Hercules at Sunset
Port Jefferson resident Steven Velazquez snapped this beautiful photo of the Hercules Pavilion in Stony Brook Village just as the sun was setting on Oct. 27.
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D. None of the Above: Thanking clinical trial volunteers who make treatments and vaccinations possible
By Daniel Dunaief
If your children are under the age of 12 and the Food and Drug Administration soon approves a COVID-19 vaccine, you’ll have many people to thank for the opportunity to return them to a more normal, and safer, childhood, including four-year-old Maggie, seven-year-old Lily and eight-and-a-half-year-old Dan Barsi.
The three siblings, who live in East Setauket with their parents James and Jennifer Barsi, recently participated in a clinical trial for the COVID-19 vaccine at Stony Brook Hospital. While the children don’t know whether they received vaccinations for the virus or the placebo, they are three of numerous children who volunteered to test the Pfizer-BioNTech vaccine to make sure it was safe before health care providers administer it to the broader population.
Their children “knew what they were signing up for,” said Dr. James Barsi, a pediatric orthopedic surgeon. “It’s something to help other people.”
Indeed, the community benefits from volunteers like the Barsis, who participate in clinical trials that evaluate the effectiveness of the treatment, help determine the correct doses, and reveal potential side effects before the rest of the population gets the COVID-19 vaccine or any other medicine or therapeutic intervention.
“We would never make advances in medicine without families — adults and children — volunteering to participate in clinical trials,” said Dr. Sharon Nachman, Chief of the Division of Pediatric Infectious Diseases at Stony Brook Children’s Hospital.
Some treatments for a range of illnesses or conditions look promising in the earlier stages of clinical development, such as phase 1 or phase 2. When they reach phase 3, during which researchers provide medicine to a much larger volunteer population, they sometimes fall short of expectations.
“Companies will tout drugs as the next best thing,” Dr. Nachman said. “When they get into phase 3, they are not better than standard therapy.”
Clinical trials on even an ineffective drug or one that produces side effects, however, can help pharmaceutical companies and health care providers by signaling what these professionals should look for in future treatments, Dr. Nachman added.
While volunteers of any age take risks by participating in these studies, they also have considerable medical oversight.
“They are well protected,” Dr. Nachman said. “When you participate in a clinical trial, you don’t just have two sets of eyes on you; you have 100 sets of eyes.”
Volunteers for clinical trials not only take some risk before everyone else in the community, but they also experience regular testing and monitoring.
The Barsi children, for example, had to have blood work and nose swabs. “We call it a brain swab,” Jennifer Barsi said. “The kids are so excited about getting a treat afterwards, but they still have to do the hard thing.”
Health care professionals throughout Long Island shared their appreciation for clinical trial volunteers. Without them “none of these innovative therapies and drugs would exist,” said Stephanie Solito, Research Manager of the Oncology Service Line at Catholic Health, which includes Smithtown-based St. Catherine of Siena and Port Jefferson-based St. Charles Hospital.
When Daniel Loen, Catholic Health’s Vice President of Oncology Services, takes any medicine, he appreciates that patients were “willing to sacrifice something or take on some kind of increased risk to get on a trial for the good of humanity and medicine.”
As for the specific COVID-19 pediatric trials, Dr. Nachman said parents and children have to approve to participate. Doctors talk with children in an age-appropriate way about these clinical trials.
Dan Barsi was born at 25 weeks old. He stayed in the hospital for several months and is now a healthy child.
Jennifer and James felt that this was their opportunity to give back to the next generation. The children who participated in clinical research before Dan was born helped make it possible for him to get the best treatment, and now they feel they’re doing the same thing.
Between You and Me: Election special from TBR News Media
By Leah S. Dunaief
Inside this issue is a treasure trove of first-hand information about the candidates and the issues in the coming election. How do I know? Because we, the different members of the editorial board of Times Beacon Record Newspapers, personally interviewed 25 people running for office across the three towns that we serve: Brookhaven, Smithtown and Huntington. The offices the candidates are running for are all local, which means that these are the officials who will have the most direct effect on our lives.
