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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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Does Gastric Bypass Surgery Save Lives Only In People With Diabetes?

>> Monday, October 16, 2017






While we know that weight loss of just 5-10% is associated with an improvement in many parameters of health, the only treatment for obesity that has been suggested to reduce mortality is bariatric surgery.  A new study suggests that if gastric bypass surgery reduces mortality, it may be people with diabetes in particular who enjoy this benefit.

The study, published in Diabetes Care, matched 2,428 people in their database who had gastric bypass surgery by age, BMI, gender, and diabetes status to a control group in the database who had not had surgery.

They found that for the 625 people who had diabetes before gastric bypass surgery, their risk of death from any cause was reduced by 56% at 5.8 years after surgery, compared to people who had diabetes but hadn't had surgery.  In particulary, death from cardiovascular disease, lung disease, and diabetes were lower in the group who had surgery.  The reduction in mortality was the greatest for people whose diabetes went into remission after surgery.

For the 1,803 people who didn't have diabetes before gastric bypass surgery, the risk of death at 6.7 years after surgery was not significantly different than those who didn't have diabetes and didn't have surgery.  When they boiled it down, the risk of death from cancer and lung diseases was lower in the people who had had gastric bypass surgery, but the risk of death from external causes (including injuries, overdose, and suicide) was higher, especially for younger people.

This study is the first to suggest that a reduction in all-cause mortality after gastric bypass surgery may be limited to people who have diabetes before surgery.  However, even if people without diabetes don't enjoy enhanced life expectancy overall, remember that there are still many health benefits to be enjoyed from bariatric surgery.   It's also important to emphasize that this study is retrospective, meaning that researchers looked back in time and analyzed pre existing data.  This type of data can be muddied by other factors that can't be controlled for (called 'confounding factors'), so we have to take them with a grain of salt.

The increased death risk from injuries, overdose, and suicide for people without diabetes who had surgery needs attention. It is known that there is a higher risk of self harm after surgery, pointing towards the need for psychological counselling and support both pre and post surgery.  There is still very little known about how bariatric surgery changes the absorption of medications and other substances, increasing the risk of potential overdose; further studies are desperately needed in this area.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017


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Apple Chai Oatmeal Cups!

>> Tuesday, October 10, 2017



(picture is from original recipe - they were eaten so quickly at our house that I didn't get the chance to snap a pic!)



Fall is here!  The leaves are golden, the air is crisp, and wafts of allspice and nutmeg are in the air.  Chai tea is a wonderful and warming favourite in the fall – so why not transport that deliciousness into something edible?  I was asked by a colleague recently to post something she can use for her kids' lunches - these little nuggets of goodness are perfect. With no sugar (aside from a little maple syrup) and no flour, I was admittedly dubious... but they turned out to be delicious! 

I switched up the coconut oil for canola in the original recipe – coconut oil, contrary to popular belief, is not good for you (read here for more on this topic).  I have also added more spice for better flavour.  We loved the apple bits – don’t skimp here!   One more tip: we tried some Roger’s Porridge (blue bag) instead of the rolled oats and they turned out perfectly.  

INGREDIENTS:
  • 3 cups rolled oats (or Roger's porridge blue bag)
  • 1 tsp baking powder
  • 1 tsp ground nutmeg
  • 1 tsp ground allspice
  • 2 tsp ground cinnamon
  • 1 large apple (or 2 small) - minced
  • 2 eggs
  • 2 tbsp maple syrup
  • 1 tbsp canola oil
  • 1 large banana (or 1.5 small)
  • 1.5 cups unsweetened almond milk



DIRECTIONS:

  1. Preheat oven to 350ºF and line a 12-count muffin tin with muffin liners. Spray with nonstick cooking spray.
  2. Place rolled oats, baking powder, and spices in a large bowl and combine.
  3. Peel a large apple and then finely dice. Set aside.
  4. Place banana in a medium size bowl and mash. Then add in eggs, maple syrup, canola oil, and almond milk. Add wet mixture into the dry mixture and fold together. Add the apple bits and mix again.
  5. Fill 12 muffin liners to the top.  Place in oven at 350ºF and bake for 19-21 minutes, until a toothpick inserted into the centre comes out clean.
  6. Let cool for 10 minutes before removing from muffin tin. 

Makes 12 muffins.  Per muffin: (using rolled oats)

Calories: 137
Carbs: 21g
Fat: 4.7g
Protein: 3.9g



Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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Are Obesity Genetics Written In Stone?

>> Monday, October 2, 2017





In my practice, I often talk about the genetic predisposition to obesity.

