were female) and the cause of their cardiac arrest.
  • Overall, around 60% of people in the trial had a cardiac arrest because of a heart related condition. Around 20% had a non cardiac condition that led to an arrest, and the cause of cardiac arrest was not known in ~20% of participants. 
  • Of the participants with a cardiac cause, around 40% had a cardiac arrest because of coronary heart disease, a third because of a heart rhythm disorder and around 18% had a heart muscle condition (cardiomyopathy).
  • The same proportion of patients in each group (63% [258 people]) had died at 30 days after their cardiac arrest.
  • There was also no difference between the two groups in death rates after 3 months.
  • Functional status and quality of life were similar in both groups at discharge and at 3 months.  

Why is the study important?

Trials of out of hospital cardiac arrest are extremely difficult to conduct, so it’s a tribute to the investigators and London Ambulance Service that they managed to deliver the trial. They persisted with the trial despite the disruptions of the COVID-19 pandemic. To complete successfully, the ARREST team had to recruit patients 7 days a week, 24 hours a day. 

The expectation was that transfer to a cardiac arrest centre would improve the prognosis of patients, so the results of ARREST were surprising.  Dr Tiffany Patterson, ARREST clinical lead, proposed one explanation: 

ARREST was performed in London, which is a densely populated urban area served by a highly effective ambulance service with access to high quality hospitals, so the standard of care in the nearest emergency department may not be so different from that in cardiac arrest centres.

Dr Tiffany Patterson, Clinical lead, ARRESTProfessor Simon Redwood, Chief Investigator of ARREST added:

The trial does not support transporting cardiac arrest patients direct to a cardiac arrest centre in London; they would fare better going to their nearest emergency department. These results may allow better resource allocation elsewhere.

Professor Simon Redwood, Chief Investigator, ARREST

However, he stressed that the trial had excluded patients who clearly had suffered a heart attack, and that this group of patients do benefit from going straight to a heart attack centre and having an attempt at reopening the coronary artery.

ARREST draws attention to the poor survival rate of OHCA, and the importance of bystander cardiopulmonary resuscitation (CPR) and early defibrillation. BHF has developed a free, online CPR training course, RevivR, to teach people how to perform CPR. The Circuit: The National Defibrillator Network is another BHF-led initiative that provides information about defibrillators across the UK so that ambulance services can quickly direct bystanders to their closest defibrillator in the crucial moments directly after a cardiac arrest.

Study details

“A randomised trial of expedited transfer to a cardiac arrest centre for non-ST elevation out of hospital cardiac arrest. The ARREST trial.”
Award reference: CS/16/3/32615
Principal Investigator: Professor Simon Redwood, King’s College London
Trial registration number: ISRCTN96585404

Publication details

Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicentre, parallel, randomised clinical trial. Lancet. 2023;402 (10410):1329-37.

PURE study describes a healthy diet

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  PURE Study and Full-Fat Dairy

The world’s largest observational study, the Prospective Urban Rural Epidemiology (PURE) Study, released its most recent paper with one of the key findings being that whole-fat dairy should be included as one of six foods that comprising a healthy diet.

Multiple papers have been published from the PURE data. This one is focused on developing a globally applicable healthy diet score, called the PURE Score.

The researchers analyzed data not only from PURE but also from five independent studies encompassing a total of more than 244,000 individuals from 80 countries.

The PURE scoring system defined a healthy diet as one relatively high in fruits, vegetables, nuts, beans, fish, and whole-fat dairy. A higher score was attributed to diets composed of more of these nutrient-dense foods.  
 
  A higher intake of these foods correlated with improved health and a reduced risk of illness, the study found.

This research has the same limitations of all epidemiological studies in that it shows correlation, not a cause-and-effect relationship. However, PURE’s contrary finding on full-fat dairy is meaningful in that it contradicts the conventional wisdom.

Dariush Mozaffarian, the influential former Dean of the Friedman School of Nutrition Science & Policy at Tufts University, cited this paper and acknowledged that full-fat dairy can indeed be part of a healthy diet. U.S. health recommendations have favored low-fat dairy for decades, but the PURE finding imply that high-fat dairy is the better option for health.  
My comment: The debate about what a healthy diet is continues. I’m still on an Atkin’s style diet and still on about 35 -85g of carb a day. I’m more willing than I used to be to enjoy my favourites such as mushroom risotto, seafood risotto and paella. I easily meet the legumes, nuts, fish and dairy intakes but don’t tend to eat the fruit and vegetable amounts suggested unless I’m on holiday where they have big self serve buffets. I know that eating more vegetables in particular is good for fibre, vitamins, and antioxidants, and are generally low in calories, but I just don’t find them as appetising as meat, fish, eggs, cheese and nuts. I probably eat one of each a day on average.

