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Blueberry Zucchini Loaf!

>> Sunday, May 21, 2017







This May long weekend, I'm sharing a delightful loaf that I concocted in my kitchen one Sunday afternoon.... I had a hankering for a healthy muffin, and I was fresh out of muffin cups after trying out an online recipe that produced something resembling a dough pellet (epic fail!).  I had just been to Costco and had way more zucchinis than I knew what to do with.... sooo... voilĂ !  And it turned out great.

Ingredients:
  • 1.75 cups whole wheat flour
  • 1/2 cup white sugar
  • 1/4 cup brown sugar
  • 1.5 tsp baking soda
  • 2 tsp cinnamon
  • 1/2 tsp nutmeg
  • 1/4 cup canola oil
  • 1/4 cup milk
  • 1/4 cup greek yogurt fat free
  • 4 tbsp egg white
  • 2tsp vanilla
  • 1.5 cups shredded zucchini
  • 1/2 cup blueberries

Directions: 

1.  Preheat oven to 350F. 

2.  Mix first 6 ingredients (the dry ones) together in a large bowl. 

3.  Whisk together canola oil, milk, greek yogurt, egg white, and vanilla in a separate bowl until smooth.  Stir into flour mixture until batter is just moistened.  Fold zucchini and blueberries into batter. 

4.  Spray a standard loaf pan (8.5" x 4.5") with non stick spray, and pour batter in. 

5.  Bake 35-40 minutes, until a toothpick inserted into the centre comes out clean.


Makes 12 slices.  Per slice: 
  • Calories: 169
  • Fat: 4.8g
  • Carbs: 28g
  • Protein 3.2g

Note: I think this would also be good with half the white sugar (1/4c instead of 1/2 cup) - if you try this, let me know how it tastes (post a comment at the end of this post). 



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Does Intermittent Fasting Work?

>> Monday, May 15, 2017




One of the diet approaches that has really taken off in popularity is Intermittent Fasting.  Essentially, this means that certain days/times you restrict eating (or don’t eat at all) and other days/times, you feast.  This can take the form of Alternate Day Fasting (fast one day and feast the next), restricting on some days (eg weekdays) and feasting on others (eg weekends), or restricting eating to only a few hours each day.

Most studies showing benefit of intermittent fasting have been of very short duration (less than 12 weeks) – and let’s face it, just about anything can work over this very short term.  Now, a one year randomized controlled clinical trial has investigated whether intermittent fasting works.

The study, published in JAMA Internal Medicine, is quite a beautifully conducted trial (in my opinion), randomizing 100 people with obesity to one of three groups:

  • Alternate day fasting: 25% of energy needs on fasting days, and 125% of energy needs on non fasting days
  • Daily calorie restriction: 75% of energy needs on all days
  • Control group: no intervention (they received 3 months of free weight loss counselling and a 1 year free gym membership at the end of the study)

Participants followed the above for the first 6 months of the study, which was the weight loss phase. 

For the second 6 months, the focus was on weight maintenance. Calorie needs were reevaluated (because we need less calories to maintain weight following weight loss), and the groups proceeded as follows:

  • Alternate day fasting: 50% of energy needs on fasting days, and 150% of energy needs on non fasting days
  • Daily calorie restriction: 100% of energy needs on all days
  • Control group: no intervention


For the scientists in the audience: Total daily calorie needs were assessed using doubly labeled water, assessed at baseline and again at the start of the weight maintenance phase (t=6 months).  Analysis was by intention to treat.

At 12 months, the rate of dropout from the study was highest in the alternate day fasters at 38%, compared to 29% in the daily calorie restriction and 26% in the control group.

They found that the weight loss between the alternate day fasting and daily caloric restriction were no different at 6 months or 12 months.  Weight loss was 6.0% greater than the control group at one year in the intermittent fasting group, vs 5.3% greater than the control group in those on daily calorie restriction.   Other than a slightly higher bad cholesterol (LDL) in the intermittent fasters, there were no differences in any metabolic parameter.

While the study is small, it is the longest and largest clinical trial of alternate day fasting to date. 