The positions range this year from county legislators to town supervisors, town council, town clerk, district attorney and sheriff. We asked them questions without bias, seeking only to understand who they were, what they believed and what we could expect from each of them, should they be elected — or re-elected, as the case might be. The setting in our conference room was relaxed, and we hoped comfortable, with opponents for each office seated together around the table responding to questions put to them by our editors and reporters.
Sometimes there were four candidates, sometimes only one who might be running unopposed or against a shadow opponent, but mostly there were two during each session. Most of the time, the hour goes by calmly, but occasionally the opponents get testy with each other — they may even become openly hostile.
At one such session some years ago, one of the candidates invited the other out to the back parking lot “to settle things.” When the other began to take off his jacket, we quickly intervened. But there were no such flare-ups this year.
The answers were timed in an attempt to get to the main ideas without running on too long. There was ample time at the end for each visitor to tell us anything more that perhaps we hadn’t elicited with our questioning.
We have written up the details of each interview in a separate article for the election section. And we discuss the candidates at the end of each hour and come to a conclusion for the endorsement.
Most of the time, the editorial group was unanimous because the choices were fairly direct. But for a couple of races, we talked over the pros and cons of each candidate at length before making the selection. These endorsements are based on both the in-depth interviews and the considerable information we know about the incumbents since we have been covering them closely throughout their terms in office. Of course, after reading the stories, you may or may not agree with our conclusions. Our job is to get you thinking.
The many hours that are given to this task, throughout the month of October, are a service for our readers. We are privileged to enjoy an extended face-to-face time with those standing for election, and we feel an obligation to pass along whatever information, facts and impressions we gather during these sessions. We sincerely hope we help in the sometimes-difficult job of casting a responsible vote.
Each year we include in the election section a sample ballot that we are able to procure from the Suffolk County Board of Elections because readers have told us that it is a great advantage for them to receive the ballot at the voting poll already knowing how it is laid out.
Our editorial board is made up of staffers with different political leanings, but when we put our journalists’ hats on, we try to judge each race strictly on the merits of the opposing candidates. And while it is technically possible for me to be tyrannical about the final selections, that is almost never the case. We decide by majority rule.
Sincere thanks to the talented staff who join in this extra work each year. We truly believe that we are watchdogs for the people, and nowhere is that more necessary than in reporting about government and its office holders. We hope we have helped you, whether you read by newspaper and/or online. Now please vote.
Editorial: Fall cleanups
Over the summer, dozens of nonprofits and organizations hosted beach and park cleanups across Long Island.
People came together with their trash bags in hand to pick up debris and trash. Families made days out of it, grabbing dinner afterward with the kids. Couples turned it into a bonding experience.
While it’s inspirational and helpful for members of the community to work together to clean up the communities in which we live, shouldn’t the town government take the lead with these efforts?
To that end, the road along Route 25A in Setauket has eyesores that detract from the beauty and safety of our community, including several dead trees, overgrown gardens, leaves and debris. Street lights that protect pedestrians and help drivers navigate the area are dimming, making them less useful as we approach days with less sunlight.
Long Islanders receive and appreciate the return on investment from their taxes, particularly when roads are cleared after a storm or when children receive excellent educations from public schools. Given the tax bill, however, shouldn’t the town be able to use some of that money for upkeep?
The community doesn’t police itself and shouldn’t need to clean up accumulating messes or detritus from trees or other vegetative growth. Residents can, and should, dispose of their own trash. Landlords should also take responsibility for the space outside their residences.
As for those public places the village, town or county oversees, those responsible for upkeep on those properties should step up their game.
We appreciate the work the municipalities do, particularly under difficult circumstances and, at times, with limited resources. We are also grateful to the go-getters whose efforts enhance the beauty of the communities we share.
At the same time, we need our elected officials and people with authority to take action to remove these dead trees, fix dim lights and remove garbage by the side of the road. The effort they put in now will save money and aggravation later, as well as improve the local environment.
SBU’s Peng Zhang scores 5 mln from the DOE for AI-driven energy research
By Daniel Dunaief
The Department of Energy is energized by the possibility of developing and enhancing microgrids.
What are microgrids? They are autonomous local power systems that have small, independent and often decentralized energy sources. Often, they use renewable energy, like wind or solar power, although some use natural gas or diesel.
