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Mental Health and Bariatric Surgery - Canadian Data

>> Monday, September 18, 2017





We know that there is a relationship between mental health and obesity, with mental health issues such as depression being associated with an increased risk of obesity, and with the risk of mental health issues developing increasing as weight increases. In people with more pronounced obesity who are considering bariatric surgery as a treatment option, it is important to consider how mental illness may impact the efficacy and safety of surgical treatment for obesity.

These issues were beautifully summarized in a recent review by Val Taylor and colleagues, published in the Canadian Journal of Diabetes, with a focus on Canadian data.

Here are a few of the highlights:

1. How common are mental health issues in Canadian bariatric surgery patients? 

Over half of patients presenting in Ontario for bariatric surgery had a history of mental illness (most commonly depression). Neither a history of depression nor bipolar disorder seem to be associated with success of weight loss with bariatric surgery, but stability and control of mental health issues preoperatively is important to optimize success.  The prevalence and severity of depression in the bariatric population are consistently decreased after surgery – but there is a risk of development of depression for some people as well, which may be related to some of the psychological challenges that can present after surgery.  Many people with mental health issues are taking medications to treat these conditions, and absorption of these meds may be affected after surgery, so close monitoring to ensure good control of the mental health issue after surgery is important.

2. Eating disorders:

Binge eating disorder (BED) has a prevalence of up to 30% in people presenting for bariatric surgery, with the data conflicting on whether BED reduces the success of weight loss with bariatric surgery. Management of the feeling of loss of control and regulation of emotions in these individuals are important factors to help reducing binge eating in this group.

Active bulimia is a contraindication to bariatric surgery.

3. Suicide risk:

While depression usually improves after surgery, the risk of suicide is increased after bariatric surgery, with a multitude of possible reasons/contributors behind this fact.  The risk of self harm seems to be increased at least 3 years after surgery, so long term psychological follow up and support of bariatric patients is essential.

4. What if there is a past history of sexual abuse?

A history of sexual abuse is present in 21.5% of people in the Ontario Bariatric Surgery Registry.  While this does not appear to influence the success of surgery, these individuals are at a higher risk of mental health issues such as depression, speaking to the need for proper assessment and follow up.

5.  Substance use/abuse:

A history of substance use (alcohol, tobacco, or recreational/illicit drugs) seems to be correlated with a risk of substance use after surgery, particularly if the substance use history is near to the time of surgery.  Alcohol abuse is a particular risk, as alcohol hits harder and fasterafter surgery.  A ‘transfer’ of addictions from one thing to another (eg, from food to gambling) after surgery has been described, and should be discussed and managed ahead of time.


Most often, mental health issues can generally be well managed to optimize success of the individual undergoing bariatric surgery.  Identifying and managing these issues before surgery is essential, and long term support after surgery is key as well.


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www.drsue.ca © 2017


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Blood Sugar and Insulin Levels As A Biomarker For Weight Loss Success?

>> Monday, September 11, 2017





To date, no particular diet composition has been shown to be superior to another for weight loss success in the general population.  However, we haven't yet ruled out that some types of diets may work better for certain specific groups of people.  For the first time, a new study suggests that people with prediabetes or diabetes, and people with higher fasting insulin levels, may have better weight loss success with either a lower glycemic load diet, or a diet containing a large amount of fiber and whole grains.

The study, published in the American Journal of Clinical Nutrition, evaluated data from three studies and stratified weight loss results by fasting blood sugar and insulin levels.

The first trial, called the DioGENES study (as blogged previously), looked at the ability to maintain weight loss using a high vs low glycemic index and high vs lower protein diet.   The results of this study overall showed that a low GI, higher protein diet was superior to a high GI, lower protein diet to maintain lifestyle-induced weight loss.  In the current analysis, they found that people with prediabetes regained 5.83kg more on a high GI diet than a low GI diet, whereas people with normal blood sugar regained only 1.44kg more on a high GI diet than a low GI diet.

The second study, called the SHOPUS study, was designed to test the New Nordic Diet, which is high in fiber and whole grains. People with prediabetes lost a mean of 6 kg on this diet, whereas people with normal blood sugars lost only 2.2kg.

Finally, in the NUGENOB study, which was designed to test nutrient-gene interactions in obesity, people with diabetes lost a mean of 2kg more on the high fat/low carb diet than on the low fat/high carb diet, whereas people with normal sugars lost only 0.43kg more on the above comparison.

When the authors incorporated fasting insulin levels into these analysis, the associations above were strengthened further.  Some interesting phenotypes were also revealed:

  • people with lower fasting blood sugar and high fasting insulin levels responded equally on all 3 pairs of diets 
  • people with high fasting sugars and low fasting insulin levels did better on diets with a lower glycemic load and more fiber and whole grains
  • people with lower blood sugar and lower fasting insulin did better on a low fat/high carb diet. 