BOTTOM LINE: The results of this study suggest that alternate day fasting is no better than daily calorie restriction for weight loss, and that the likelihood of sticking to the diet is lower with alternate day fasting.


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www.drsue.ca © 2017
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Let's Take ACTION - Barriers To Effective Obesity Management In Canada

>> Monday, May 8, 2017





Obesity is a chronic medical condition that affects 25% of Canadian adults. As we know from the recently released Canadian Report Card On Access to Obesity Treatment, we are doing very poorly in terms of providing publicly funded access to treatment for obesity.

So what are the barriers that are preventing people with obesity from getting access to obesity care?  In addition to collecting important statistics in the Canadian Report Card, we also need to understand barriers from the perspectives of people living with obesity as well as their health care providers.

The ACTION study is the first nationwide study in Canada to investigate barriers to effective obesity management from the perspective of people with obesity, healthcare providers, and employers who provide health programs or health insurance coverage.  This study aims to generate insights to guide collaborative action to improve care, education, and support for people with obesity, and to provide evidence upon which to change how patients, health care providers, and employers treat obesity.

The ACTION study steering committee (of which I am a member) has been working to construct questionnaires that will be deployed to patients, health care providers, and employers across the country, to gather information on these important topics.

By understanding these perspectives, we hope to improve communication, education, and break down barriers to allow better access and provision of care for people with obesity.

Stay tuned for the results of this study early next year!


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

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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Do GMO Foods Cause Obesity?

>> Monday, May 1, 2017






Genetically modified organisms (GMO) refers to any living thing that has had its DNA modified by genetic engineering techniques.  GMO foods have been developed to be resistant to pests and herbicides, and/or for better nutritional content.   With the introduction of GMO foods, we have seen a parallel rise in obesity rates.  Could GMO foods have a role in this?

There is very little data on this issue. One study looking at American food trends and obesity found that consumption of corn products correlates with the rise in obesity.  Most American corn that is grown is genetically modified - so is it an increased calorie intake from corn products, or that it is genetically modified, that may be responsible correlation?  Or is the correlation purely coincidental? More research needs to be done.

A comprehensive review of dietary and policy priorities for cardiovascular disease, diabetes, and obesity published in the journal Circulation in 2016 found that existing evidence does not support that GMO food causes harm, but that the data are limited.   They point out that any potential effect of a GMO food on human health (positive or negative) would relate to specific compositional changes in the food, not to the GMO method itself.

As these authors state:

Based on current evidence, whether a food is organic or genetically modified appears to be of relatively small health relevance in comparison with the overall types of foods and diet patterns actually consumed. 


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Breaking News - Canada's Report Card On Access To Obesity Treatment

>> Tuesday, April 25, 2017


Obesity is a treatable chronic medical condition that affects over 25% of Canadian adults.  But how well are we doing at treating obesity in Canada?

Today, the Canadian Obesity Network has released the Report Card On Access To Obesity Treatment For Adults In Canada. This is the first rigorous assessment of the degree to which Canadians with obesity can access publicly funded treatments such as dieticians, psychological counselling/support,  medically supervised weight management programs, medications for obesity, and bariatric surgery.

The Report, not unexpectedly, showed that access to care for obesity in Canada is extremely limited.

  • There is very little publicly funded access to dietary counselling, mental health support, cognitive behavioural therapy, or exercise professionals. 
  • There is no public coverage for anti-obesity medication, and only about 20% of private medical plans offer coverage. 
  • Bariatric surgery is available to only 1 out of every 183 adult Canadians per year who may be eligible for it (this varies widely by province, with the best availability of 1/90 in Ontario, and the lowest availability of 1/1,312 in Nova Scotia).  


So why is access to obesity care in Canada so poor?

1.  Despite the Canadian Medical Association declaring that obesity is a chronic medical condition (and not a lifestyle issue) in 2015, neither Health Canada, nor the federal government, nor any provincial governments have followed suit. This results in a lack of policies that support obesity care.

