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Diabetes Canada Guidelines 2018 - Physical Activity

>> Monday, May 14, 2018




There is a ton of great, new information in the 2018 Diabetes Canada Physical Activity guidelines chapter.  Here are some of the highlights:


1. Avoid prolonged sitting. Try to get up briefly every 20 to 30 minutes.  Bluntly put, this is because we now know that habitual, prolonged sitting is associated with an increase risk of death and major cardiovascular events (eg heart attack).

2. While it is still recommended to engage in 150 minutes per week of aerobic exercise and at least 2 sessions per week of resistance exercise if possible, it is now recognized that smaller amounts of activity still provides some health benefits. Something is better than nothing!

3.  Make use of strategies that increase motivation, such as setting specific physical activity goals, and using self monitoring tools (eg a pedometer that counts steps). (My editorial comment - some of these devices can also remind you to get up if you've been sitting for too long.)

4.  Medical clearance: It was previously recommended that anyone with diabetes who is about to begin a program more vigorous than walking should have medical clearance first.  This has been relaxed a little - now, this need for clearance is more focussed on middle aged and older people who wish to undertake prolonged or very vigorous exercise, and of course, anyone with symptoms suggestive of cardiovascular disease.

People with more advanced diabetic eye disease should be treated and stabilized before vigorous exercise, and people with severe diabetic nerve disease in their feet/legs should inspect their feet daily and wear appropriate footwear.   It is also recommended to ideally see a qualified exercise specialist before starting strength training (eg weights) to avoid injury.

5.  There is a great list of suggested strategies to help people with type 1 diabetes reduce the risk of lows with exercise.


Bonus Practical Stuff: 

Resources for people with diabetes: (scroll down to Exercise) - including info on how to plan and maintain physical activity, videos on resistance exercises, and more!

Resources for health care providers: under 'Management' - scroll down to 'Physical Activity and Diabetes' - tools including how to write an exercise prescription


Enjoy - and have fun!





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www.drsue.ca © 2018







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New 2018 Diabetes Canada Guidelines - Nutrition Therapy

>> Monday, May 7, 2018





It's hard to know how to eat right - there is a lot of conflicting information out there, and unfortunately lots of claims that have no scientific backing nor evidence of long term success.
Eating well with diabetes is no exception.

Thankfully, we have the Diabetes Canada Clinical Practice Guidelines to give us evidence based recommendations on healthy eating with diabetes.

The updated Nutrition Therapy chapter in the 2018 Guidelines contains a lot of great information.   I really encourage interested readers to snuggle up with a cuppa to read the whole chapter, but let's go through some of the key points here:

1.  Nutrition therapy can reduce hemoglobin A1C (the diabetes report card) by 1-2% (that's as much as 1-2 diabetes medications!)

2.  The proportion of carbs vs protein vs fat should be flexible within the recommended ranges, and will depend on individual treatment goals and preferences.

3.  Eating low glycemic index foods instead of high glycemic index foods helps to improve diabetes control.

NEW: Aim for a fibre intake of 30-50g per day, with 10-20g coming from soluble fibre, to improve blood sugars and cardiovascular risk.

4.  Added sugars should be MAXIMUM 10% of total daily caloric intake.

5.  Intensive health behaviour interventions in people with type 2 diabetes can improve weight, fitness, diabetes control, and cardiovascular risk factors.

6. NEW: People with diabetes should be encouraged to choose the dietary patterns that best align with their values, preferences, and treatment goals. (check out the new sections on ethnocultural diversity in Canada, and on Ramadan, as well!)


Here are some of my favourite Key Messages For People With Diabetes: 

1.  Try to prepare more of your meals at home, using fresh and unprocessed ingredients.

2.  Prepare meals together and eat as a family. This is a good way to model healthy food behaviours to kids and teens, which can help reduce their risk of developing overweight or diabetes.