Low carb diets have almost all the nutrients you need

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Adapted from BMJ Open Access: Assessing the nutrient intake of a low carb high fat diet: a hypothetical case study design.

Abstract
Objective: The low-carbohydrate, high-fat (LCHF) diet
is becoming increasingly employed in clinical dietetic
practice as a means to manage many health-related
conditions. Yet, it continues to remain contentious in
nutrition circles due to a belief that the diet is devoid of
nutrients and concern around its saturated fat content.


This work aimed to assess the micronutrient intake of the
LCHF diet under two conditions of saturated fat thresholds.


Design: In this descriptive study, two LCHF meal plans
were designed for two hypothetical cases representing the
average Australian male and female weight-stable adult.


National documented heights, a body mass index of 22.5
to establish weight and a 1.6 activity factor were used to
estimate total energy intake using the Schofield equation.


Carbohydrate was limited to <130 g, protein was set at
15%–25% of total energy and fat supplied the remaining
calories.

One version of the diet aligned with the national
saturated fat guideline threshold of <10% of total energy
and the other included saturated fat ad libitum.


Primary outcomes: The primary outcomes included all
micronutrients, which were assessed using FoodWorks
dietary analysis software against national Australian/New
Zealand nutrient reference value (NRV) thresholds.


Results: All of the meal plans exceeded the minimum NRV
thresholds, apart from iron in the female meal plans, which
achieved 86%–98% of the threshold.

Saturated fat intake was logistically unable to be reduced below the 10%
threshold for the male plan but exceeded the threshold by
2 g (0.6%).


Conclusion: Despite macronutrient proportions not
aligning with current national dietary guidelines, a wellplanned LCHF meal plan can be considered micronutrient replete.

This is an important finding for health
professionals, consumers and critics of LCHF nutrition, as
it dispels the myth that these diets are suboptimal in their
micronutrient supply. As with any diet, for optimal nutrient
achievement, meals need to be well formulated.

My comments: Achieving nutritional completeness is almost impossible on a high carb, low fat, low protein diet. Despite the nutritional superiority of a well formulated low carb diet, there are some take home notes from the dieticians involved. 1. Your requirements for Vitamin D cannot be met solely by diet. You either need year round sun exposure or nutritional supplementation with a Vitamin D/K2 supplement. 2. In women of childbearing age, they may need extra iron in the diet, even if they eat red meat regularly. This is due to the effects of menstruation and pregnancy. This may involve eating red meat with fruit juice, avoiding tea with meals, and taking extra iron supplements. Latest thinking is that iron supplementation on alternate days or even less often reduces the bowel problems such as constipation that are usually caused.

Age Related Macular Degeneration could probably be prevented by avoiding processed food

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Adapted from The Displacing Foods Age Related Macular Degeneration by Chris A Knobbe. Medical Hypotheses 109 2017 184-198

Chris A Knobbe from the University of Texas has studied factors that are thought to be important in the causation of Age Related Macular Degeneration. (AMD).

AMD is the leading cause of irreversible blindness in developing nations. In 2020 some 196 million people were affected worldwide. And Dr Knobbe thinks this is almost always down to dietary factors, in particular the consumption of processed food such as sugar, vegetable oils, refined white flour and trans fats.

Historically, between 1851 and 1930, AMD was a rarity. It rose modestly in the 1930s but became an epidemic in the UK and USA by 1975.

By 2009 63% of the American diet consisted of processed sugars, starch and oils. My comment: Dr Google now puts this at 73% “hyper-processed foods”.

By looking at the food intake and AMD in 25 nations, it was seen that as the traditional diets were replaced with processed foods, the incidence of new onset AMD correspondingly rose.

If sugar intake is moderate but polyunsaturated fat ingestion is rare, AMD does not rise.

It would therefore appear that processed and nutrient deficient foods are toxic to the retina.

AMD could probably be entirely preventable through reverting back to ancestral dietary patterns, should that be feasible, or eliminating processed foods that have become ubiquitous. Avoidance of these foods is likely to be extremely important for people who have been diagnosed with early or moderate AMD.