2.  Medical schools have little to no formal obesity training, and very few Canadian doctors pursue additional obesity training of their own accord.   Only 40 out of 80,544 doctors in Canada have completed certification through the American Board of Obesity Medicine. (there is no formal obesity training equivalent in Canada)

3.  There remains a powerful and pervasive obesity stigma in Canada, which has been shown to be even worse in the medical community than in the general population.  Person-first language is often not used in government resources nor in medical literature - meaning that obesity is used as a description of a person rather than as a diagnosis. (The correct terminology is a 'person with obesity', not an 'obese person'.)

4.  Government programs tend to focus on health promotion and obesity prevention, which is important, yes, but with a lack of attention to helping people who have obesity and need treatment for it.


So, where does this leave us?  The Report recommends:

  • Government, employers and the insurance industry need to adopt the position that obesity is a chronic medical condition and orient their approach and resources accordingly;
  • Government needs to recognize and help break down weight bias and stigma;
  • Obesity training for health care professionals needs to increase;
  • Governments need to increase funding and access to interdisciplinary care, weight management programs, anti-obesity medications, and bariatric surgery; 
  • The Canadian Clinical Practice Guidelines, last published in 2006, need to be updated (and we are starting work on this!)

It seems we have a lot of work to do. 


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Dangers of Green Tea Extract

>> Monday, April 17, 2017



Unfortunately, in today's society and times, more people are reaching out than ever before for anything to help manage their weight, including naturopathic remedies.  On this list is green tea extract. Sounds like it must be safe, right?  It comes from something natural, after all....

CBC's Marketplace launched an investigation into green tea extract, featuring my colleague in obesity medicine,  Dr Sean Wharton.   They discovered more than 60 documented cases worldwide of liver failure associated with green tea supplements, with at least 2 deaths that may have been related to taking these pills.

Take 20 minutes and have a listen.

The bottom line is this:  Because it's natural does not mean it is safe.




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Could Yo-Yo-Ing Weight Increase Risk Of Heart Attack?

>> Monday, April 10, 2017




In the effort to manage excess body weight, many people have experienced the 'yo-yo' effect: start a diet, weight goes down... end the diet, weight goes back up (and then some, in many cases).  We already know that this fluctuation in weight is damaging to metabolism, in that our bodies essentially remember the highest weight we have ever had, making powerful hormonal and metabolic changes to drive us back up to our highest weight.  Now, a study in the New England Journal of Medicine demonstrates that fluctuation in body weight is associated with a higher rate of heart attack and death in people who have coronary artery disease.

The study evaluated fluctuations in body weight amongst 9,509 people with heart disease, who were enrolled in the TnT trial of cholesterol medication atorvastatin, taking the opportunity to evaluate whether fluctuations in weight made a difference in terms of risk of having a cardiovascular event.  In a post hoc analysis, they found that the greater the weight fluctuation, the higher the risk.  Specifically, for every 1 Standard Deviation (SD) in weight, there was a 4% increase in risk for any cardiovascular event, and a 9% increase in risk of death, independent of other cardiovascular risk factors.  Among patients in the top 20% for fluctuations in body weight, there was an 85% higher risk of a cardiovascular event and over a double increased risk of death, compared to those in the lowest 20% for fluctuations in body weight.  The risk associated with weight fluctuation was higher in those with obesity or overweight, compared to those of normal body weight. Also, a greater body weight fluctuation was also associated with a higher risk of developing type 2 diabetes.

One wonders whether these findings could simply reflect that people who had wide fluctuations in weight were sicker in general (eg big weight loss with illness), though this clinical trial did exclude people with a poor prognosis. The study also did not assess whether the weight fluctuations were intentional (eg dieting) vs unintentional (eg illness).  

We cannot infer causality from this study - in other words, we can't be sure that the weight fluctuations were the cause of the increased cardiovascular events - but the association between weight fluctuation and cardiovascular events was nevertheless strong.  Given these findings, it seems more important than ever to avoid yo-yo weight changes by making permanent lifestyle changes rather than engaging in temporary solutions/programs to optimally manage weight.


