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New 2018 Diabetes Canada Guidelines - Cardiovascular Protection

>> Tuesday, April 24, 2018





We know that reducing the risk of heart attacks and strokes in people with diabetes includes much more than just having good blood sugar control.

So what's new in the Cardiovascular Protection chapter of the Diabetes Canada Guidelines since the last Guidelines in 2013?  Well, as for every chapter, there are now...


KEY MESSAGES FOR PEOPLE WITH DIABETES: 

Ask your doctor about the ABCDEs to reduce your risk of heart attack and stroke:

A = A1C - blood sugar control (the target is usually 7% or less)

B = BP - blood pressure control (less than 130/80)

C = Cholesterol - LDL cholesterol less than 2.0 mmol/L.  Your health care profider may advise you to start cholesterol lowering medication.

D - Drugs to protect your heart - these include blood pressure pills (ACE inhibitors or ARBs), cholesterol lowering medication ('statins'),  and in people with existing cardiovascular disease, certain blood glucose lowering medications, which can protect your heart even if your BP and/or LDL cholesterol are already at target

E = Exercise/Eating - Regular physical activity, healthy eating, and achievement and maintenance of a healthy body weight.

S = Stop smoking and manage stress.


The recommendations for ACE/ARB have loosened a little bit.  While it was recommended in 2013 that anyone over the age of 55 with diabetes should be on an ACE or ARB provided no contraindications, this recommendation has now been modified, as no studies have clearly demonstrated CV benefit for people with diabetes over 55 without any additional cardiovascular risk factors.  However, ACE/ARB is still recommended for:

  • anyone with clinical cardiovascular disease
  • anyone with microvascular complications
  • age 55 or older with an additional cardiovascular risk factor or organ damage (protein in the urine, retinopathy, left ventricular hypertrophy)
So, since most people with diabetes age 55 or older have at least one additional cardiovascular risk factor, the vast majority of people over age 55 will still be recommended to take an ACE or ARB.

As far as cholesterol medication goes, guidelines for treatment with statins are unchanged.  If LDL cholesterol goals (LDL of less than 2 mmol/L, or greater than 50% reduction from baseline) are not achieved, consideration for the addition of ezetimibe is recommended. In people with diabetes who also have cardiovascular disease, a PCSK9 inhibitor may be used.


And, as blogged last week, for people with type 2 diabetes and established cardiovascular disease, consideration should be given for using a glucose lowering medication that has been shown to reduce the risk of cardiovascular events. 

Aspirin continues to be recommended for patients with established cardiovascular disease, at a dose now of 81-162mg daily (in line with the Canadian antiplatelet therapy guidelines). 

One of the Key Messages is also that there is emerging evidence that heart failure, even in the absence of a previous heart attack, is an important (and often unrecognized) complication of diabetes.  Health care professionals should be on the lookout for heart failure in their patients with diabetes.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018


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2018 Diabetes Canada Guidelines - Medications for Type 2 Diabetes

>> Monday, April 16, 2018



It can seem daunting to consider that in the treatment of type 2 diabetes, there are now 9 classes of medications available that lower blood sugars (and several different medications within each of these classes).  Which medications to choose, and in which order, are driven by data surrounding efficacy, safety, and ability to prevent cardiovascular events (one of the major diabetes complications we are aiming to prevent).  Over the last few years, we have seen several diabetes medications emerge that reduce the risk of cardiovascular events, and with this information, we are seeing more of an algorithm emerge that guides clinicians on which order to consider these different medications.

The 2018 Diabetes Canada Clinical Practice Guidelines Pharmacotherapy chapter now provides an algorithm that not only takes into account cardiovascular risk protection, but also prioritizes the diabetes medications that do not cause two unwanted side effects that are cause by some types of diabetes medications: weight gain, and low blood sugars (hypoglycemia).

This chapter is excellent, comprehensive, (necessarily) big and the list of key messages is long - I encourage patients to read the Key Messages for People With Diabetes, and clinicians to read the entire chapter, but here are some of the highlights:

1.  In people with type 2 diabetes with A1C less than 1.5% above the individual patient's target, glucose lowering medication should be added if targets are not reached with healthy lifestyle interventions within 3 months.