The DOE’s dedication to developing these microgrids may cut costs, create efficiencies and enhance energy reliability.
Peng Zhang, SUNY Empire Innovation Professor in the Department of Electrical and Computer Engineering at Stony Brook University, is leading a diverse team of researchers and industry experts who received $5 million of a $50 million investment the DOE recently made to developing, enhancing and improving microgrid technology.
Bringing together these energy experts, Zhang hopes to use artificial intelligence to create a usable, reliable and efficient source of energy, particularly during periods of power outages or disruption to the main source of energy.
“The traditional microgrid operation is based on models and human operators,” Zhang said. “We developed this data-driven or AI-based approach.”
Artificial intelligence can enhance the safety and reliability of microgrids that can receive and transmit power.
One of the objectives of the systems Zhang and his collaborators are developing will include protecting the power supplies against faults, accidents from natural disasters and cyberattacks.
“This project led by Professor Zhang is a great example demonstrating the impact of this novel research on essential infrastructure that we rely on daily,” Richard Reeder, Vice President for Research at Stony Brook University, said in a statement.
Zhang said he has verified the methods for this AI-driven approach in the lab and in a simulation environment.
“Now, it’s time to demonstrate that in more realistic, microgrid settings,” he said. He is working with microgrid representatives in Connecticut, Illinois and New York City. His team will soon work with a few representative microgrids to establish a more realistic testing environment.
The urgency to demonstrate the feasibility of this approach is high. “We need to kick the project off immediately,” said Zhang, whose team is recruiting students, postdocs, administrative staff and technicians to meet a two-year timeline.
The group hopes AI-grids can be used in different microgrids around the country. If the platform is generic enough, it can have wide applications without requiring significant modifications.
While operators of a microgrid might be able to know the ongoing status, they normally are not able to respond to contingencies manually. “It’s impossible for the operator to know the ongoing status” of power sources and power use that can change readily, Zhang explained. “That’s why we had to rely on a data driven approach.”
Additionally, end users of electricity don’t necessarily want their neighbors to know about their power needs. They may not want others who are using the same microgrid system to know what appliances or hardware are in their homes.
Instead, the system will rely on the data collected within each microgrid, which reflects the behavior at different intervals. Those energy needs can change, as people turn on a TV or unplug a wind turbine.
At the same time, the power system load and generation need to remain in balance. Microgrids that produce more energy than the system or end users need can send them to a utility grid or to neighboring microds or communities. If they don’t send that energy to others who might use it, they can lose some of that energy.
Power needs to be balanced between supply and demand. Storage systems can buffer an energy imbalance, although the cost of such storage is still high. Researchers in other departments at Stony Brook and Brookhaven National Laboratory are pursuing ways to improve efficiencies and reduce energy storage costs.
Balancing energy is challenging in most microgrids, which rely on intermittent and uncertain renewable energy sources such as sunlight. In this project, Zhang plans to connect several microgrids together into a “mega microgrid system,” that can allow any system with a surplus to push extra energy into one with a deficiency.
Microgrids aren’t currently designed to replace utilities. They may reduce electricity bills during normal operations and can become more useful during emergencies when supplies from utilities are lower.
While artificial intelligence actively runs the system, people are still involved in these programmable microgrids and can override any recommendations.
In addition to having an alarm in the event that a system is unsafe or unstable, the systems have controllers in place who can restore the system to safer functioning. The programming is flexible enough to change to meet any utility needs that differ from the original code.
In terms of cybersecurity, the system will have three lines of defense to protect against hacking.
By scanning, the system can localize an attack and mitigate it. Even if a hacker disabled one controller, the control function would pop up in a different place to replace it, which would increase the cost for the attacker.
Stony Brook created a crypto control system. “If an attacker got into our system, all the information would be useless, because he would not understand what this signal is about,” Zhang said.
While he plans to publish research from his efforts, Zhang said he and others would be careful in what they released to avoid providing hackers with information they could use to corrupt the system.
For Zhang, one of the appeals of coming to Stony Brook, where he arrived two years ago and was promoted last month to Professor from Associate Professor, was that the university has one of the best and best-funded microgrid programs in the country.