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www.drsue.ca © 2017








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After Bariatric Surgery - Patients' Perspectives

>> Monday, April 3, 2017





There is no doubt that bariatric surgery is a hot topic of research these days.  Most of this research focuses on the medical benefits that can be enjoyed after bariatric surgery, such as improvements in diabetes control, high blood pressure, sleep apnea, and so forth.  Much less qualitative research has been done - the kind of research that looks at things that are hard to measure with numbers, such as psychological effects and changes in quality of life. Most of the qualitative information that has been published is on small groups of individuals, and it is challenging for patients or clinicians to synthesize this smattering of data as a whole.

Coulman and colleagues recently collected information on this topic in the first systematic review of qualitative research in the bariatric surgery field.  Published in Obesity Reviews (and free to download!), they included 33 studies reporting on the patient perspective on living with the outcomes of bariatric surgery.

Three themes were identified:

1.  Control.  Patients reported making the decision to undergo bariatric surgery to gain control over eating, weight, and health.  In general, a feeling of improved control was experienced in the first year after surgery, but after a year, there was less of a sense of physical control (described as 'stomach control'), and it became more about relying on their own 'head control' to manage food intake.

2. Normality.  A sense of 'normality' was something that many patients were striving for after bariatric surgery - lives less burdened by physical and psychological ill health, ability to participate in normal everyday activities, and what patients described as a more 'socially acceptable' appearance.  While many people felt more 'normal' after surgery, there were also several issues identified that challenged patients' desire to feel 'normal'.  This included a change in their own or others' perceptions of their bodies, unpleasant gastrointestinal side effects (eg vomiting or diarrhoea), not being able to eat like others, and loose hanging skin.

3.  Ambivalence. Patients reported that while some things changed for the better, other changes were difficult to cope with or adapt to. This included physical pros (improvement in metabolic health) and cons (gastrointestinal and nutritional side effects of surgery).  This also included psychological pros (improvement in depression, self esteem, control) and cons (eg continued depression and self esteem issues with a realization by some that bariatric surgery was not going to fix these issues; challenges of finding ways other than food to cope with emotions; feeling a loss of protection from the outside world and a feeling of vulnerability with weight loss).

This review is a treasure trove of information, including quotes from patients, and is a great read in its entirety.   These findings highlight that while bariatric surgery is an excellent treatment strategy for some people, for others it may not be the best choice.  These findings certainly speak to the need for long term follow up for patients who have had bariatric surgery, including long term psychological and nutritional support.

As the authors write: Surgery was not the end of their journey with obesity, but rather the beginning of a new and sometimes challenging path.


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www.drsue.ca © 2017

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Is the Birth Control Pill Less Effective In Obesity?

>> Monday, March 27, 2017





The birth control pill is used by many women for prevention of pregnancy.  While generally very effective to prevent pregnancy if taken correctly, failure to prevent pregnancy can occur.

It has been noted in observational studies that women with obesity may have a higher risk of birth control pill failure, compared to women without obesity.  How could this be?

It turns out that the oral contraceptive has altered pharmacokinetics in obesity - meaning that the way the body handles the medication is a little bit different. Specifically, some research has suggested that the half life of the birth control pill is longer, meaning that it takes longer for the pill to reach therapeutic levels in women with obesity (ie at the beginning of the pack each month).

Strategies to minimize birth control pill failure in women with obesity have been suggested, such as taking the pill continuously, or using a higher dose than the low dose regimens that are commonly prescribed.   However, these strategies would have to be weighed against the potential for increased risks such as potential increased risk of blood clots with higher estrogen exposure.  One thing I feel we can conclude from this information is that taking the pill correctly (not starting a new pack late, not missing doses, and taking it within the required time frame each day) is especially important.


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www.drsue.ca © 2017

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New Cholesterol Medication Evolocumab Reduces Cardiovascular Events

>> Sunday, March 19, 2017





In follow up to my recent blog post, we now have the detailed results from the FOURIER trial, demonstrating that the PCSK9 inhibitor evolocumab reduces cardiovascular events in patients with cardiovascular disease.

Just published (and free to read online) in the New England Journal of Medicine, this large study randomized 27,564 patients to either evolocumab or placebo, to examine the impact on the primary endpoint of cardiovascular death, heart attack, stroke, hospitalization for unstable angina, or coronary revascularization.  Patients in the study already had existing cardiovascular disease, had a bad cholesterol (LDL) of 1.8 mmol/L or greater, and were all on statin therapy (the current gold standard group of lipid lowering medications).