We often talk about precision medicine - customization of health care decisions based on each individual's genetics, lab results, hormone levels, and so on; yet in obesity medicine, we have very little routinely measured information that can help us determine what type of management program may be best for our patient.  Finally we have some data, using easily measurable blood tests, that may help to guide us.

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www.drsue.ca © 2017




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Obesity, Addiction, Alcohol and Bariatric Surgery Part II

>> Tuesday, September 5, 2017





We know that the factors behind each individual's struggle with obesity are unique, with a long list of physiologic, psychological, and environmental factors as potential contributors.  We are also learning increasingly that there are many areas of neurophysiologic (brain), psychological and behavioral overlap in the realms of obesity and addiction.

In part I of this two-part blog post, we discussed some of the changes that happen after bariatric surgery, as discussed in a recent review.

Now, some threads that weave a connection for some people between obesity and addiction: 

1.  For some people, food is an addictive substance.  People who have high scores on food addiction questionnaires have similar patterns of brain activation as in people with other addictions.  Also, overconsumption of certain nutrients (eg sugar) elicits chemical responses in our brains, similar to those that result from consumption of drugs or alcohol.

Some people think that combatting a food addiction is no different than trying to quit smoking.  But remember, a person who quits smoking can (and ideally will) lead their life without ever touching another cigarette.  But the person battling a food addiction can't stop eating - they have to continue to eat for the rest of their lives, while controlling the addictive component that leads to overeating: a very, very difficult thing to do. 

2.  Some people with obesity have more 'turbo-charged' food reward circuits in their brains, which results in a powerful drive to seek high calorie food.  Obesity can also be accompanied by a reduced brain-driven ability to resist temptation and control impulses to eat, with data suggesting that there is a genetic component to these differences.  After gastric bypass surgery, research has identified some changes in this brain activity, and these changes may be associated with the amount of weight lost after surgery.

Know that feeling of: I am so hungry I don't care what it is it just has to happen RIGHT NOW...?
For some people, this feeling may come only if meals are skipped for many hours, or after a fierce workout.  For others, they may feel like this until their body is at a higher body weight 'set point'.  The level of energy reserves, or time from last meal that contributes to the threshold for this feeling to set in, is very different from person to person.

So for people who have a food addiction, as well as for people who have a more powerful reward circuitry, weight management will be difficult, but not impossible - having a psychologist with professional training in obesity management is an important part of the team to help manage their weight struggles.

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www.drsue.ca © 2017








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Obesity, Addiction, Alcohol and Bariatric Surgery Part I

>> Monday, August 28, 2017







We know that the factors behind each individual's struggle with obesity are unique, with a long list of physiologic, psychological, and environmental factors as potential contributors.  We are also learning increasingly that there are many areas of neurophysiologic (brain), psychological and behavioural overlap in the realms of obesity and addiction.  A recent review draws on our knowledge of alcohol use after bariatric surgery to help us understand these connections.

After gastric bypass surgery:
  • 9.4% of patients who have had gastric bypass surgery report a period of excessive alcohol intake at some point after surgery
  • 7% of patients with no preoperative history of excessive alcohol intake develop a problem after surgery
  • middle aged females seem to be at higher risk
  • post bariatric surgery addiction problems seem to be fairly specific to alcohol (though addictions to other substances, or activities such as gambling are also seen - see 'addiction transference' below)
  • when a person who has had gastric bypass surgery drinks alcohol, there is a faster rise, higher peak, and longer duration of blood alcohol levels 
Interestingly, some people who were frequent alcohol consumers before surgery actually have a decreased enjoyment of alcohol after surgery, which may be mediated by an increase in the gut hormone GLP-1, and a decrease in the hunger hormone ghrelin.

Psychological and social factors can also have a big influence on alcohol consumption after surgery.  As blogged previously, food addiction seeking a new outlet (called 'addiction transference') may be a factor for some people.  A need for a coping mechanism as a person watches their body change after surgery may be involved.   Some may reach for alcohol as a way to manage the complex psychological issues that can arise after surgery. 

Stay tuned for the next blog post, where I'll discuss some of the parallels between obesity and addiction that may be relevant for some people, discussed in this review. 


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www.drsue.ca © 2017




  


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Por-Puffed Wheat Squares

>> Monday, August 21, 2017





So I'm sure you're already wondering... what on earth is a PorPuffed Wheat Square?

A couple of weeks ago, I wandered into a local cafe in Calgary, and found these enormous puffed wheat squares staring me in the face:



I bought one of these mammoth creations.... and before digging into it, I decided to cut it up just to see how many appropriately (in my opinion) portion-sized squares it would make.  I thought maybe 4, 5, 6.....