2.  In people with type 2 diabetes with A1C 1.5% or more above the patient's target, medication should be initiated concomitantly with healthy behavior interventions, and consideration could be given to initiating combination therapy with 2 medications.

(note that the old guidelines used an A1C of 8.5% as the cutoffs above. The new wording reflects that the A1C target, though usually 7% or less,  can be different from one person to the next - more on this here.)


3. Insulin should be started immediately if there is syptomatic hyperglycemia or metabolic decompensation.  In the absence of metabolic decompensation, metformin is still the first choice of medication in people with new type 2 diabetes.

4.  Target diabetes control should be achieved within 3-6 months.


5.  In people with cardiovascular disease in whom A1C targets are not achieved, a medication with cardiovascular benefit should be added to existing therapy: empagliflozin, liraglutide; or canagliflozin (with a lower grade and level of evidence for canagliflozin).

6.   In people without cardiovascular disease who are not at glycemic targets, DPP4 inhibitors, GLP1 receptor agonists, and/or SGLT2 inhibitors should be considered as add on medication over sulfonylureas, meglitinides, insulin and thiazolidinedones, if lower risk of hypoglycemia and/or weight gain are priorities. (Grade A, Level 1A evidence)

7.  In people who are on insulin who are not at blood sugar targets, adding a GLP1 receptor agonist, DPP4 inhibitor, or SGLT2 inhibitor may be considered before adding or intensifying mealtime insulin therapy, with less weight gain and comparable or lower hypoglycaemia risk.


8.  Newer basal insulins (degludec and U-300 glargine) may be considered over U-100 glargine to reduce overall and overnight hypoglycaemia.


This chapter now includes an excellent table (see table 1 here) that lists the effect of diabetes medications on A1C, weight, cardiovascular outcomes, and other therapeutic considerations as well.




Follow me on twitter! @drsuepedersen



www.drsue.ca © 2018



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2018 Diabetes Canada Guidelines Are Out!

>> Monday, April 9, 2018



The Diabetes Canada (formerly Canadian Diabetes Association) Guidelines are issued in full every 5 years.   As a coauthor of the Weight Management Chapter, I can tell you that these Guidelines have truly been a labor of love for all of us - more than two years with several rounds of evidence review, drafting, re-drafting as new data comes out.... and this is what makes our guidelines one of the most respected diabetes documents in the world!

The 2018 Guidelines are exciting, with a number of substantial changes from the 2013 edition in terms of approach, rigour of methodology, and recommendations.

Each chapter in the Guidelines is structured with a framework including:

Key Messages

Key Messages For People With Diabetes (this is new and awesome, and reflects that the Guidelines are intended not only for the use of health care providers, but also for people with diabetes)

Recommendations


Over the next weeks, I will be posting blogs highlighting some of the key points and changes to the guidelines, and I'll always include a link to the chapter itself if you'd like to read it in full.

Enjoy!

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018




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The Easter Waftata

>> Saturday, March 31, 2018






It's always fun to play around with a new recipe on the long weekend, when there's a little extra time!

I had never heard of a Waftata, but apparently it is a recipe reincarnated from days of yore - and super easy to cook in a modern day waffle iron! I have upped the flavour factor from the original recipe, and given options below for using eggs or egg whites in the recipe.  I think there is lots of opportunity to get creative with flavour - try adding paprika or oregano for an extra twist!

Ingredients:

  • 2 large eggs (or 1/2 cup egg white)
  • 1/3 cup part skim ricotta cheese
  • 2 tbsp onion, finely diced
  • 1 tsp minced garlic
  • 3 tsp freshly chopped parsley
  • 1/8 tsp salt
  • 1/4 tsp ground pepper
  • 1/2 cup peeled and shredded white potato
  • 1/2 cup finely diced apple (with or without skin)




Directions:

1.   Beat eggs in a small bowl.

2.  Add ricotta, onion, garlic, parsley, pepper and salt.  Whisk well.

3.  Preheat your waffle iron.

4.  Stir potato and apple into the mixture.

5.  Spray waffle iron with non stick spray and pour mixture onto it.

6.  Close lid and bake until eggs are set and golden brown.


Makes 2 servings.  Per serving:  (with whole eggs)

  • Calories: 160
  • Carbs: 12.5g
  • Fat:  6.5g
  • Protein:  11g

If you substitute 1/2 cup egg whites for the two eggs:
  • Calories: 115
  • Carbs: 12.5g
  • Fat: 2g
  • Protein: 13g


Enjoy!