My comment: I was recently at a Hospice ladies lunch group and was sitting at a table with six other women who were about 10-20 years older than myself. Five of them were currently getting eye injections for AMD. Diets that are considered the healthiest by Dr Google are the Mediterranean, Japanese, South Korean and French. None included processed foods.

Insulin as a murder weapon: the case of Colin Norris

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Adapted from Journal of Forensic and Legal Medicine Feb 2023 Insulin murder and the case of Colin Norris by Alan Wayne Jones University of Linkoping, Sweden.

Although insulin is an essential medicine and a life saving drug, it has been used in many poisonings. These can be accidental, suicidal or to deliberately cause harm. An insulin overdose causes severe low blood sugars, and if untreated can lead to coma, irreversible brain damage and death.

Normally, in non- diabetic individuals, the beta cells in the pancreas secrete the same amounts of insulin and C peptide into the portal venous system. In the liver, the insulin is broken down faster than the C peptide, so normally there is more C peptide in the general circulation than insulin. When there is more insulin in the system than C peptide, that is a very strong indicator that insulin from a non- pancreatic source has been administered.

Sophisticated biochemical measuring systems can identify insulin analogues. This provided part of the evidence that convicted Colin Norris, a nurse, of injecting insulin into five of his patients, four of whom died as a result.

Clinical symptoms of low blood sugars occur when the blood sugars drop below 2.5 (UK) or 45 (USA), although the exact threshold can vary between individuals. If this is prolonged for up to 6 hours or more then the brain damage can be irreversible and death can occur. The hormonal response to correct low blood sugars also prolongs the QT interval in the heart electrical pacing mechanism leading to an increase in cardiac arrhythmias and sudden death.

Proof of insulin poisoning requires positive identification of the causative agent in plasma or serum samples taken from the victim before the low blood sugar is corrected.

The first proven case of murder by insulin occurred in the mid 1950s and forensic evidence was obtained from analysing tissue samples from around injection marks on the victim’s buttocks.

During an investigation into suspicious deaths caused by insulin, the entire case scenario and totality of the evidence must be carefully considered. Tissue samples around any injection marks need to be kept for later analysis of insulin and C peptide levels.

In a Leeds hospital, in September 2002, a Mrs Hall was recovering from a hip joint operation and seemed to be making good progress. In the early hours she was found unresponsive. A bedside test showed that her blood sugar was only 1.5. Although intravenous dextrose was given, she never regained consciousness and later died. She did not have diabetes. Assays showed that the insulin level was far higher than the C peptide level indicating that pharmaceutical insulin had been injected. It was believed that she may have been mistakenly injected with insulin which was kept for patients in an unlocked fridge.

Nurse Colin Norris became the prime suspect. As part of the investigation a retrospective review of other unexpected deaths and incidents which could have been due to insulin administration were found. Four incidents had occurred in the previous year when Colin Norris was on duty. Three earlier deaths had been attributed to natural causes at the time and there was no toxicological evidence that any of them had been injected with insulin. Colin Norris maintained his innocence throughout the investigation.

In October 2005 Colin Norris was charged with murdering four patients and attempting to murder a fifth by the injection of insulin. The trial started at Newcastle Crown Court in October 2007. In March 2008 he was found guilty and was sentenced to life imprisonment. He was described by the judge as a “thoroughly evil and dangerous man…arrogant and manipulative….with a real dislike of elderly patients. There cannot be any suggestion that you were motivated to hasten their ends to spare them suffering”.

After the first appeal against Norris’s conviction failed in 2009, clinical evidence emerged that spontaneous attacks of hypoglycaemia in elderly and frail patients are not as rare as the jury had been led to believe. Indeed, a literature review showed that 2-10% of elderly frail patients, who can be malnourished, with co-morbidities such as sepsis, liver disease, or kidney failure are vulnerable to attacks of hypoglycaemia.

Other weaknesses in the case were:

The insulin vials on the ward were not subject to any inventory.

No insulin or needles were found near Mrs Hall.

The fingertip blood sample showing low blood sugar was not verified with a venous blood sample.

The very high insulin level was found on an NHS assay machine, not a more accurate forensic one. Rigour in following chain of custody procedures were not done. A confirmatory sample had also not been done.

The low blood sugar had been corrected before the low C peptide versus high insulin was found.

Spontaneous hypos can indeed occur in the elderly and frail.