Sixteen.

SIXTEEN!!

I cut it up into 16 pieces and brought them to work to share with my work family.

(And yes ok maybe I caved and bought a Rice Krispie square too.)



ONE Rice Krispie square is cut up in the bag on the left.
ONE Puffed Wheat square is in the bag cut up on the right.

So the teaching today is about portions: sadly, portion sizes have grown by 3-4x (and in this case, 16x!) compared to what portion sizes were in the marketplace 30-40 years ago.  This is a problem especially out of control in North America (travellers may notice that portions are usually smaller on other continents).

So here's my recipe for PorPuffed Wheat Squares (short for Portioned-Puffed).  There are many permutations on this out there - this one is chocolaty, delightful, and will make a square that stays fairly soft for several days, if you follow my guidance below.

Disclaimer: the ingredients are high glycemic index and not healthy (though puffed wheat squares will have a lower calorie bill than something more dense like a brownie or granola-based bar), but portioned appropriately, they are a delectable and very reasonable little treat once in a while.

INGREDIENTS:

  • 1/2 cup corn syrup
  • 1 cup brown sugar
  • 1/2 cup margarine
  • 5 tbsp cocoa powder
  • 8 cups puffed wheat

DIRECTIONS: 

1.  Melt the first 4 ingredients under low-medium heat until the mixture just starts to boil.  (don't wait any longer or the squares will be too hard)

2.  Remove from heat and fold in the puffed wheat.

3.  Press into a 9x13" pan, lightly greased with margarine. 

That's it!  Super easy. 

Makes 20 squares. Per square: 
  • Calories: 135
  • Carbs: 21g
  • Fat: 4.8g
  • Protein: 1g

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www.drsue.ca © 2017

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Eating for Two? Risks of Too Much - or Too Little - Weight Gain In Pregnancy

>> Monday, August 14, 2017






Many studies have suggested that too much, or too little, weight gain in pregnancy can be harmful to both baby and mother.  A recent review brings together data from over 1.3 million women, to help us understands what the health risk are of inappropriate weight gain in pregnancy.

First, let's review the recommendations for weight gain in pregnancy.  The recommended amount is based on Body Mass Index pre pregnancy, which is calculated by your weight in kg, divided by your height in metres squared (kg/m2). Note that these numbers apply to single pregnancies only (recommendations are higher for twin, triplets etc).


  • BMI less than18.5:  28-40 lbs (about 13-18 kg)
  • BMI 18.5-24.9:       25-35 lbs (about 11-16 kg)
  • BMI 25-29.9:          15-25 lbs (about 7-11 kg)
  • BMI 30 or more:     11-20 lbs (about 5-9 kg)


The review, published in the Journal of the American Medical Association, found that gestational weight gain fell below these guidelines in 23% of pregnancies, and above these guidelines in 47% of the pregnancies studied.

For women not gaining enough weight in pregnancy, there was a 53% higher risk of having a small for gestational age baby, and a 70% increase in the risk of preterm birth.

For women gaining excessive weight in pregnancy, there was an 85% higher risk of having a large for gestational age baby, and a 30% increased risk of needing a C section.

Not only do we know that it is important to manage weight during pregnancy, but optimizing weight prior to pregnancy is important too, as underweight or overweight pre-pregnancy is also associated with adverse outcomes.

If you are pregnant or thinking about becoming pregnant, be sure to speak with your doctor about optimizing weight both before and during pregnancy.


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www.drsue.ca © 2017




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Could Antacid Medications Affect Blood Sugar Control in Diabetes?

>> Tuesday, August 8, 2017






Proton pump inhibitors (PPIs) are medications commonly prescribed to treat heartburn and peptic ulcer disease [eg omeprazole (Losec), pantoprazole (Pantoloc), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Pariet)].    Since PPIs work by blocking acid secretion in the stomach, and since a higher acid content of food lowers its glycemic index, I was asked whether PPIs could increase the effective glycemic index of a meal and thus have a negative impact on diabetes control.

It turns out that PPIs have a very interesting relationship with pancreatic function and blood sugars.

Firstly, as PPIs work by blocking acid secretion in the stomach,  PPIs do increase the pH in the stomach and very high up in the small intestine (proximal duodenum).  However, there is little to no effect on pH in the majority of the small intestine, where carbohydrates are absorbed.

PPIs raise serum levels of a hormone called gastrin, which is responsible for stimulating acid secretion in the stomach.  This is because the gastrin secreting cells in the stomach sense that acid production is low, so more gastrin gets cranked out in an attempt to increase acid secretion.