After a median of 2.2 years, evolocumab reduced cardiovascular events by 15%, with 9.8% of patients on treatment having an event, vs 11.3% of patients on placebo. This difference was driven by a reduction in heart attack, stroke, and coronary revascularization, with no significant difference in cardiovascular death or hospitalization for unstable angina.

Evolocumab reduced LDL by 59%, from a median baseline value of 2.4 mmol/L to 0.78 mmol/L. The reduction in cardiovascular events was consistent, regardless of baseline LDL.  The only side effect that was significantly different between the evolocumab vs placebo groups was injection site reaction, seen in 2.1% vs 1.6% of patients respectively.

While these results give us important information regarding the benefit of evolocumab in patients with established cardiovascular disease, we still need data to know if these benefits would also be enjoyed by people with high cardiovascular risk but without established cardiovascular disease. We also need to know more about long term effects of PCSK9 inhibitors.  As noted in the accompanying editorial, it is not known whether prolonged exposure to extremely low LDL levels could affect neurocognitive function (though no difference was seen in the FOURIER study); longer term studies are underway.

The benefits of additional LDL lowering with evolocumab in addition to statins to reduce cardiovascular events in patients with established cardiovascular disease are clear from this study.  Cost of currently available PCSK9 inhibitors (evolocumab and alirocumab) are currently a major limitation to their use, but hopefully this will change with time as evidence regarding benefits hopefully accumulate.

Disclaimer: I have been involved as an investigator in a clinical trial of PCSK9 inhibition.

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www.drsue.ca © 2017








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Excess Weight Is Risk Factor for Developing Multiple Myeloma

>> Monday, March 13, 2017




We know that carrying excess weight is a risk factor for many types of cancer, including colon, breast, liver, kidney, and several others.  A new study suggests that in people who carry a risk factor for multiple myeloma called MGUS, having excess body weight increases the risk of developing multiple myeloma.

MGUS stands for Monoclonal Gammopathy of Undetermined Significance.  When people have MGUS, their bone marrow makes too much of one type of white blood cell, which makes this MGUS protein.  In most cases, MGUS does not lead to any problems, but in some cases, MGUS can progress to a cancer called multiple myeloma.

The study, published in the Journal of the National Cancer Institute, analyzed data on 7,878 patients from the US Veterans Affairs database (predominantly men), diagnosed with MGUS. Over a median of 5-6 years, they found that 4.6% of patients with overweight and 4.3% of patients with obesity went on to develop multiple myeloma, compared with only 3.5% of patients with normal weight.

In the multivariable analysis that controls for other factors, they found that patients with overweight and obesity with MGUS had a 55% and 98% higher risk of progression to multiple myeloma, respectively, than normal-weight patients with MGUS.

I have seen many online agencies reporting on this study leading with titles like 'Weight Loss May Help Prevent Multiple Myeloma'.  While this study does suggest that carrying excess weight increases the risk of multiple myeloma, this does not prove that weight loss decreases the risk.  Additional studies need to be done to understand whether healthy weight loss in people with MGUS helps to prevent progression to multiple myeloma.



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Slow Cooked Pulled Pork Tenderloin With Apples!

>> Monday, March 6, 2017






One word: YUM.  Ok two words: HEALTHY!  Pulled pork is a favourite for adults and kids alike... the only problem is, it is usually made with high fat cuts of pork and doused in high sugar, high calorie barbeque sauce or something similar.   Pork shoulder has a whopping 24g of fat and 317 calories per 100g serving - contrast this with pork tenderloin, which has just 3.5g of fat and 143 calories per 100g serving!

I went on a mission to come up with a delicious concoction using pork tenderloin, which is a lean cut of pork, and voilĂ ! Success. I used this recipe as the base, and sauced it up Dr Sue style.  It was a huge hit at our house!