Zhang feels like he’s settled into the Stony Brook community, benefiting from interacting with his neighbors at home and with a wide range of colleagues at work. He appreciates how top scholars at the Massachusetts Institute of Technology, Harvard and national labs have proactively approached Stony Brook to establish collaborations.
Zhang is currently discussing a Phase II collaboration on a microgrid project with the Navy, which has funded his research since his arrival. “Given the federal support [from the Navy], I was able to recruit top people in the lab,” he said, including students from Columbia and Tsinghua University.
Editorial: Give voters a chance
TBR News Media is preparing for our special election coverage editions that will be out Oct. 28. Our articles are based on debates with candidates to help voters make informed decisions when they choose their representatives.
With everyone’s busy lives, it’s difficult to find a mutual day and time for competing candidates to sit down and discuss the issues and challenges that affect the office they seek. What’s even more frustrating is when we discover a candidate is just a placeholder, in other words, they’re not actively campaigning. Too many times in the past, we’ve spoken with a candidate for a one-on-one interview instead of in a debate, and it will happen again this year.
Both political parties have been guilty of nominating someone to run for office and putting their name on the ballot, even though the person has no intention of knocking on doors or engaging in the democratic process to discuss their ideas.
This happens often when the office has a strong incumbent where a party has a feeling their candidate has no chance of winning. However, at the same time, they know the person will get a good number of votes because they understand some people just vote down their party line.
During divisive times, the Democrat and Republican committees owe the public much more. Whether an election involves federal, state, county, town or village levels, it is important for the entire process to be credible. Some may say our local elections are even more important as the decisions made by elected officials have more of an impact on our everyday lives, such as how often our garbage is picked up and whether or not our roads will be repaired.
We suggest both parties take every election seriously and produce candidates who will actively campaign instead of providing a random name for those voting for a D or an R. One of the most important things an elected official can do is show up for the election from start to finish.
Anyone whose name goes on a ballot should be a bona fide candidate seeking office, and not merely a token way for a party to remain visible. Before checking off whom you want to represent you for any office, do your research. Find out the races that affect your area. Read up on the candidates, and don’t vote for any candidate who places so little value on your vote and can’t bother to campaign. When you are at the polls, you don’t have to choose someone in every race. If you are not familiar with the candidates, or if you don’t like them for whatever reason, you can skip that row.
Simply voting for someone just because they belong to the same political party as you is a reflection on your belief in a party or even a machine — and not in the individual. That’s like choosing a partner based on his or her last name or heritage without considering whether that person is right for you. We need candidates who are ready to represent us and our districts, and who are willing to listen to our concerns, values and priorities. Choose wisely, and in doing so, you’ll send a message that people count more than parties.
Cooking Cove: Candied apples for the Halloween sweet tooth
By Barbara Beltrami
If there’s one holiday that caters to the population’s sweet tooth, it’s Halloween. Candy corn and bite-size candy bars notwithstanding, some of the best treats are candy apples whether the ones with the red crackly coating for traditionalists, those with a caramel nut coating for caramel nuts, or those with a chocolate and M & M coating for chocoholics. All of them are pretty expensive if you buy them, but inexpensive, fun and easy to make yourself. And speaking of teeth, they’re all a dentist’s dream.
Old-fashioned Candy Apples
YIELD: Makes 4 apples
INGREDIENTS:
4 wooden lollipop or popsicle sticks
4 Granny Smith apples, rinsed and dried
Nonstick cooking spray
1 1/4 cups sugar
1/4 cup corn syrup
1/4 cup water
1/2 teaspoon red food coloring
DIRECTIONS:
Insert lollipop sticks into tops of apples, one-third to one half of the way. Line a baking sheet with parchment paper and coat with nonstick cooking spray. In a small saucepan combine sugar, corn syrup and water; over medium heat bring to a boil; add red food coloring; continue cooking; swirl pan but do not stir.
When candy thermometer reaches 290-300 F after about 10 minutes, remove pan from heat and, twirling apple over pan to let excess liquid drip off, immediately dip each apple in coating. Place apples on prepared parchment to cool and let candy coating harden. Serve with peppermint stick ice cream.