Modern science has now identified over 100 genes that are associated with obesity, with each of these genes contributing a pound or two to the overall weight struggle.  So if a person has a high number of these 'bad' genes, they will have a bigger struggle with obesity, and a higher 'set point' of body weight, than someone who has only a few of these genes.   This can seem like a huge bummer - you can't change your genes (side bar: well actually you can but not in a good way - that's a story for another day) - so does this mean that the efforts to lose weight are hopeless?

The answer is, no.  Even for people who have more of the obesity-engendering genes, it is possible to lose weight, though a realistic weight goal will likely be higher than someone who has less obesity engendering genes.  In addition, a new study sheds light on gene-environment interactions in obesity, teaching us that certain behaviours can modify the effect of our genes on our body weight.

The study, published in PLOS Genetics, looked at gene-environment interactions for body mass index, using a large database of over 350,000 Caucasian people from the UK Biobank.  They found 15 lifestyle factors that influence our genes' effects on body weight, including:

  • alcohol intake frequency
  • usual walking pace
  • socioeconomic status
  • number of days per week of physical activity lasting at least 10 minutes
  • time spent watching TV
  • frequency of climbing stairs
  • smoking 
So, the good news here is that we CAN influence our genes' effect on body weight to some extent with the lifestyles we lead. While some of the ability to use these factors may be affected by e.g. physical limitations, I think it's encouraging to know that the effect of our genetics are not set in stone.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017


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How Successful is Gastric Bypass Surgery 12 Years Later?

>> Monday, September 25, 2017




We know that gastric bypass surgery is a powerful tool in the management of obesity and metabolic syndrome.  However, there is not a lot of data available following patients out over the very long term.  A recent study is the first prospective study looking only at Roux-en-Y gastric bypass surgery, to give us data out as far as 12 years.

The study, published by Adams and colleagues in the New England Journal of Medicine, enrolled 418 patients in Utah, USA who underwent gastric bypass surgery, and compared them over the long term to 417 patients who wanted surgery but did not have surgery (primarily because of lack of financial insurance coverage), and a third group of 321 patients with obesity who were not interested in surgery. They had an excellent rate of follow up of over 90% of patients at 12 years.

Here are some of the key findings: (skip to take home messages below for the short version)

1.  Weight loss:
  • Two years after gastric bypass surgery, the mean weight loss was 45 kg. 
  • At 6 years postop, the mean weight loss was 36.3kg (so there was about 20% weight regain, which is very consistent across studies).
  • At 12 years postop, the mean weight loss was 35kg – so weight was overall stable from 6 years to 12 years after surgery.

 [At 12 years, people who wanted surgery but didn’t have it had lost 2.9 kg (probably because they were part of this study), and people with obesity who did not want surgery had lost 0 kg (also notable for no weight gain over the long term).]


2.  Type 2 diabetes:

Among patients in the surgery group who had type 2 diabetes before surgery:
  • At 2 years postop, 75% of diabetes had gone into remission.
  • At 6 years postop, 62% of diabetes cases were in remission
  • At 12 years postop, 51% of diabetes cases were in remission.
  • The likelihood of diabetes being in diabetes remission at 12 years was 8.9 times higher for those who had had surgery compared to those who wanted but did not get surgery, and 14.8 times higher than those who did not want surgery in the first place.
  • At 12 years, the likelihood of being in diabetes remission was highest in people who had diet controlled diabetes before surgery (remission rate 73%), less for people who needed pills to treat their diabetes before surgery (remission rate 56%), and lowest for people who required insulin to treat their diabetes before surgery (remission rate 16%). 
  • At 12 years, there was a 91-92% lower risk of having new type 2 diabetes develop in patients who had had bariatric surgery, compared to the non surgery groups.


3.  Mortality rates:

At 12 years, mortality in people who had gastric bypass surgery was lower than those who wanted surgery but didn’t get it, but there no different between those who had gastric bypass surgery than those who didn’t want surgery in the first place, likely because the group not wanting surgery was healthier at baseline. There were 5 suicides in the group that had bariatric surgery, compared to 2 suicides in the non surgical group.  (see here and here and here for discussion of suicide risk after bariatric surgery ) 


Take home messages from this study:
  • On average, weight loss is stable over the long term after gastric bypass surgery – though the results can be different for different people, and certainly lifelong dedication to permanent lifestyle changes are essential for continued success.

  • Gastric bypass surgery can be a powerful tool to not only put diabetes into remission, but also to decrease the risk of developing diabetes later on.  Earlier intervention is better, because the longer a person has diabetes, the more tired their pancreas gets (ie decreased beta cell function, which are the cells that produce insulin), and a tired pancreas may be too tired to control blood sugars after bariatric surgery without help from medication.  Thus, considering bariatric surgery early in the course of diabetes, or even in the prediabetes phase, may have the most powerful impact.


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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