Interestingly, gastrin stimulates glucose-induced insulin secretion from the beta cells of the pancreas.  There is also some experimental evidence that gastrin may stimulate the production of new beta cells.   Further, PPIs slow emptying of the stomach, because less acid in the stomach means that it takes longer for solid food to be broken down and be ready to pass into the small intestine.

So, based on these mechanisms, it seems that PPIs could possibly have a benefit to blood sugar levels.  While the studies on this are still quite limited, the available evidence suggests that PPIs could lower A1C (a marker of diabetes control) by 0.5% to as much as 1% - possibly as much as a diabetes medication!

PPIs are medications that have benefits but also potential risks, including increased risk of gastrointestinal infections, malabsorption of important micronutrients like calcium, magnesium, vitamin B12, and iron, increased risk of fracture, changes in gut bacteria, and others (note this list is not exhaustive), and they should not be prescribed for the purpose of blood sugar control.

That being said, I will be watching blood sugar control with extra interest the next time one of my patients with diabetes is started on a PPI for their gastrointestinal issues.


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www.drsue.ca © 2017

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Is Resveratrol Good For Me?

>> Monday, July 31, 2017






You may just be kicking back with a good glass of Merlot to read my blog this evening, with the thought that you are doing your body a favour by choosing red wine over, say, a bottle of beer.  The reported benefits of red wine have often been attributed to resveratrol.  'Naturally' (haha), the supplement industry has jumped all over this, and now markets resveratrol supplement.  Resveratrol is touted as having a whole list of benefits... but is it really good for us?

Resveratrol is a natural phenol which is actually found not only in grapes, but also blueberries, raspberries, and peanuts.  The highest readily available quantities per serving are found in grape juice or red wine.   Resveratrol got some attention with the discovery that moderate consumption of red wine (1-2 glasses (5oz each) per day) may be associated with a decreased risk of heart disease, and since then, high doses of resveratrol (in supplement form) has been touted to carry a number of health benefits, including a decreased risk of cancer, improved diabetes control, neurological benefits, and even benefits to the skin.

While the evidence overall seems to suggest that red wine is associated with a decreased risk of cardiovascular disease, the reasons for this are not clear. Red wine increases levels of good cholesterol (HDL), but it's not clear if it's the resveratrol, or flavonoids in red wine, or something else that brings these benefits.

As for the remainder of the long list of supposed health benefits of resveratrol - these are far from being proven.  A systematic review was undertaken a few years ago (which is the best way to look for evidence when there are only a smattering of studies otherwise), stating that the published evidence was not strong enough to recommend resveratrol beyond the dose that is found in dietary sources.

In terms of side effects, they found that there was no valid data on the the toxicity of chronic intake, and that the main known side effect of high doses of resveratrol is a laxative effect.  Since then, a small randomized controlled clinical trial was recently published suggesting that resveratrol supplements had no benefit on any aspect of metabolic syndrome, and that high dose resveratrol actually had detrimental effects on cholesterol.

As for any supplement, in an industry which is very loosely regulated (and I use the term 'regulated' loosely at that), there is a huge amount of variation in the amount of resveratrol that one might actually get in a particular supplement.  Purity varies as well, with the supplements containing other chemicals with unknown effects on human health.

Bottom Line: We find resveratrol in the same camp as most other natural remedies - there is insufficient data to suggest a benefit of taking high doses (supplements) to human health, and we don't know about the safety of doing so.

As for getting resveratrol from red wine: It is not recommended to begin alcohol consumption for health reasons, as alcohol has many dangers and toxicities associated with it as well.  For those who do enjoy a small amount of alcohol, it seems that red wine may be a good choice.  See Canada's Low Risk Alcohol Drinking Guidelines for more information on what is considered to be safe in terms of alcohol consumption.

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www.drsue.ca © 2017






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Could Artificial Sweeteners Cause Weight GAIN?

>> Monday, July 24, 2017



While artificial sweeteners have previously been touted as an excellent way to replace sugar in your diet and help with weight loss, they have in recent years been found to impact our biology in ways that may have adverse effects on our metabolism.  Rather than helping in a quest for weight loss, is it possible that sweeteners could actually cause weight gain and metabolic disease?

A recent systematic review and meta-analysis was recently published in the Canadian Medical Association Journal, which collected the currently available evidence to try to answer this question and received worldwide attention in doing so.  They included 37 trials (including 7 randomized controlled trials and 30 cohort studies), looking at a total of over 400,000 individuals (about 1,000 of whom were in the randomized studies).

In their analysis of the randomized controlled trials, over a median follow up of 6 months, they found no significant effect on body mass index (BMI) or measures of body composition.  So, use of sweeteners did not result in weight loss, but there was no weight gain seen either.

In the cohort studies, over a median follow up of 10 years, they found an increase in weight, BMI, and waist circumference, and a higher incidence of obesity, metabolic syndrome, type 2 diabetes, high blood pressure, stroke, and cardiovascular events.

