Michael Mindrum, MD

What happened to the vegans? Is it only low carb folks left on X?

I spend my clinic days working with patients on methods of achieving metabolic health and my days in hospital treating the complications of these terrible diseases so appreciate where you are coming from. Yet it is absurd, from my view, to look at societal health and ASCVD risk reduction from the vantage point of a very small subset of individuals who achieve resolution of diabetes or metabolic syndrome via low carb who also develop diet induced hypercholesterolemia. It happens extremely infrequently yet takes up so much air. This community consistently over promises and oversimplifies the likelihood of achieving long term diabetes remission and contorts conversations about CV risk into an extremely narrow view. It gets tiresome.

The core argument from the low-carb community is that conventional medicine focuses on pharmaceutical interventions to the exclusion of actually trying to make lifestyle change happen in patients. The culture of allopathic care favors prescribing a pill vs actually making a patient healthier. While LDL is certainly associated with heart disease, it is far down on the list in terms of the strength of that association. Diabetes, metabolic syndrome, and insulin resistance top that list. These are reversible conditions, yet I've never met a single T2D patient who has been told what insulin resistance is. And very few who've been told their disease is reversible. I'm ambivalent on statins, but the fact is that meds are pushed on patients with no further digging into their health. I see this in both my clinical experience and personal interactions with doctors.

The ignorance that these non-clinician “influencer scientists” spread is tough to measure. This is not complicated. The relevance of apoB and LDL becomes quite clear when you understand how to estimate an individuals baseline risk of cardiovascular events. The context of “metabolic markers” and baseline risk is baked into basic clinical practice. We know that there is a drop in relative risk for each mmol/l in LDL-c. What makes that RRR meaningful is dependent on baseline risk.

@operationmilly @MarketPalmer_ Do you all ever research things to make an informed opinion? Or talk with a physician?

@MarketPalmer_ True. Prob tons of student loan debt.

Recently learned that 25% of 60-year old doctors have a net worth below $1 million. How…?

@MichaelAlbertMD I wonder where Novo would be now if they had opened with the 7.2 mg dose

The FDA approved Wegovy HD (semaglutide 7.2 mg) today. Here's the clinical context every obesity medicine provider needs. The STEP UP trial delivered 20.7% mean weight loss at 72 weeks in people with obesity — with approximately 1 in 3 patients achieving ≥25% weight loss. In the T2D subgroup, the figure was 14.1%. A few things worth noting beyond the headline number: The 20.7% figure is the efficacy estimand — the effect if everyone remained on treatment. The treatment-regimen estimand (which captures real-world dropouts) was 18.7%. Both figures are meaningful improvements over semaglutide 2.4 mg, which has been the ceiling for injectable GLP-1s since 2021. The FDA awarded a Commissioner's National Priority Voucher, accelerating review — a signal of how seriously the agency is treating the obesity epidemic as a public health priority. For our patients who have plateaued on 2.4 mg, or who came in with higher baseline BMI and greater metabolic burden, this opens a legitimate clinical conversation about dose escalation. This isn't about chasing a number. It's about getting people to durable, meaningful weight reduction — and increasingly, the data shows higher doses get more people there. US launch is expected April 2026. The trajectory of this field continues to move faster than most of us anticipated even two years ago. Press Release: novonordisk.com/news-and-media…

🚨Breaking: Retatrutide's first Phase 3 T2D data just dropped. ▸ A1C: −2.0% at 40 weeks ▸ Weight: −36.6 lbs (−16.8%) at 12 mg ▸ No weight loss plateau — curve still descending at study end Triple agonism (GIP + GLP-1 + glucagon) is no longer theoretical. My deep dive on the molecule 👇 substance-over-noise.beehiiv.com/p/the-drug-tha… Press Release: investor.lilly.com/news-releases/…

@MurseDarius Yes, for the most part. But I don’t follow the relevance to this particular topic.

I certainly have a biased view since I see people come into the ER who are already on statins and other meds. At the end of the day, healthy people are healthy because of their lifestyle habits. Meds, at best, only somewhat mitigate the effects of a poor lifestyle. I'm speaking generally, of course. There is certainly more nuance. But the patients I see rarely consider the health impacts of the food they eat or their lack of exercise. People aren't trying to decide between keto or plant-based diets, they're trying to decide between McDonald's or KFC.

@_MDV_ Yes

@MichaelMindrum What happens when people stop hypertention drugs or thyroid drugs or any drugs….

tldr: don’t stop an effective drug; look beyond metric of weight regain.

