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Does Earlier Menopause Mean A Higher Risk of Diabetes?

>> Monday, November 20, 2017



Menopause is a major life transition for women, both psychologically and physiologically.  A number of changes occur in a woman's body that alters metabolism, unfortunately tipping the scales towards an increase in cardiovascular risk.  We know that an earlier age of menopause increases the risk of cardiovascular disease, and that a later age of menopause onset seems to be protective.

Whether earlier age of menopause increases the risk of developing type 2 diabetes has been somewhat controversial; a new study sheds additional light on this question.

The study, published in the journal Diabetologia, evaluated 3639 postmenopausal women from the population based Rotterdam study.  They followed these women for a median of 9.2 years, with the goal of assessing how the risk of developing type 2 diabetes may vary depending on the age of menopause.

They found that the risk for developing type 2 diabetes, compared to women with late menopause (at more than 55 years old), is:

  • 3.7 times higher for women with premature menopause (at less than 40 years old)
  • 2.4 times higher for women with early menopause (at 40-44 years old)
  • 1.6 times higher for women with normal age of menopause (at 45-55 years old)
They found that for every year later that menopause occurred, the risk of developing diabetes decreased by 4%.

So why would the risk of diabetes go up with earlier menopause? With menopause comes a natural decrease in our reproductive hormones (estrogen, progesterone, and testosterone).   These changes promote a loss of muscle and an increase in fat, especially the visceral fat that sits around our abdomen and internal organs - this is the fat that has negative effects on our metabolism.  A loss of progesterone, and hot flashes from having lower estrogen levels, can impair sleep, which is a known risk factor for obesity and metabolic syndrome.  The emotional challenges of menopause may bring out an increase in emotional eating for some women, which can promote weight gain and increase diabetes risk as well.

Interestingly, this study looked at several reproductive hormone levels at the start of the study, and showed that earlier menopause was associated with an increase risk of diabetes, independent of these hormone levels, and also independent of body mass index at baseline or shared genetic factors.

The authors hypothesize that earlier menopause and type 2 diabetes may be a consequence of epigenetic changes, which are changes that alter the physical structure of our DNA.  Epigenetic changes can be caused by a number of factors, including poor diet, smoking, and many other environmental factors. 

Further studies need to be done looking at epigentic changes to determine if these may be responsible for the association between earlier menopause and diabetes risk. If epigentic changes are at play here, living well and healthily throughout life is more important than ever!

After menopause, we can combat cardiovascular and diabetes risk by:
  • Keeping active - engage those muscles! This helps to combat the decrease in muscle mass. 
  • Making healthy permanent lifestyle changes 
  • Having good sleep hygiene
  • Getting help from your doctor if you are struggling with menopausal symptoms.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017









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Time To Take ACTION! Barriers To Effective Obesity Care

>> Tuesday, November 14, 2017



Despite the fact that obesity is one of the most prominent medical conditions in existence, it is sadly one of the most poorly treated. There exists very little education about obesity for health care providers, and the stigma against obesity is even stronger in the medical community than it is in the general population. Although this is slowly changing, only a small minority of people with obesity actually have this medical condition addressed and treated with the help of their health care provider.

The ACTION study was thus designed to better understand the barriers to effective obesity care. This study was a survey conducted in USA, completed by three groups of people:
  • 3,008 people with obesity
  • 606 health care providers (primary care/family medicine, internal medicine, and obesity specialists)
  • 153 employers who provide health insurance or wellness programs to their employees
Here are some of the key findings: 

1.  While over 80% of health care providers viewed obesity as a chronic disease, only 55% of people with obesity reported receiving an actual diagnosis of obesity. (How can a health care provider move towards treatment of this medical condition if they are not making the diagnosis?)