3.  The best strategy is one that you can maintain long term.

4.  With prediabetes and newly diagnosed type 2 diabetes, weight loss is the most important and effective dietary strategy if you have overweight or obesity.  A weight loss of 5-10% may help to normalize blood sugars.

5.  Diabetes friendly eating habits can improve blood sugars and decrease the risk of cardiovascular disease, including:

  • select whole foods instead of processed
  • avoid sugar sweetened beverages
  • pay attention to both carbohydrate quantity, and quality (low glycemic index instead of high)
  • considering learning how to count carbs
  • preferred dietary fats are unsaturated - maximum saturated fats has now been increased to 9% of total calorie intake (previously 7%) - and avoid trans fats completely
  • choose lean animal protein, and eat more vegetable protein


The data for many different diets/patterns of eating is reviewed, with many different types of diets being suggested for an improvement in type 2 diabetes control, including Mediterranean, vegetarian, and DASH diets, as well as diets that include pulses (eg beans), vegetables, fruits, and nuts.  The details of what is in these diets is provided in the chapter, and available data in type 1 diabetes is reviewed as well.  At the end of the day, the key is to choose a healthy way of eating that is in keeping with individual preferences, as this gives the greatest likelihood of being able to follow it long term.


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New 2018 Diabetes Canada Guidelines - Weight Management

>> Monday, April 30, 2018




As an author of the Weight Management chapter of the new 2018 Diabetes Canada Clinical Practice Guidelines, I'm thrilled to share with you some key points and exciting changes!

So what is new since the last guidelines in 2013?

1.  People first language.  We have made an important change in the entire 2018 Diabetes Canada guidelines in the way we talk about obesity.  Obesity is a diagnosis, and not a way to describe a person.  Thus, instead of the terminology 'overweight or obese people', the correct terminology is 'people with overweight or obesity'.  This is a critical step in breaking down the stigma against obesity!


2.  New information on medications for weight management in type 2 diabetes.  Liraglutide (Saxenda) is a new medication available for weight management in Canada since the last guidelines.

(note: Naltrexone/Bupropion (Contrave) is now approved in Canada as well, but this approval occurred after the literature reviews for the Guidelines were completed, so is not included in this iteration)

Medications for weight management have not been adequately studied in people with type 1 diabetes.


3.  Updates on bariatric surgery:

  • Gastric banding is not as effective as other bariatric procedures for type 2 diabetes control or remission.  
  • Predictors of who is more likely to enjoy type 2 diabetes remission after bariatric surgery include a shorter duration of diabetes, younger age, not needing insulin preoperatively, and higher preoperative serum C-peptide (a marker of insulin production). 
  • An update on the effect of bariatric surgery on complications of diabetes is discussed as well.
  • The BMI criteria for bariatric surgery remain unchanged.  Evidence of risk and outcomes of bariatric surgery for people with a BMI of 30-35 is limited and cannot be recommended at this time. 
  • Bariatric surgery has not been adequately studied in people with type 1 diabetes. 



KEY MESSAGES: 

1. Sustained weight loss of 5% or more can improve diabetes control and cardiovascular risk factors.

2.  In people with diabetes and obesity, weight loss and improvement in diabetes control can be achieved with healthy behaviour interventions.  Weight management medications can improve diabetes and metabolic control.

3.  Bariatric surgery may be considered appropriate for people with diabetes and obesity.

4.  When selecting the most appropriate diabetes medications, the effect on body weight should be considered.



KEY MESSAGES FOR PEOPLE WITH DIABETES: 

1. When you have diabetes, having overweight or obesity increases your risk for complications.

2.  Healthy behaviour modifications, including regular physical activity and eating well can help with your blood sugar control, and reduce your risk for other health problems associated with diabetes.

3.  Your diabetes health care team can help you with weight management.  For some people with diabetes, weight management medications and bariatric surgery may be helpful.