Caramel-Peanut Apples
YIELD: Makes 6 apples
INGREDIENTS:
2 cups sugar
1/4 cup light corn syrup
1/2 cup heavy cream
2 tablespoons butter
1/2 teaspoon vanilla extract
Pinch of salt
6 Granny Smith apples, rinsed and dried
6 wooden lollipop or popsicle sticks
Nonstick cooking spray
1 cup finely chopped salted peanuts
DIRECTIONS:
Combine sugar, corn syrup and half a cup of water in a small saucepan over medium-high heat and give a quick stir to thoroughly combine. Attach a candy thermometer to the inside of the saucepan and bring mixture to a boil; cook until mixture begins to turn amber, then swirl it to even out the color. Continue to cook until it turns a deep amber and thermometer reads 375 to 380 F; remove from heat. Gently pour in cream, then whisk to combine; stir in butter, vanilla and salt till smooth. Let sit off heat but don’t remove thermometer. Pierce the apples’ tops 1/3 to 1/2 way with the sticks. Line a baking sheet with parchment paper and coat with cooking spray. Place peanuts on a plate. When the thermometer reads 190 F dip each apple in caramel and twist and swirl to cover; let excess drip back into pan. (If caramel gets too stiff, gently heat and stir over low heat to liquify.) Immediately dip and roll apples in peanuts and place them upside down on parchment. Serve with vanilla ice cream.
Chocolate-dipped Apples
YIELD: Makes 4 apples
INGREDIENTS:
6 Granny Smith apples, rinsed and dried
1 pound semi-sweet chocolate, diced
1 cup M&M’s, finely chopped
Nonstick cooking spray,
6 wooden lollipop or popsicle sticks
DIRECTIONS:
Insert sticks halfway into apple core. In a double boiler over medium-high heat, bring water to a boil; add chocolate to top part of double boiler and stir until chocolate is almost completely melted; remove from heat and continue stirring until chocolate is smooth and warm but not hot. Place M & M’s on a plate. Line a cookie sheet with parchment paper and coat with nonstick cooking spray. Swirl the apples in the chocolate and, coating them as much as possible, let extra drip back into double boiler. Immediately roll apples in M & M’s and place on parchment. Serve with chocolate ice cream.
D. None of the Above: Thoughts on items to include in a 2021 time capsule
By Daniel Dunaief
With 10 weeks left until the end of 2021, it seems fitting to consider what we might put into a time capsule that future generations might open to understand the strange world that was so incredibly different from the one just two years ago.
Here are a few items I’d throw into a box I’d bury or shoot into space.
— Masks. Even with so many events where people aren’t wearing masks, including huge gatherings of fans at sporting events, masks are still a part of our lives in 2021.
— A Netflix app. I’m not a streaming TV person. Most of my regular TV watching involves sports or movies (many of which I’ve seen a few times before). Still, I got caught up in the “Stranger Things” phenomenon and am now impressed with the storylines from “Madam Secretary,” which include prescient references to our withdrawal from Afghanistan and to the potential (and now real) pandemic.
— Pet paraphernalia. The number of homes with pets has climbed dramatically, as people who seemed unwilling or uninterested in having dogs are out with their collection of poop bags, leashes and pieces of dog food to entice the wayward wanderer in the right direction.
— A zoom app. Even with people returning to work, many of us are still interacting with large groups of people on a divided screen. Future generations may find all this normal and the start of eSocializing and virtual working. Many of us today are still trying to figure out where to look and avoid the temptation to scrutinize our own image.
— Cargo ships. The year started off in March with the blocking of the Suez Canal. For six days, the Ever Given kept one of the world’s most important canals from functioning, blocking container ships from going from the Mediterranean Sea to the Red Sea. As the year has progressed, concerns about shortages and supply chains have triggered fears about empty shelves.
— A small model of the Enterprise. The ship from the show “Star Trek” seems apt in a 2021 time capsule in part because William Shatner, who played the fictional Captain James T. Kirk (or admiral, if you’re also a fan of the movies), traveled briefly into space. In many ways, the science fiction of the past — a telephone that allowed you to look at someone else — is the fact of the present, with FaceTime and the aforementioned zoom.
— Competing signs. Protesting seems to have returned in full force this year. As the year comes to a close, people who do and don’t believe in vaccinations often stand on opposite sides of a road, shouting at cars, each other and the wind to get their messages across.
