The Peanut Butter and Jelly Principle of Microvascular Disease

Richard M. Bergenstal, MD
Chief Medical Editor

Peanut butter is a good snack, actually a meat alternative, according to http://www.MyPyramid.gov.  Jelly has less intrinsic nutritional value but is enjoyed all the same. Alone each has found a certain place but neither has “set the world on fire.” Put them together and their true value emerges – peanut butter and jelly – a classic, a staple, a standard of care (or at least a standard fare).

Are there examples in medicine of this PB&J principle of both together being better than one alone? Here are a few:

• Vision or Action.

Vision without action is a daydream. Action without vision is a nightmare.

• Art or Science.

Wisdom (experience) or knowledge (evidence-based). These must be paired up to succeed in medicine.

• Prevention or Treatment.

Let’s stop arguing. Only with effective strategies addressing both will we make headway against diseases like diabetes and AIDS.

Examples of the PB&J principle in diabetes might include:

• Insulin deficiency and Insulin resistance.

Both contribute to hyperglycemia.

• Fasting and Postprandial.

Both contribute to the HbA1c.

• HbA1C and SMBG (glucose patterns and excursions).

Both important for assessing glycemic control and likely contribute to risk for complications.

• Inpatient and Outpatient glucose control.

Both require effective algorithms and standard approaches to avoid complications .

• Cost and Effectiveness.

Focus on one alone and some people will suffer.

Finally some examples of the PB&J principle in microvascular disease assessment:

• Eye – Diabetic retinopathy and Macular edema.

We must screen for both particularly in type 2 diabetes. Add a screen for visual acuity, cataracts and glaucoma to be complete.

• Kidney – Microalbuminuria and Serum creatinine.

One early, one late helps stage the disease. Add a calculated GFR and we have a good renal assessment and staging.

• Nerve – Tuning fork and Monofilament.

One early, one late helps stage the disease progression. Add a neuropathy symptom assessment including an autonomic survey and we have a good neuropathy evaluation.

In 2004, the journal Family Economics and Nutrition Review published an article entitled “Children Rate the Summer Food Service Program.” You guessed it, hands down the kids preferred the old familiar PB&J much more than the trendy sandwich wraps and definitely more than the universally dreaded bologna sandwich.

It is time we teach clinicians that patients will be better served if we tackle both of what are often considered opposing or redundant elements in medicine, diabetes and microvascular disease. We need it both ways – tastes great and less filling!