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www.drsue.ca © 2018

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New 2018 Diabetes Canada Guidelines - Cardiovascular Protection

>> Tuesday, April 24, 2018





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

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


KEY MESSAGES FOR PEOPLE WITH DIABETES: 

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

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

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

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

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

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

S = Stop smoking and manage stress.


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

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

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


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

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

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


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2018 Diabetes Canada Guidelines - Medications for Type 2 Diabetes

>> Monday, April 16, 2018



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

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

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

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

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

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


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

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


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

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

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


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


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




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www.drsue.ca © 2018



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2018 Diabetes Canada Guidelines Are Out!

>> Monday, April 9, 2018



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

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

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

Key Messages

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

Recommendations


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

Enjoy!

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www.drsue.ca © 2018




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The Easter Waftata

>> Saturday, March 31, 2018






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

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

Ingredients:

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




Directions:

1.   Beat eggs in a small bowl.

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

3.  Preheat your waffle iron.

4.  Stir potato and apple into the mixture.

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

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


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

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

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


Enjoy!

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www.drsue.ca © 2018

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

>> Monday, March 26, 2018


(this is fat tissue under a microscope)



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


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

Key findings were truly fascinating.

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

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

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

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

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

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

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

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

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


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How Your Diet Influences Where You Lose Fat

>> Monday, March 19, 2018




In weight management, our goal is to improve overall health.  In a perfect world, it would be preferable if we could melt away the fat around and inside the internal organs (called 'visceral fat') rather than the fat under the skin, as it is this visceral fat that contributes most to health complications of obesity such as diabetes, high blood pressure, and metabolic syndrome.

A recent study suggests that what we eat actually can help us to target this visceral fat.

The CENTRAL study, published in the journal Circulation, randomized 278 sedentary adults with either abdominal obesity or high cholesterol to follow either the Mediterranean diet versus a low fat diet for 18 months.  Six months into the trial, participants were also randomized to follow an exercise program or not. They used MRI scans to evaluate fat under the skin, fat around the organs, fat in the liver, pancreas, and even around the heart.

At the end of the 18 month study, weight loss was the same between all four groups (Mediterranean vs low fat diets, with or without exercise) at -3.2%.   However, where fat was lost from, and how this influenced health, was different between groups:


  • People on the Mediterranean diet lost more fat from the liver, pancreas, and around the heart. 
  • Exercise with either diet had a greater effect on reducing visceral fat. 
Whether or not total body weight was lost: 
  • Losing visceral fat and/or liver fat improved cholesterol.
  • Losing fat deep under the skin improved insulin sensitivity.
  • Losing fat just under the skin had no effect on health and reduced levels of leptin (a hormone that tells our brains that we feel full). 
The findings that the Mediterranean diet preferentially reduces the more dangerous visceral fat may explain why it is the only diet that has been convincingly found to prevent cardiovascular events.  

These results also show us that it's not about numbers on the scale, as this does not reflect the important changes going on with fat deposit patterns inside. 



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Why Short Term Weight Gain Can Be Easier to Lose Than Long Term Weight

>> Monday, March 12, 2018





No weight gained is easy to lose, but - have you ever wonder how Hollywood's actors can gain weight for a movie role, and the next thing you know, they are back at their usual weight for their next photo shoot?  While one may think that it’s simply the superstar access to personal chefs and trainers that gets actors back in shape, there is actually a physiologic basis that can make it less difficult to shed a quick/temporary/intentional weight gain than excess weight that has been present for the long term.

As discussed in a recent Scientific Statement on Obesity Pathogenesis by the Endocrine Society, obesity is associated with inflammation in various tissues, including muscle, fat tissue, vascular system, and liver, and this inflammation appears to be a consequence of chronic obesity.    There is also inflammation in the hunger/fullness centre of the brain, called the hypothalamus.

For a person who has been struggling with weight long term,  inflammation in these tissues causes maladaptive changes in those tissues that make them more resistant to weight loss.    It takes time for this inflammation to develop, so for a person who has had a fairly acute weight gain, it may be easier to drop pounds because they don't have this inflammation working against them.