— A syringe. We started the year with people over 65 and in vulnerable groups getting their first doses of a vaccine that has slowed the progression of COVID-19, and we’re ending it with the distribution of booster shots for this population and, eventually, for others who received a vaccine eight months earlier.
— Take-out menus. I would throw several take-out menus, along with instructions about leaving food at a front door, into the time capsule. While numerous restaurants are operating close to their in-dining capacity, some of us are still eating the same food at home.
— An Amazon box. Barely a day goes by when I don’t see an Amazon delivery truck in the neighborhood, leaving the familiar smiling boxes at my neighbors’ front doors.
— Broken glass. I would include some carefully protected broken glass to reflect some of the divisions in the country and to remember the moment protesters stormed the capital, overwhelming the police and sending politicians scrambling for cover.
— Houses of gold. I would throw in a golden house, to show how the value of homes, particularly those outside of a city, increased amid an urban exodus.
— A Broadway playbill. My wife and I saw a musical for the first time in over two years. We were thrilled to attend “Wicked.” The combination of songs, staging, acting, and lighting transported us back to the land of Oz. Judging from the thunderous applause at the end from a fully masked audience, we were not the only ones grateful to enjoy the incredible talents of performers who must have struggled amid the shutdown.
Between You and Me: With frogs in my pool and woodpeckers on my shingles, I wonder what Nature plans next
By Leah S. Dunaief
There I was, tapping on my computer keyboard, when what sounded like a pneumatic drill started tapping right outside my window. I jumped up, ran down the hall, out the front door and around the house to be greeted by the sight of an unperturbed woodpecker.
Busily bobbing his beak into my shingles, he ignored me for a few seconds, despite my frantic hand waving and yelling, then cocked his head to see what the fuss was about. We looked at each other but he didn’t leave. I picked up a pine cone that had fallen on my driveway and threw it in his direction, along with a couple of words I wouldn’t repeat in polite company. Slowly, letting me know it was his idea, he flew away.
He left behind three black holes on the side of the house, each the size of a quarter. I went back inside to my computer, and then there he was again, rat-tat-tatting on the shingles. The words, “How much wood could a woodpecker peck if a woodpecker would peck wood?” passed through my mind as I again ran out the door and yelled. This time he moved away more quickly. I made a little pile of pine cones along the side of my driveway and returned to my computer. Not five minutes later, the scene repeated itself. I replenished my arsenal, knowing he would be back, and he was.
Good heavens, what was I to do, stand guard all day? What if I hadn’t been home? From the number and size of the holes, he had clearly been there before.
A truce seemed at hand. I pulled out my cell phone and dialed my neighbor. Yes, he was aware that there was an energetic woodpecker among us. In fact, hadn’t I heard? The neighbor on the other side of my house was having his wood shingles removed and replaced with vinyl that looked like wood but obviously didn’t taste the same. Maybe the culprit had just moved over to my shingles.
Next, I called my trusty neighborhood hardware store. Yes, they had heard of such a problem before and they did have one possible remedy, a roll of reflective tape for $7 that I should cut into 3-foot strips and hang from my house.
We rushed down to get the tape and also bought a roll of twine.
Back home we did as instructed, knotted the red and silver streamers to the twine at five-foot intervals as if on a clothesline, then hung the entire line high up across the side of the house. We repeated the process for the front of the house where he had also started pecking. I am lucky to have saintly friends who executed these maneuvers on ladders for me. When it was done, we stood back and looked at the handwork. The house looked decorated for Halloween.
As you might expect of me, I researched “woodpeckers” on my computer and found four reasons that woodpeckers would carry on this way. The first was to make a “satisfyingly loud noise and proclaim that this was his territory and attract a mate.” Bully for him.
The other three explanations were less romantic but more practical: to find food in the shingles, especially larvae of carpenter bees, leafcutter bees and grass bagworms; to store food; for nesting.
I further found some good news, or at least some consolation. It seems that ancient cultures associated woodpeckers with luck, prosperity and spiritual healing. To other cultures they represented hard work, perseverance, strength and determination. Woodpeckers are, apparently, among the most intelligent and smartest birds in the world.