So overall, none of the evidence assessed showed a benefit to weight, and the observational data suggested adverse effects of sweeteners on weight and health - none of which is good news.  And why is there a difference in conclusions between the randomized trials versus the observational (cohort) data?

Well, it's possible that the randomized trials were not long enough or big enough to show a negative impact on health, and that if they had been longer trials, perhaps results would have been different.

On the other hand, observational (cohort) data does not give us as trustworthy of an answer to any research question, because the results can be muddied by other factors. One concern is that these data may be confounded by 'reverse causation' - meaning that people with obesity, or those more prone to develop obesity (eg family history of obesity) are more likely to use sweeteners to help manage their weight (rather than the sweeteners being the cause of weight gain).

Either way, there is research to suggest biological mechanisms by which sweeteners could have an adverse impact on our metabolic health, particularly in relation to changes they induce in our gut bacteria, as well as our neurobiological response to these chemicals.  Further research is clearly needed to better understand their effect on our health.

Remember also that there is no doubt that excess sugar consumption is associated with weight gain and all of the above metabolic complications - so swapping sugar back in is not the answer either.


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Children's Fitness Falls In Summer

>> Monday, July 17, 2017





You'd think that summertime would be a time of peak physical fitness for kids, right?  The weather is great, the days are long, school is out, and there is nothing but time for just being a kid... running, jumping, playing all day long.

Think again.

A study in the UK, which was presented recently at the Congress of the European College of Sport Science, tracked the fitness of over 400 children for just over a year.  They found that at the start of the school year in September, kids were not able to run as far as they could at the end of the prior school term in June.   They also found that body mass index (BMI) climbed between June and September (though BMI percentile would be the more appropriate measure).  The decrease in fitness was particularly evident in kids from areas of lower socioeconomic status.

These findings suggest that kids may be more often spending their summer holidays being inactive, perhaps in front of the TV or video games rather than being active in the great outdoors.  Active child care activities during the summer (eg summer camps) can be costly, so kids from less affluent homes may have less access to organized activities.

If you're having trouble keeping your young ones active this summer, here are some suggestions:

  • Limit screen time.  Kids will find other things to do that are likely more active.
  • Check out your local community facilities, parks and pools to see what is on offer.  
  • Enjoy the warm weather and bright evenings with a family walk or bike ride! 
  • Consider signing your kids up for a race (eg family fun run, or even a kids' triathlon!) and get them engaged to train for it.  


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www.drsue.ca © 2017


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Testing Blood Sugar - Is There A Point?

>> Monday, July 10, 2017







In the management of people with diabetes, we routinely equip patients with glucose meters and ask them to check sugars at home.  While the importance and utility of checking sugars at home for people using insulin is clear, there is much debate about whether this is useful for people with type 2 diabetes who are not on insulin.  A recent study, which got a lot of media hype, tackled this question.

The study, published in JAMA Internal Medicine, randomized 450 people with type 2 diabetes and not using insulin, to either a) no home glucose montoring; b) checking sugars once daily; or c) checking sugars once daily plus automated educational/motivational messages delivered to the patient from the meter.

The researchers found that there was no difference in diabetes control (A1C) nor health related quality of life after 1 year, and concluded that glucose monitoring in people with non-insulin-treated type 2 diabetes should not be routine.

I have some major beefs with this conclusion:

1.   Testing once a day does not tell a person very much about their blood sugar.   In order for home testing to be useful, I advise 'paired meal testing': checking before a meal, and checking again 2 hours later.  This can be very helpful to see how certain types of food affect your blood sugar, and can be help to eat mindfully and manage portion control.  I don't necessarily advise doing this every day: checking each of breakfast, lunch, and dinner once per week can be enough.  However, depending on what kind of medication a person is taking, I may recommend more often.  Also, if diabetes control is not great, then checks (in my opinion) should be done more frequently so that we can figure out how to bring down the sugars effectively and safely.

2.  As the authors note, the study was not powered to determine if there are benefits to checking sugars around the time of medication or dose changes.  It is very difficult for a doctor to know what the next best medication may be without knowing the pattern of blood sugars through the day.  Knowing the pattern of blood sugars is extremely important when new medications are added onto sulfonylureas and insulin in particular, because these medications can cause low blood sugar.  For example, if sugars are highest in the morning and lower later in the day, there is a risk of causing low sugars if a treatment is added that brings down sugars in the morning (as sugars later in the day will go down too).

3.  Compliance with sugar checks in the study was poor by one year, declining gradually over the year, with only about 55% of people in the monitoring groups checking sugars each day by the 1 year mark.  Interestingly, the diabetes control (A1C) was better at 3, 6, and 9 months in the glucose monitoring groups, compared to those not monitoring - perhaps the lack of difference in A1C by 1 year was due to the poor compliance with glucose checks by that point in time.