INGREDIENTS:

  • 1 kg pork tenderloin (2 tenderloins)
  • 3 Gala apples, sliced into wedges
  • 1 sweet onion, sliced into strips
  • 5 cloves of garlic, chopped finely
  • 2 cups 100% apple juice
  • 1 cup chicken broth
  • 1/4 cup pure maple syrup
  • 2 tbsp oregano
  • 3 tbsp Mediterranean spice (or Italian)
  • salt and pepper to taste


DIRECTIONS:  It really IS this easy!

1. Put everything into your slow cooker. Put the pork tenderloin in first so that it is submerged in liquid while cooking.  Set on low and cook for 8 hours.

2. Around 5-6 hours into cooking, use two forks to start pulling the pork apart parallel to the fiber of the meat.

3.  Around 7 hours, finish pulling the pork apart - at this point it should really be looking like pulled pork (tendrils of meat).


Serve over one half of a whole wheat bun, or eat on its own!

Makes 10 servings.  Per serving: (not including the bun)

Calories: 223
Fat: 3.5g
Carbs: 19.5g
Protein: 26g


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www.drsue.ca © 2017

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How Does Breastfeeding Protect Against Obesity?

>> Monday, February 27, 2017



Breast is best, when women are able to breast feed – we know this without a doubt.  Infants who are breastfed enjoy a long list of health benefits, including a reduced risk of infections, autoimmune diseases, SIDS, leukemia, and more.

Breastfeeding reduces the risk of obesity as well – the available data on this suggests that there is a 15-30% reduction in adolescent and adult obesity rates if any breastfeeding occurred in infancy, compared with no breastfeeding.  With the reduction in obesity risk comes a 40% decreased risk of the child developing type 2 diabetes later in life as well.  

So, how does breastfeeding protect against developing obesity later in life?  Well, there are a number of hypotheses.  For one, when a baby is breastfeeding, the amount of milk s/he takes in is self regulated. Simply put: when they are full, they stop drinking.  When a baby is bottle fed, there may be a push for baby to finish the bottle  - possibly resulting in the baby taking in more food than s/he otherwise would have.  Thus, with breastfeeding, the baby’s brain is programmed to self regulate how much s/he wants to eat – programming that is likely carried on with them later in life.

Secondly, the gut bacteria that the baby develops may be influenced by whether the baby is breast or bottle fed.  We now know that the type of gut bacteria we carry can have a significant impact on the risk of obesity and metabolic disease such as diabetes.   Also, if a baby needs to take antibiotics, this can change the bacteria in his/her gut and may affect the risk of obesity.  Breastfed infants have a markedly lower risk of respiratory and gastrointestinal tract infection, portending a lower risk of needing antibiotics as well.

Thirdly, what the baby is being fed is of course different.  While every effort has been made to make infant formula as close to human milk as possible, there are many differences, with many factors unique to human milk that may affect nutritional status, energy balance and/or satiety.   

Still so much we need to research, learn, and understand about this fascinating area!


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www.drsue.ca © 2017




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Will Bariatric Surgery Help Me Control My Diabetes?

>> Monday, February 20, 2017






One of the major reasons why we might suggest bariatric (obesity) surgery to our patients with obesity and type 2 diabetes, is that studies have shown bariatric surgery to be very effective in improving diabetes control, or even putting diabetes into remission.  However, it has been slow to grow the body of research data in this area, as it is difficult to conduct high quality, long term studies in this field.

Now, just published, we have 5 year data showing that bariatric surgery (gastric bypass surgery and sleeve gastrectomy) are superior to medical therapy to treat type 2 diabetes in people with obesity.

I blogged on the 3 year data in this trial, called the STAMPEDE trial, when it came out in 2014 - where you can read about the structure, goals of the study and the results at that time.

Now, published in the New England Journal of Medicine, the extended results of the STAMPEDE study show that 5 years after bariatric surgery, 29% of patients who had gastric bypass surgery had tight control of their diabetes, vs 23% of those who had sleeve gastrectomy, vs only 5% of those who had intensive medical treatment alone.  A duration of diabetes of less than 8 years before surgery was the main predictor of achieving tight control of diabetes, suggesting that earlier intervention with bariatric surgery may give the maximum benefit in glycemic control.