Another hypoglycaemia related death had occurred at the hospital but it had not been mentioned as Norris had not been on duty. Thus the police were suspected of cherry picking cases to incriminate Norris.

Toxicological evidence of hypoglycaemia was only found for Mrs Hall. Death certificates for the other suspected hypoglycaemia deaths had been attributed to old age and other natural causes.

The cause of death of Mrs Hall was brain damage due to insulin induced hypoglycaemia but it was not known if the pathologist had looked for any insulin secreting tumours.

One of the senior police officers had been involved in the Dr Harold Shipman case two years previously and he may have been primed to find another serial killer in the health profession.

The Criminal Case Review Committee, which is the official authority in the UK charged with looking into miscarriages of justice, have examined the evidence and recommended that the court of appeal have a fresh look at the case.

My comment: It will be interesting to find out what happens and what their reasoning regarding this case will be. Meanwhile, look after yourself, look after your diabetes, keep up a healthy lifestyle and keep out of hospital!

PHC: How low carbing can help the NHS, meeting in Edinburgh

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The Public Health Collaboration is hosting a morning meeting on Saturday 18th March in Edinburgh from 9 am till 1pm.

The morning speakers will be explaining the role low carbing has on:

Improving mental health and particularly the results with bipolar disorder.

Improving weight and glycaemic control in type two diabetes.

Reducing the costs of managing type two diabetes.

Public education and group coaching initiatives in Scotland.

The PHC Ambassadors are having an afternoon meeting to discuss their projects.

The meeting is at the Quaker Meeting House in the old part of Edinburgh at the bottom of the castle and the fee is £15.

Please contact Sam Feltham at the Public Health Collaboration for more details and to register for the event.

Nutrients and exercise can reduce cancer risk

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Adapted from Nutrients and exercise affect tumour development by Carla Martinez May 27 2022 and

Three pronged approach may reduce cancer risk in the elderly by Nadine Ekert June 7 2022 Medscape

In a Madrid Oncology conference researchers discussed an update on lifestyle factors and cancer.

Diet and lifestyle can have an influence on each of the successive stages that occur in the development of cancer: initiation, promotion and progression.

A deficit of certain nutrients is one of the factors involved in the initiation stage. Various deficiencies affect different parts of cell metabolism adversely. Such nutrients include folate, B12, B6 and B3, Vitamin C, Selenium, Zinc, Magnesium and Vitamin D.

Aflatoxins from foods of vegetable origin are detrimental. The foods include cassava, pepper, corn, millet, rice, sorghum, wheat, sunflower seeds and peanuts, but the effect very much depends on how these foodstuffs are stored.

Added nitrates to foods such as processed meats and sausages because they become nitrosamines which affect cancer development. Natural nitrates in food however do not cause cancer.

Smoking causes 72% of lung cancer and 15% of all cancers. Eating processed meat causes 13% of intestinal cancers and 1.5% of all cancers. The most problematic foods for nitrosamines are cured meat, and smoked meat and fish. Cooking meats also causes polycyclic aromatic hydrocarbons especially chicken.

Various cooking strategies will reduce the formation or dilute the effects of polycyclic aromatic hydrocarbons.

Marinate mean in an acid solution for more than one hour.

Season meats and fish before grilling them. Good spices to use are: pepper, paprika, garlic, onion, ginger, turmeric, cumin, cinnamon, clove, fennel, and star anise.

Cook at a low temperature eg boiling.

Eat meats with lots of brassicas such as broccoli, cabbage, kale, turnip, brussel sprouts and mustard.

Grilled foods contain benzopyrene which can cause a mutation in DNA and thus cause cancer. Brassicas are rich in sulforphane which works on genes that produce glutathione s-transferase which promotes the elimination of benzopyrene.

Other factors that promote cancer include psychological stress, circadian disruption such as shift work, physical inactivity, obesity, hyperglycaemia, hyperinsulinaemia, gut bacteria disruption, and vitamin D deficiency.

The common factor here is increased inflammation. Some nutrients act as anti-inflammatories including the omega 3 oils EPA and DHA. Ginger, green tea, turmeric and broccoli all help too.

Daily rituals determine our health, so think about how you can optimise your routines.

The influence of exercise on cancer has only been studied in the last ten years.

Hypoxia is one of the main triggers of tumour aggression. Exercise has been shown to improve oxygenation and reduce hypoxia. Physical exercise in combination with chemotherapy has been proven to reduce tumour volume and progression. The best exercises in this regard are those that build up lactate in the muscle such as resistance exercise and cycling.