4.  The study team did not engage with patients after their baseline visit - meaning patients were on their own to interpret their blood sugars without help from the study team.  Their family doctors received a copy of blood sugar results, but the study did not collect info on what was done with that data, and these clinicians had minimal interaction with the study team.  

Diabetes is a team sport - an important part of the benefit of checking blood sugars is to discuss these results with your health care team for help in optimizing control.  While the setup of this study was intended to be 'real world', I would submit that what patients perceived as their 'health care team' during the study (their usual doctors plus study investigators) were not working as a team and this may have limited the best possible use of home glucose monitoring.  And perhaps compliance with checking sugars in the study would have been better if that team was working together and more engaged with the patients, as is the ideal model of care.  We are blessed in Canada to be able to say that for most people in our country, the 'real world' does consist of free access to a team to help each individual with their diabetes care.

5.  For any patient on a sulfonylurea (and of course insulin), sugars must be checked before driving.   For a paper to conclude that glucose monitoring should not be routine (in a study where 36% of patients were on sulfonylurea!) is inappropriate.

Unfortunately, the media took hold of this study and has been shouting from the rooftops that people with non-insulin-requiring diabetes do not need to check their blood sugar.    I would be most saddened if patients get the message that they should stop testing their blood sugars, and would strongly advise people to continue to follow their doctor or diabetes educator's recommendations on how frequent of sugar checks is appropriate.

I hope this blog helps to provide some balance and perspective on what I feel is a study full of limitations.

Disclaimer: I have received speaking honoraria from makers of glucose meters.



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AMA Says Watch Your Language! Combatting Obesity Stigma

>> Tuesday, July 4, 2017






As blogged previously (see here and here and here and here and here), obesity stigma is a major problem in our society, and sadly, even worse amongst health care providers.  To combat this stigma, the American Medical Association has stepped up and passed a resolution to destigmatize obesity.

Obesity stigma in a medical office can take several forms, which we can categorize as direct, or indirect: 


Direct obesity stigma examples:

  • referring to a patient as an 'obese patient', rather than a 'patient with obesity' (more on this below)
  • using terms like 'fat' or 'morbidly obese'
  • telling a person they are lazy or that it is their fault that they have obesity
  • any other form of 'fat shaming'
Indirect obesity stigma examples: 
  • furniture in the office is not appropriate (eg chairs with armrests that restrict size; exam tables are too narrow; stools to step up on to exam table are too narrow)
  • weight scale maximum is too low
  • magazines in waiting room are promoting of thin body image (eg fashion magazines that often arrive at a doctor's office for free)

To combat these stigma, the resolution, which was authored by members of the Obesity Medicine Association, calls for: 

1.  Use of Person-First Language in all discussions: 'person with obesity', not 'obese person'.  Remember that obesity is a diagnosis, not an adjective to describe a person.

2. Use of preferred terms when discussing obesity, such as 'weight' or 'unhealthy weight', and avoiding stigmatizing words like 'fat'.

3. Equipping the medical office with appropriately sized chairs, blood pressure cuffs, scales, examination gowns etc. 

I hope that with the AMA passing this resolution, that more much needed attention is drawn to the critical need to destigmatize obesity.  Educating health care professionals on obesity is desperately lacking in all aspects of the disease; if health care providers were to better understand the pathophysiology of obesity, this would help to break down the stigma against it.

I am hopeful that editors of medical journals and textbooks will heed and follow this resolution - non-patient-first language still plagues almost all scientific publications and guidelines around the world.  Clearly, more awareness and education is needed to break down the obesity stigma - please feel free to share this blog post to disseminate the word!



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www.drsue.ca © 2017





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Low Carb Diets Part II: What If I Have Diabetes?

>> Sunday, June 25, 2017





In last week's blog post, we talked about low carb diets, definitions, and whether they work for weight management.  Today we'll discuss low carb diets in people with diabetes: Are they beneficial? Are they safe?

As far as potential benefit goes, the available data are not consistent in their findings.  In a review article published by Feinman and colleagues in the journal Nutrition, data is summarized reporting an improvement in blood sugar control, along with a reduction in medications required to control blood sugars.  However, systematic reviews and meta analyses have not consistently shown improvements in blood sugar control.  At least some of the variability likely has to do with adherence - low carb diets are not easy to stick to for many people.

If a low carb diet is going to be embarked upon, the type of medication that a person with type 2 diabetes is taking to control blood sugars is very important to consider.   Medications that can cause low blood sugars [insulin; sulfonylureas such as gliclazide (Diamicron) and glyburide; and meglitinides (eg Gluconorm)] may need to be decreased with the help of your health care provider, in order to avoid low blood sugars.