2. Top 5 reasons that health care providers reported as to why they may not initiate a conversation about weight loss: 
  • not enough time
  • more important issues to discuss
  • they did not believe their patient was motivated to lose weight 
  • they did not believe their patient was interested in losing weight (au contraire - data supports that the vast majority of people with obesity are interested in losing weight)
  • concern over patient's emotional state or psychological issues

3.  Top 5 barriers to initiating a weight loss effort (agreed to be the same top 5 by people with obesity, health care providers, and employers):

  • lack of exercise (note: exercise is less important for weight loss and more important for weight maintenance)
  • lack of motivation (could this be because of a lack of understanding of the causes and contributors to each individual's weight struggle?)
  • preference for unhealthy food (could this be because food is being used to medicate untreated depression or pain by releasing 'happy hormones' in our brains?)
  • controlling hunger
  • cost of healthy food
4. Only 24% of people who had a discussion about obesity with their doctor had a follow up appointment scheduled. (Obesity requires long term management - one appointment isn't enough!)

5. Only 17% of people with obesity felt that their employers' wellness offerings were helpful in weight management.


The ACTION study is truly a treasure trove of information that should help all components of  society better identify, understand, and gradually overcome the barriers to successful weight management.

You may be wondering if the results of the ACTION study applies to Canada or other countries, as attitudes and approaches can be very different in different parts of the world.  I'm thrilled to share that the ACTION study is currently underway in Canada (I am on the steering committee for this study) - stay tuned for our results next year. ACTION will be conducted in several countries around the world as well, with deployment planned to begin in 2018.


Disclaimer: The ACTION study is funded by Novo Nordisk, the maker of weight management medication Saxenda (liraglutide 3.0mg).



Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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Dexcom G5 Continuous Glucose Monitor - New Glucose Monitoring Technologies Part 2

>> Monday, November 6, 2017

The traditional way of monitoring blood sugars is with finger pokes, but there are other newer technologies out there that make it not only easier to check, but provide more data as well.

Two new technologies have recently arrived in Canada: the Freestyle Libre (see last week's post on this), which is a poke free glucose monitor, and the Dexcom G5 continuous glucose monitor, which allows you to broadcast sugars wirelessly to family or caregivers.   This week, we’ll review the Dexcom G5.  

The Dexcom G5 is a continuous glucose monitor (CGM). This consists of a sensor that you apply to your abdomen (lasts 7 days) which measures glucose in the interstitial fluid that surrounds your cells under your skin, as an estimate of blood glucose levels.  There is a transmitter that fits onto the sensor (lasts 3 months), which transmits continuous sugar readings to the reader that comes with it.  It has alarms for low or high sugars.  It needs to be calibrated against finger poke readings every 12 hours, so while the CGM can decrease the number of finger pokes, it doesn’t eliminate them entirely.  

While CGMs are not new to Canada, the exciting new feature of this model is that it transmits glucose values not only to the reader, but also to smartphones, iPads, and some smart watches.  Also, the Dexcom5 has been approved in Canada and the USA for making treatment decisions (the previous model, the Dexcom4, is not).  Though there have been reports of inaccuracies, the FDA concluded that 'the benefits of additional information gained from this device outweigh the inaccurate results, rates of change, and false negative and positive alarms and alerts'.  As far as the clinical trials go, the accuracy is reported to be within about 9% of actual blood sugar.  The cost is about $3100 per year (ouch!).

This can be a useful tool for parents (it’s approved down to age 2) or caregivers who want to keep an eye on their loved one’s sugars.  Also, CGMs with alarms have helped to keep many a patient of mine who have lost their ability to feel low blood sugars safer, waking them up at night when sugars are going low.   As for all of the interstitial glucose monitoring technologies - if in doubt about the glucose reading - check with a finger poke.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017





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Poke Free Glucose Monitor Has Arrived In Canada! New Glucose Monitoring Technologies Part 1

>> Monday, October 30, 2017




The traditional way of monitoring blood sugars is with finger pokes, but there are other newer technologies out there that make it not only easier to check, but provide more data as well.

Two new technologies have recently arrived in Canada: the Freestyle Libre, which is a poke free glucose monitor, and the Dexcom5 continuous glucose monitor, which allows you to broadcast sugars wirelessly to family or caregivers.   Today, we’ll review the Libre, and I’ll follow up with a separate post on the Dexcom5.