More good news in the form of fortune cookie messages: When they appear, it is time to unleash one’s potential and change any situation to one’s best advantage. From woodpeckers one can imbibe the skills of being resourceful and determined. They encourage the power to unshackle ingenuity and creativity in those around them.
Well, now you know. Whatever success ensues, I will owe it to my woodpecker.
P.S. After one more short visit, he has not come back.
Medical Compass: Preserving your vision when you have diabetes
Annual eye exams are crucial
By David Dunaief, M.D.
Diabetic retinopathy is a frequent consequence of diabetes and is the number one cause of blindness in the U.S. among those 20 to 74 years old (1). Diabetic retinopathy (DR) is an umbrella term for microvascular complications of diabetes that can lead to blurred vision and blindness.
Among the risk factors for DR are diabetes duration, glucose (sugar) that is not well-controlled, smoking, high blood pressure, kidney disease, pregnancy and high cholesterol (2). As of 2019, only about 60 percent of people with diabetes had a recommended annual screening for DR (3). Herein lies the challenge, because the earlier you catch it, the more likely you will be able to prevent or limit permanent vision loss.
Over time, DR can lead to diabetic macular edema (DME). Its signature is swelling caused by extracellular fluid accumulating in the macula (4). The macula is the region of the eye with greatest visual acuity. An oval spot in the central portion of the retina, it is sensitive to light. When fluid builds up from leaking blood vessels, there is potential for vision loss.
Those with the longest duration of diabetes have the greatest risk of DME. Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated early, patients can experience permanent damage (3).
In a cross-sectional study using NHANES data, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (5). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietician in more than a year — or never.
The problem is that the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder, often after it’s too late to reverse damage. According to the authors, there needs to be an awareness campaign about the importance of getting your eyes examined on an annual basis if you have diabetes.
Treatment options
While DME has traditionally been treated with lasers, intravitreal (intraocular — within the eye) injections of anti-VEGF medications may be more effective. These work by inhibiting overproduction of a protein called vascular endothelial growth factor (VEGF), which contributes to DR and DME (6).
The results from a randomized controlled trial, the gold standard of studies, showed that intravitreal (delivery directly into the eye) injections with ranibizumab (Lucentis), whether given prompt laser treatments or treatments delayed for at least 24 weeks, were equally effective in treating DME (7). Other anti-VEGF drugs include aflibercept (Eylea) and bevacizumab (Avastin).
Some diabetes drugs increase risk
You would think that using medications to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective study, a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (8). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This incidence was persistent through the 10 years of follow-up. Note that DME is not the only side effect of these drugs. There are important FDA warnings of other significant issues.
To make matters worse, those who received both thiazolidinediones and insulin had an even greater incidence of DME. There were 103,000 diabetes patients reviewed in this trial. It was unclear whether the drugs, because they were second-line treatments, or the severity of the diabetes itself may have caused these findings.
This is in contrast to a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (9). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).
What does this ultimately mean? Both of these studies were not without weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (10). Thus, there needs to be more study done to sort out these results.
Glucose control and diet
The risk of progression of diabetic retinopathy was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (11). Medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. But an inference can be made: A nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy and further vision complications (12, 13).
The best way to avoid diabetic retinopathy and DME is obviously to prevent diabetes. Barring that, it’s to have sugars well-controlled. If you or someone you know has diabetes, it is imperative that they get a yearly eye exam from an ophthalmologist so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. It is especially important for those diabetes patients who are taking the oral diabetes class thiazolidinediones.
References:
(1) cdc.gov. (2) JAMA. 2010;304:649-656. (3) www.aao.org/ppp. (4) www.uptodate.com. (5) JAMA Ophthalmol. 2014;132:168-173. (6) Community Eye Health. 2014; 27(87): 44–46. (7) ASRS. Presented 2014 Aug. 11. (8) Arch Intern Med. 2012;172:1005-1011. (9) Arch Ophthalmol. 2010 March;128:312-318. (10) Arch Intern Med. 2012;172:1011-1013. (11) www.nei.nih.gov. (12) OJPM. 2012;2:364-371. (13) Am J Clin Nutr. 2009;89:1588S-1596S.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.
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