SGLT2 inhibitors are a class of medications to treat type 2 diabetes, which are associated with a risk of 1 in 1000 people per year developing diabetic ketoacidosis (DKA), which is a type of acid buildup in the blood that is life threatening. For people on these medications [canagliflozin (Invokana), dapagliflozin (Forxiga), empagliflozin (Jardiance)], low carbohydrate diets are associated with an increased risk of DKA.  As to whether a mildly low carb diet is safe is not known, as there is very little data available in this area.  One small study did show an increase in ketones in people with type 2 diabetes on an SGLT2 inhibitor on just a very mildly restricted carbohydrate diet (40% calories, as compared to people on a 55% carb calorie diet), but how much this may increase the risk of DKA is not known.

A ketogenic diet should be avoided for anyone with type 2 diabetes on insulin or SGLT2 inhibitors, because of the risk of ketoacidosis.

For people with type 1 diabetes, there is very limited data on which to guide us.  There is some data suggesting that a low carb diet may improve hemoglobin A1C (a marker of blood sugar control).   However, there is a concern that there may be a blunted response to glucagon as an emergency treatment for severe low blood sugar in people with type 1 diabetes following a low carb diet.

A ketogenic diet should be avoided for anyone with type 1 diabetes due to the increased risk of ketoacidosis.

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Low Carb Diets - What Are They... And Do They Work?

>> Monday, June 19, 2017




One of the more currently in vogue weight management approaches is a low carbohydrate diet.  I get asked about this a lot, so I figured it's time to put my thoughts in e-print!  I'm going to take this in two parts.  Today's blog will be about low carb diets in general, and the second will be about the low carb diet in people with diabetes.

So, what is a low carb diet exactly?  Well, they have many names and forms: low carb, lower carb, very low carb, lower carb high/healthy fats (LCHF), ketogenic.  Definitions of each of these vary, making comparisons and scientific study challenging.  However, we can generally categorize these diets as follows:

Low Carb:
  • providing less than 45% of the day's calories, OR
  • less than 130g of carbs per day (= 520 calories)

Ketogenic or Very Low Carb: 
  • maximum carbs of 20-50g per day

LCHF : (low carb, high/healthy fat)
  • the amount of carbohydrate recommended varies, but would fall in the low carb zone as defined above
  • the restriction in carb calories is replaced with healthy fat choices

So, does a carbohydrate restricted diet result in more effective weight management?   When compared to a low fat diet, the studies suggest that while there may be superior weight loss in the short term (eg 6 months), there is no difference after 1 year.   The bottom line of the extensive studies on dietary composition shows that there is no particular macronutrient composition (carbs vs protein vs fat) that is superior to another when it comes to weight loss.  

What is important is finding a permanent lifestyle change that works for each individual, and the composition of that diet is going to vary based on taste preferences, cultural differences and so forth.
I often hear of people feeling that they are being instructed to eat too many carbs, more than they actually want to eat.  Their health care providers are probably following the teachings of Canada's Food Guide (CFG), which many obesity experts (including myself) would argue advises a carbohydrate intake that is too high for many people at up to 65% of total daily caloric intake.   Remember that Canada's Food Guide (CFG) was designed for weight maintenance in adults, but that the majority of Canadian adults have overweight or obesity.  Ergo, the CFG is only applicable to a minority of Canadian adults.  Also, the average woman age 50+, and the average man age 70+, will gain weight following the CFG recommendations.

Most dietary guidelines recommend at least 45% carbohydrate, in order to limit excessive intake of saturated fat.  It is important that the fats in our diet are the healthier unsaturated fats - in fact, the Mediterranean style of eating, which provides 35-47% of calories as fat, has been shown to reduce the risk of cardiovascular disease and breast cancer.

For some people, a restricted carbohydrate intake may work well - it eliminates the option of grabbing many high calorie food items on the run (eg bakery, vending machine, coffee shop products and so forth).   There are also some people who may have an addiction-type response in their brain circuitry to high sugar foods, and avoiding these may help to break the cycle of overeating.  But it's definitely not for everyone.  

In terms of weight maintenance and prevention of weight gain after weight loss, there is evidence to suggest that a higher protein, lower glycemic index diet may be better than a lower protein, higher glycemic index diet. 

Stay tuned for part II: Can people with diabetes safely eat low carb?


Follow me on twitter! @drsuepedersen


www.drsue.ca © 2017



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Diabetes Medication Canagliflozin Reduces Cardiovascular Events

>> Tuesday, June 13, 2017






The eagerly awaited results of the CANVAS trial were just released yesterday at the American Diabetes Association Meeting, and published simultaneously in the New England Journal of Medicine.