In the DO-HEALTH study, more than 2,000 healthy elderly people over the age of 70, were observed over three years. A combination of high dose vitamin D, omega 3 fatty acids and a simple home training programme reduced the risk of cancer by 61% compared to placebo.

The risk of getting cancer increases as you get older. Apart from not smoking and sun protection, getting appropriate vaccines and screening, there is not that much left to do. As Vitamin D, omega 3 fatty acids and physical exercise are all promising factors in cancer reduction, various combinations of them were tried. Blood pressure, physical performance, cognition, fractures and infections were looked at. They were divided into 8 groups looking at placebo, training only, and then various combinations and single interventions.

Most groups showed no difference from placebo but the combination of vitamin D, omega 3s and training did. The number needed to treat to prevent one cancer over the three years was 53 which is considered pretty good. Researchers thought the outcome was good enough to recommend this to any one over 70 who was looking to improve their health.

Cardiovascular outcomes are improving for type two diabetics

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There have been large reductions in myocardial infarction, cardiac death, and all cause mortality over the last fifteen years in Denmark for type two diabetics. For instance, the cumulative seven year risk of myocardial infarction reduced from6.9% to 28%. These reductions occurred over a period of time when there has been a lot more emphasis on using drugs to reduce cardiovascular risk. (Diabetes Care 2021)

In Sweden blood was tested to see how much dairy products were being consumed. Those who consumed the most dairy fat had 25% less risk of myocardial infarction compared to the lowest risk.

As many dietary guidelines recommend limiting dairy products in order to limit saturated fat intake, perhaps they should take note.

An article in the American Journal of Clinical Nutrition suggests that if the carbohydrate – insulin model of obesity is correct, then instead of calorie control diets and exercise to reduce obesity, focus should be put on low carbohydrate diets.

What do white rings round your corneas indicate?

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Adapted from BMJ 23 Nov 2021

In a German study of ten thousand people aged between 40 and 80 years old, 21% of men and 17% of women had white rings round their irises of the eyes. You may have noticed these in your parents or yourself and may have wondered what this means.

The average age of the group was 60. Researchers noted that corneal arcus is more likely in men than women, increases with age, and increases with lipid levels.

Corneal arcus has no relevance to socioeconomic status, body mass index, arterial blood pressure or HbA1c levels.

A ketogenic drink has been found to improve cognitive performance in those with mild cognitive impairment

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Adapted from A ketogenic drink improves cognition in mild cognitive impairment: Results of a 6 month RCT by Melanie Fortier et al. Alzheimer’s and Dementia. 2021.

Brain energy rescue is being tested to see if it can reduce cognitive decline in patients with mild cognitive impairment. It has previously been discovered that the brain has problems using glucose for fuel even before symptoms develop, but brain ketone use remains constant in both Alzheimers (A) and Mild Cognitive Impairment (MCI). Increasing ketones available to the brain has been shown to improve cognitive symptoms.

A really easy way to increase blood ketone levels is to give a drink containing ketogenic medium chain fatty acids. This has been found to increase brain energy uptake via PET scans. This follow on trial was done to assess whether improvement in cognition after six months occurred.

This study was conducted in Quebec Canada. Very strict entry criteria were applied and the patients were randomised to the ketogenic drink or to a placebo drink. The drinks appeared and tasted identical.

122 participants were enrolled. In total 39 completed the ketogenic arm and 44 the placebo arm. They were well matched regarding age, sex, education, functional ability and cognitive scores, absence of depressive features, blood pressure, blood chemistry and APOE 4 status. ( A genetic variability that greatly increases the chance of developing dementia).

More participants dropped out of the ketogenic group mainly due to gastrointestinal side effects. The drop out rate overall was 32% and 38% in the ketogenic group. None of the side effects were serious.

The results showed that performance on widely used tests of episodic memory, executive function and language improved over 6 months in the ketogenic group compared to the placebo group. Improvement was directly correlated with the plasma level of ketones.

The dose used was 15g of kMCT twice a day.

This seems to be a very reasonable intervention for early cognitive decline particularly since no drugs are approved for MCI and drugs used for Alzheimers do not delay cognitive decline in MCI. It is possible that effects would be enhanced if patients also undertook a ketogenic diet. Further trials are now warranted to see if diagnosis of Alzheimers can be delayed in those suffering from mild cognitive impairment.