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018

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How Weight Loss Affects Different Body Tissues, Fat Genes, And Inflammation

>> Monday, March 26, 2018


(this is fat tissue under a microscope)



We know that a 5-10% weight loss improves many health conditions associated with obesity.  However, it is very interesting to note that some health issues like blood sugar starts to improve with as little as 2-3% weight loss, whereas other health issues like sleep apnea require closer to 10% weight loss before we start to see improvements.  Why is this?


An eloquent study helps us to understand how different tissues in our body respond to weight loss.  This was a randomized controlled clinical trial, assigning 40 patients to a target 0%, 5%, 10%, or 15% weight loss, and then conducted an array of testing to understand the metabolic changes that occur at each of these degrees of weight loss.  Testing was extensive and included assessment of body composition, 24h blood pressure monitors, blood testing for metabolic parameters and inflammatory markers, tests of organ-specific insulin sensitivity, and even biopsies of fat tissue. Participants were weight stable for at least 3 weeks before testing was conducted.

Key findings were truly fascinating.

After a 5% percent weight loss:
  • There was a decrease blood sugar, insulin levels, triglycerides, ALT (liver test)
  • systolic blood pressure decreased (the top number), but not diastolic (bottom number)
  • NO effect on good cholesterol (HDL), bad cholesterol (LDL), glucose tolerance test (OGTT)
  • improvement in insulin sensitivity in fat, liver, skeletal muscle 
  • improvement in beta cell function (the cells in the pancreas that make insulin)

After 11% weight loss: (the 10% group ended up losing 11%)
  • continued reduction in insulin and triglycerides 
  • altered gene expression in subcutaneous fat tissue - including genes involved in fat synthesis, cholesterol flux, and inflammation
  • no additional benefit to insulin sensitivity in fat tissue or liver
  • additional improvement in insulin sensitivity in skeletal muscle
  • additional improvement in beta cell function

After 16% weight loss: (the 15% group ended up losing 16%)
  • reduction in inflammatory markers (plasma free fatty acids, CRP)
  • more marked altered gene expression in subcutaneous fat tissue - including genes involved in fat synthesis, cholesterol flux, and inflammation
  • continued reduction in insulin and triglycerides
  • no additional benefit to insulin sensitivity in fat tissue or liver
  • additional improvement in insulin sensitivity in skeletal muscle
  • additional improvement in beta cell function

So what is the BOTTOM LINE from this (rather complicated) study?   

1. A 5% weight loss has important benefits to our health, primarily related to a decrease in our body's resistance to insulin.  

2. Further weight loss continues to improve our body's insulin resistance (particularly in muscle), with additional improvements in our metabolic health.  

3.  At 11% weight loss, we start to see changes in how our fat tissue expresses genes, in favour of better health.

4.  At 16% weight loss, there is a decrease in inflammation in our bodies, and a more marked change in fat tissue gene expression.

While a smaller degree of weight loss (even just 2-3% based on other studies) has a very important impact on our metabolic health, the changes in inflammation and fat gene expression seen at over 10% weight loss may well be what it takes to see benefits in other medical conditions associated with obesity, such as obstructive sleep apnea and arthritis.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018




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A HEARTFELT WELCOME!

I am excited that you have arrived at my site, and I hope you are too - consider this the first step towards a Healthier New You!! As a medical doctor, Endocrinologist, and obesity specialist, I am absolutely passionate about helping people with weight management. Though there is certainly no magic cure for obesity, there IS a successful treatment plan out there for you - it is all about understanding the elements that contribute to your personal weight struggle, and then finding the treatment plan that suits your needs and your lifestyle. The way to finding your personal solution is to learn as much as you can about obesity: how our toxic environment has shaped us into an overweight society; the diversity of contributors to obesity; and what the treatment options out there are really all about. Knowledge Is Power!!


Are you ready to change your life? Let's begin our journey together, towards a healthier, happier you!!




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