The CANVAS program was a cardiovascular outcome trial of the SGLT2 inhibitor, canagliflozin (Invokana).  This program enrolled 10,142 people with type 2 diabetes and high cardiovascular risk, and randomized them to receive either canagliflozin 100mg, canagliflozin 300mg, or placebo, in addition to their usual care.

After a mean of 3.6 years, they found that canagliflozin reduced the risk of a combination of cardiovascular death, non fatal heart attack and non fatal stroke by 14%, with the benefit being particular to those with established cardiovascular disease at baseline.  The individual outcomes above were not significantly reduced when considered separately, but were significant when considered together.   Canagliflozin also reduced the risk of hospitalization for congestive heart failure by 33%, reduced the risk of poor kidney outcomes by 40% (a composite of a sustained 40% reduction in GFR, need for renal replacement therapy, or death from renal causes), and reduced progression of albumin in the urine by 27%.

In terms of risks of canagliflozin, unexpectedly, there was an increase in the risk of amputation, with 3.3% of people on canagliflozin requiring an amputation (most commonly a toe or forefoot) during the course of the trial, vs 1.5% in the placebo group.    There was also an increase in the risk of fracture, with 15.4 fractures per 1000 patient years on canagliflozin, vs 11.9 per 1000 patient years in the placebo group.  There was an increased risk of genital yeast infection, as expected for this class of medications, but no increased risk of urinary tract infection.

The CANVAS program adds to our understanding of the SGLT2 class of medications.   As the EMPA REG trial showed us that the SGLT2 inhibitor empagliflozin (Jardiance) also reduces CV events in people with type 2 diabetes and cardiovascular disease, this is looking more likely to be a 'class effect' of the SGLT2 inhibitors (we still await the DECLARE study of the SGLT2 inhibitor dapagliflozin (Forxiga) to be completed).

In terms of the risks seen in the CANVAS trial, much discussion is underway in the medical and scientific community, and more studies will need to be done to better understand these findings.  As always, the benefit vs risk of any medication must be carefully considered in finding the best medications for each individual patient.


Disclaimer: I receive honoraria as as continuing medical education speaker and consultant from the makers of canagliflozin (Janssen), empagliflozin (Boehringer-Ingelheim and Lilly), and dapagliflozin (Astra Zeneca).  I am involved in research of SGLT2 inhibitors as a treatment of diabetes. 


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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Are Calorie Equations Accurate In Obesity?

>> Monday, June 5, 2017






Some people who are working on losing weight like the approach of a calorie prescription, which is the daily amount of calories in food/drink that they should not exceed in order to lose weight.

This calorie prescription starts with an estimation of Resting Energy Expenditure (REE), which equals the number of calories we burn at rest over 24 hours, and can be estimated by any of a number of equations that have been developed for this purpose.  These equations incorporate various factors that influence REE, including age, gender, height, and weight.  From there, we typically multiply the REE by an activity factor to calculate the number of calories a person needs in a day, and then usually subtract 500 calories per day in order to achieve an initial rate of weight loss of around 1lb (0.5kg) per week.  

Most of these equations were generated using normal weight individuals, including very few people who carry excess weight.  But are these equations accurate in people with obesity?

A study, published in the International Journal of Obesity, evaluated a number of these formulae in 1,851 people with obesity, comparing the calculations to actual measures of Resting Energy Expenditure (using a technique called indirect calorimetry). 

They found that the accuracy of the equations to predict Resting Energy Expenditure was very low in people with obesity, and were even less accurate in people with a higher degree of obesity (BMI >40), especially females.   Even the Mifflin St-Jeor equation, commonly cited as the most accurate equation, performed poorly. These equations generally underestimated the calorie needs of participants by several hundred calories, with the degree of underestimation increasing with increasing BMI.

As these equations come in low, the calorie prescription ends up being too low.  This could mean that a person with obesity leaves their health care provider’s office with a calorie prescription that is too restricted – for example, that patient may be told that she should take in 1500 kcal per day in order to lose 1 lb per week, when actually her prescription should be 1900 kcal per day to lose 1lb per week.  For her, sticking to 1500 kcal per day would be very difficult – it may cause more rapid weight loss at the beginning but would be very tough to stick with.  

So why would these equations be less accurate in people with obesity? Fat tissue is less metabolically active than lean tissue (eg muscle), so having a higher proportion of fat can reduce accuracy of estimation using equations that were developed in a lean population.  It is also not clear which weight to use in these equations – actual weight, ideal weight, or adjusted weight.

Indirect calorimetry is a much better way to estimate calorie needs than equations, but has a price tag and limited availability. 

Clearly, we are in need of equations that are validated in people with obesity to estimate resting energy needs. 



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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