Conclusions and recommendations: Where the Discordant Doppelganger Dilemma occurs in clinical practice is when the SGLT2i drugs are always chosen as first line, as per the latest ESC guidance. We then may potentially lose the chance to leverage diet and lifestyle changes first (TCR and VLED). The possible risk of hypoglycaemia or euglycaemic ketoacidosis exists when combining significant dietary change with SGLT2i. The physiology has been described as far as we know it earlier here and is constant and reproducible. The drugs work in highly controlled clinical trials but can have side effects and the lifestyle changes work in observational trials and specialist centres, but could be hard to maintain for everyone. So how can we get the drug-like outcomes, without financing or taking the drug? What is the right way to move forward when both can produce “mirror-like” results but they cannot therefore be combined? In a way we are lucky to have new options to improve the outlook for these patients but there remains a pertinent analogy: If we found out tomorrow that cancer could be prevented in 50% of people (or put into drug-free “remission”) by avoiding the ingestion of known substances, but at the same time an expensive drug could eliminate those substances from the body, what would be the best course of action for everybody? Taking this from a philosophical, moral, ethical, economic and human perspective? Should one avoid the known substances or keep ingesting the substances whilst concurrently eliminating them with the new “wonder” drug? Tight physiological glycaemic homoeostasis should be a human right but it has been somewhat hijacked by our need for food “rewards” and the vested interests of the processed food industrial complex. The sooner we return the power to individuals, in the form of continuous glucose monitoring and education on sensible dietary advice for a healthy life, the sooner we may stem the tsunami of morbidity and mortality associated with preventable cardiovascular disease.
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