@NeilFlochMD I was just in Barcelona! Beautiful country

I am on my first vacation that is longer than 6 days. It has been 26 years since I was away any longer… nuts. …still took care of 4 patients and their issues today while in Spain. 🇪🇸

@Ashwinreads Any idea who would be capable of making a generic?

one reason why i’m less bullish on canada as d2c telehealth play when the sema patent expires is because the likelihood is very, very high that insurers will start reimbursing for glp-1s which kinda destroys the incentive for the consumer to pay out of pocket.

@ethanjweiss @theproof @nicknorwitz @raphaels7 @realDaveFeldman @AdrianSotoMota I’ve been here as well. It’s better here.

@theproof @nicknorwitz @raphaels7 @realDaveFeldman @AdrianSotoMota it took you longer to get to the same place I have been now for quite some time...

I haven’t yet verified the validity of his criticisms, however, they are verifiable and don’t come with the usual ad hominem attacks - refreshing! Looking forward to @realDaveFeldman @nicknorwitz @AdrianSotoMota rebuttal

@TPieleanu Weird question, its 1998

@MichaelMindrum What year is this?

I am moving from aol to yahoo for email. Seems like a much better model.

Can AI read an ECG like a cardiologist - from just an image? We built ECG-GPT, a vision-text transformer that generates complete diagnostic reports directly from photos of 12-lead ECGs Now out in @ESC_Journals #EHJDigitalHealth Kudos to @aakhunte & @Veer_Sangha_ for leading this @cards_lab 🧵

I used scholara.ai to do this, an AI-native systematic review platform I co-founded (the chart I made in Claude!)

So true. So then their argument would be that type 2 DM and metabolic syndrome can be fixed by “cutting the carbs”, eat my way, and then don’t worry about LDL-c. And if offered any other advice realize that dietitian or doctor are ignorant, a pharma shill, part of the establishment, and likely will try to jab you with a vaccine.

@MichaelMindrum The women's health study keeps coming up in cholesterol denialism NO ONE ever said "No problem, have diabetes" LP-IR is also bad here NO ONE ever said "No, problem, don't worry about metablic health" EVERYONE said "don't get diabetes", "also pay attention to lipids"🤦

🚨 Holy shit...A developer on GitHub just built a full development methodology for AI coding agents and it has 40.9K stars on GitHub. It's called Superpowers, and it completely changes how your AI agent writes code. Right now, most people fire up Claude Code or Codex and just… let it go. The agent guesses what you want, writes code before understanding the problem, skips tests, and produces spaghetti you have to babysit. Superpowers fixes all of that. Here's what happens when you install it: → Before writing a single line, the agent stops and brainstorms with you. It asks what you're actually trying to build, refines the spec through questions, and shows it to you in chunks short enough to read. → Once you approve the design, it creates an implementation plan so detailed that "an enthusiastic junior engineer with poor taste and no judgement" could follow it. → Then it launches subagent-driven development. Fresh subagents per task. Two-stage code review after each one (spec compliance, then code quality). The agent can run autonomously for hours without deviating from your plan. → It enforces true test-driven development. Write failing test → watch it fail → write minimal code → watch it pass → commit. It literally deletes code written before tests. → When tasks are done, it verifies everything, presents options (merge, PR, keep, discard), and cleans up. The philosophy is brutal: systematic over ad-hoc. Evidence over claims. Complexity reduction. Verify before declaring success. Works with Claude Code (plugin install), Codex, and OpenCode. This isn't a prompt template. It's an entire operating system for how AI agents should build software. 100% Opensource. MIT License.

@MichaelAlbertMD We should create something

I’m sorry for big academic publishers, but there’s no compelling reason their business models should persist in the AI/tech era. The shift toward self-publication and open access is accelerating. You can replicate much of what journals like NEJM or The Lancet provide—distribution, visibility, even curation—almost overnight. There’s little justification for traditional paywalled models to keep thriving in their current form.

@dylanarmbruste3 It is odd. Further, hard to say “conventional medicine ignores metabolic factors” when we consider T2D an ASCVD equivalent.

@MichaelMindrum One wonders how you get, "..how irrelevant the lipid markers appear to be.." when looking at the forest plot.

If anything, statins are under-prescribed in moderate to high risk populations. Could be because the family physician or specialist did not calculate or consider their risk, or that it was discussed and patient opted out, or statin prescribed but patient never picked it up, or they picked it up and never started it, or they started it and then just stopped at some point. It’s tough to take a medicine daily for years to decades when you don’t feel any better and perhaps didn’t get a full explanation of the rational. The noise of statin side effects and the BS spread by Bikman et al doesn’t help.

@MichaelMindrum I have to disagree with this. I see patient after patient after patient with labs indicative of metabolic syndrome, yet I almost never see it as a diagnosis, let alone any efforts to intervene beyond meds. Practically never are there preventative diagnostics like CAC.