Finger pokes are uncomfortable, and can be a barrier to checking blood sugars.  As blogged previously, the Freestyle Libre system (pictured above) is an entirely new technology, consisting of a tiny monofilament sensor that you apply to your arm every 14 days.  It measures glucose in the interstitial fluid that surrounds the cells under your skin, as an estimate of blood glucose levels. Hold the reader near the sensor and Ding! - it will tell you your current glucose level, which direction your sugar is heading (up, down, or steady), a message on the screen if glucose is going low or high, and – get this – it will show you your last 8 hours of glucose readings in a graph. 

The Libre sensor is calibrated right out of the box, so there is no need for finger poking to calibrate it.  It is approved by Health Canada for making treatment decisions, provided that you take into account all of the info on the screen when you scan the reader.

You DO need to check with a finger poke (built into the reader) if:

  • sugar reads low or going low (very important, as the Libre may inaccurately indicate hypoglycemia)
  • during a time of a rapid blood sugar change (for example during exercise, after eating, or after taking a bolus of insulin; the reason being because interstitial glucose changes lag behind blood glucose changes); or
  • if your symptoms do not agree with the number you see when you scan (remember, though, that some people with diabetes are not able to feel it when their sugars go low - in that case, confirming with a finger poke may be needed more often) 

It’s less accurate on the first day you wear it, so I would suggest more reliance on finger pokes on day 1.  The accuracy improves to within about 9-11% of actual blood sugar after that. (Standard finger poke monitors have varying accuracy, and the analysis method for accuracy is different, but Diabetes Canada accepts within 15% accuracy for those monitors.)   It costs about $50 for the reader (one time cost), and about $90 for each sensor (replaced every 14 days).   There is a built in ketone meter as well, which is handy if there is a need to check ketones (more on this here).

The Libre provides the opportunity to decrease the need for finger pokes, and scanning just 3 times a day (every 8 hours) is enough to give a full 24h glucose profile, which can help you and your diabetes care providers understand your blood sugars in even more detail.

Stay tuned for info on the Dexcom5 continuous glucose monitor!


Disclaimer: I have received honoraria as a continuing medical education speaker and consultant from the makers of the Freestyle Libre (Abbott).

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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Anemia, Mortality, and Type 2 Diabetes

>> Monday, October 23, 2017





Health care providers out there may have noticed that anemia is a not-infrequent finding amongst patients with type 2 diabetes.

It turns out that there are multiple reasons for anemia in type 2 diabetes - and the health consequences may be severe.

A study was recently published evaluating the prevalence, risk factors, and prognosis of anemia in two groups of Australian patients.  They found that the prevalence of anemia was double to triple in people with type 2 diabetes, compared to people without diabetes.

They found multiple risk factors independently associated with a higher risk of anemia, including:

  • impaired kidney function: related at least in part to reduced erythropoeitin production by the kidneys, which is a hormone that stimulates red blood cell production
  • longer duration of diabetes: 5% increased risk of anemia per year of having diabetes - may be due to decreased red blood cell production and/or increased destruction, as consequences of chronically elevated blood sugar
  • metformin use: likely related to vitamin B12 deficiency, but other mechanisms such as low magnesium are considered
  • thiazolidinedione use [pioglitazone (Actos) or rosiglitazone (Avandia)]: likely related to fluid retention
  • peripheral arterial disease: possibly related to higher oxidative stress, inflammation, atherosclerosis
Other risk factors were identified as well, such as low iron, and low testosterone in men.

After adjustment for other independent predictors of mortality, anemia was associated with a 57% increased risk of mortality over the mean of 4.3 years of study, compared to people with diabetes but without anemia.

The good news is that many of these risk factors for anemia are treatable, and even preventable.  For example: optimizing blood sugar control; checking vitamin B12 in people on metformin; checking iron levels in people who are anemic and investigating for the cause of low iron if so.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017


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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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