There were also greater improvements in body weight, several measures of cholesterol, need for insulin, and quality of life in the surgical groups.  No late major surgical complications were reported except for one person in the sleeve gastrectomy group who underwent gastric bypass at year 4 to treat a gastric fistula.  Follow up at the 5 year mark was 90%, which is excellent.

While I still take issue to the target for diabetes control being too tight in this study at an A1C of 6.0%, this study does now give us good 5 year data to support that bariatric surgery can be an effective tool to help treat type 2 diabetes in people with obesity.

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Benefits of Continuous Glucose Monitoring With Insulin Injections in Type 1 Diabetes

>> Monday, February 13, 2017






In people with diabetes, continuous glucose monitoring (CGM) is an alternative to checking sugars with frequent finger pokes.  CGM is available as a stand alone tool, or can be integrated with an insulin pump system.  Most studies showing the benefits of CGM were done in people using insulin pumps.  Now, two studies show the benefits of CGM in people with type 1 diabetes using insulin injections to treat their diabetes.

The first study, published in JAMA, randomized 158 people with type 1 diabetes using insulin injections to use of either the usual form of self blood glucose monitoring (finger pokes) vs CGM.  At 6 months, the hemoglobin A1C (a marker of diabetes control) was 0.6% lower in the people using CGM compared to those using finger pokes.   People using finger pokes to check sugars during the study were also wearing a CGM during the study, but they could not access the readings on the CGM, with the purpose being for researchers to analyze what the CGM showed in the people using finger pokes during the study.  Importantly, this analysis found that people using CGM spent 37 minutes less per day with low blood sugar (43 minutes per day, compared to 80 minutes per day for people using finger pokes).

The second study, also published in JAMA, compared the effect of CGM vs finger poke monitoring in the same person, using a crossover design.  Patients were randomized to use either CGM or finger pokes for 6 months, then did the reverse for the next 6 months (with a 17 week break in between).  Amongst these 161 patients with type 1 diabetes, hemoglobin A1C was 0.43% lower during the time of CGM use, and they also reported less fear of hypoglycemia, greater well being and greater treatment satisfaction while using CGM. Patients were hypoglycemic 4.79% of the time while using finger pokes (using data from masked CGMs), vs 2.79% of the time with use of CGM.

One thing that I found particularly disturbing about these studies was the amount of time patients spent with low blood sugars.  While CGM improves upon this, we would ideally like patients with diabetes to have zero hypoglycemia.  CGM units have alarms that alert a patient when blood sugar is low, which can be lifesaving, especially for people who don't feel their low sugars and are at risk of sleeping through a low.  Hopefully improved glucose monitoring technology, as well as better insulins being developed, will help us to reduce lows further.  CGMs are unfortunately quite expensive, though some people are able to get the expense covered - talk to your insurance provider (if you have one) and/or your diabetes educator to find out about your options.

These studies clearly support the potential benefits of continuous glucose monitor (CGM) use in people with type 1 diabetes using insulin injections.


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www.drsue.ca © 2017


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New Class of Cholesterol Medication Prevents Heart Attacks

>> Monday, February 6, 2017




Statin medications have long been the main class of medications that have been recommended to lower cholesterol, as they have been shown to be very powerful to reduce the risk of cardiovascular events.  Now, a new class of medications joins the ranks of statins: the PCSK9 inhibitor evolocumab (Repatha) has been shown to reduce cardiovascular events.

The top-line results of the study, called the FOURIER study, have now been released.  This was a study of 27,500 patients with cardiovascular disease who were already on optimized statin therapy, randomized to receive either evolocumab or placebo.  They found that evolocumab reduced the risk of their primary endpoint, which was the sum of cardiovascular death, non fatal heart attack, non fatal stroke, hospitalization for unstable angina, or coronary revascularization (angioplasty).

I am looking forward to learning more about the results of this trial and the amount by which risk was reduced - these data will be released in March at the American College of Cardiology meeting in Washington DC.  It will be interesting to compare these results to the results of the IMPROVE-IT trial, which showed that the combination of statin therapy with the cholesterol lowering medication ezetimibe lowered the risk of cardiovascular death, major coronary events, or non fatal stroke by 2.0 percentage points compared to statin therapy alone.

It is encouraging to see a new class of cholesterol medications being developed that reduce cardiovascular events.  There are many patients who do not tolerate statin therapy; perhaps the PCSK9 inhibitors may also reduce cardiovascular risk for them (studies on this are currently underway).  PCSK9 inhibitors are extremely expensive, which limits their use in clinical practice.  Perhaps with these data, guidelines will be revised and we may hopefully see more coverage options so that the benefits of PCSK9 inhibitors to reduce cardiovascular events can be more widely enjoyed.

Disclaimer: I have been involved in a clinical trial of PCSK9 inhibition. I have received honoraria as a medical education speaker and consultant from the makers of ezetimibe (Merck).



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www.drsue.ca © 2017




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Bariatric Surgery - Can We Predict Remission of Diabetes?

>> Monday, January 30, 2017




One of the most important benefits of bariatric surgery (especially gastric bypass and sleeve gastrectomy) is its ability to improve the control of type 2 diabetes, often to the point where type 2 diabetes actually goes into remission after surgery.  Not everyone with type 2 diabetes who has bariatric surgery will experience remission - about 70-80% of patients having gastric bypass and about 50-60% of patients having sleeve gastrectomy will experience remission.  Ideally, we would be able to predict the likelihood of diabetes remission before the surgery is done, as this is arguably one of the most important potential benefits of bariatric surgery.

A recent study tried to answer this question using a scoring system called the DiaRem Score, which looked at at 4 preoperative variables amongst a group of 407 patients who underwent gastric bypass surgery:
  • age
  • need for insulin 
  • diabetes medication use (points assigned varied by type of medication)
  • hemoglobin A1C (a blood test which is a 3 month report card of diabetes control)

They found that this score, which is based on the above 4 variables, was highly predictive of who went into remission from their type 2 diabetes and who did not.

Other scoring systems and variables have been looked at as well.  Other variables that stands out in the literature are a shorter duration of diabetes, and preoperative serum C peptide level, which is a marker of a person's ability to produce insulin.

It is exciting to know that as we learn more about bariatric surgery, that we can become better at predicting who may benefit from a diabetes standpoint.  However, a word of caution - longer term studies suggest that for people who do enjoy diabetes remission after bariatric surgery, the diabetes recurs in about 50% of these people by 5 years post op.  While there is still certainly a health benefit to being free of diabetes for a number of years, it is important to remember that the diabetes can return and must be screened for regularly and lifelong.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017



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Marijuana and Diabetes Risk - Friend or Foe?

>> Monday, January 23, 2017




In follow up to my blogs about the increased risk of diabetes associated with smoking (read more here), some of my colleagues have asked me to comment on whether there is also an increased risk of diabetes associated with marijuana use.  With the advent of medical marijuana, and the plans to legalize marijuana use in Canada, this is definitely an excellent question.

A question, which it turns out, we have very little data on which to base an answer.

One study examined body fat, insulin sensitivity, and various aspects of beta cell function (the pancreatic cells that make insulin) in 30 cannabis smokers, and compared them to people matched for age, gender, ethnicity, and body mass index. They found that cannabis smokers had a higher percentage of abdominal visceral fat (the fat around the organs that is the metabolically dangerous (diabetes inducing) fat).  Good cholesterol (HDL) was a little lower, and carbohydrate intake a little higher, but otherwise, there was not much difference between groups.

Another study evaluated metabolic parameters in 4657 adults from the American NHANES (National Health and Nutrition Examination Survey), 579 of whom were current marijuana users. They found that current users had a 16% lower fasting insulin level, and had less insulin resistance as well  (17% lower HOMA-IR, for the scientists in the audience), suggesting a lower risk of developing type 2 diabetes. Use of marijuana in this study was associated with smaller waist (a crude way to measure abdominal visceral fat - which contrasts with the findings in the first study above).

Other than these studies, there is very little data on marijuana and its effect on diabetes risk.

At this point, the available data does not suggest that marijuana carries the increased risk of developing diabetes that cigarette smoking does, with one study suggesting that it may even be protective of developing diabetes. However, the data is extremely limited, and further study of the effects of marijuana is much needed.


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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