So then you may wonder - why do some people seem to lose quickly gained weight more easily than others? (e.g. after pregnancy)?

Well, the story of the hunger/fullness centre in the brain is a little more complex.  It turns out that this inflammation may not only be a consequence of long term obesity, but may actually be present in some people before obesity develops.   Some animal studies suggest that eating a high fat diet triggers these inflammatory changes, damaging the neurons in the hypothalamus, which may then result in a disruption of sensations of hunger/fullness, lead to weight gain, plus make it harder to lose it again.

In other words, people who struggle to lose weight after a fairly quick/new weight gain may have inflammation in their hunger/fullness centre that was there before the weight gain, thus making them not only more prone to weight gain, but also making it harder to lose weight than the person without the inflammation. 


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www.drsue.ca © 2018

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The Sleeping Beauty Diet

>> Monday, March 5, 2018




I was shocked and saddened to learn about yet another potentially harmful way that some people may be trying in a desperate attempt to lose weight.

The Sleeping Beauty diet involves taking sleeping pills, with the goal of sleeping through normal waking hours to avoid eating.  Also referred to as 'narcorexia', this fad is not only ineffective, but also dangerous:


1.  While it is true that not enough sleep is associated with higher body weight, so to is too much sleep.


2.  When you are sleeping, your body's metabolism is at its slowest.  When you are awake and moving around, you burn more calories.  Thus, people who sleep more than what their body needs are putting themselves at risk of weight gain by decreasing their overall calorie burn.

3.  Sleeping at unusual hours alters the body's circadian rhythm and the normal hormonal rhythm, which can has a negative impact on health from many perspectives.  Poor sleep quality caused by messing up the body's normal daily rhythm is associated with weight gain, due to alterations in the normal rhythm of hunger/fullness hormones, and an increase in craving for unhealthy foods.

4.  Most importantly: sedation induced by sleeping pills increases the risk of all manner of dangers  and problems due to impaired brain function while under the influence - car accidents, accidents at home, mistakes at home or the workplace... need I go on.

I am so terribly saddened that people out there are so desperate to lose weight that they are literally willing to sleep their life away to do it.  Yet another powerful and compelling reason why the health care profession, and society in general, needs to uniformly accept obesity as a chronic medical condition and help people get the support and care they so desperately need.

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How Do Our Gut Bacteria Contribute To Obesity... And Can We Treat Them?

>> Monday, February 26, 2018




As blogged previously, we are learning that the bacteria we carry in our intestines (called the gut microbiota) have a role in obesity.  While we still seem to have more questions than answers on this topic, a fascinating review was just published, discussing some very interesting perspectives on this topic.  Here are some key points:

1.  We know there is an association between certain types of gut bacteria and obesity.  However, which is the 'chicken' and which is the 'egg', so to speak, is not clear, and the answer may be both.  In other words, there is evidence that certain types of gut bacteria contribute to the development of obesity, while others are protective.   There is also evidence that developing obesity can change the gut bacteria in favour of those that further contribute to obesity.


2.  Several ways that gut bacteria can contribute to obesity are identified:
  • some gut bugs are better at helping us extract calories from food by fermenting otherwise indigestible fibers
  • gut bacteria can influence permeability (leakiness) of the gut lining, allowing bacterial products into the bloodstream that can trigger an obesity-promoting low grade inflammatory response 
  • short chain fatty acids produced by gut bugs may have an effect on the gut's barrier function, as well as inflammation and appetite
  • (particularly fascinating in my opinion:) gut bacteria can have an impact on the genes we express in the hunger/fullness center in the hypothalamus in our brains through effects on inflammation and nerve signalling. 


3.  Can we treat obesity by changing our gut bacteria?

Knowing that some types of gut bacteria contribute to the development of obesity, the next natural question then is whether we can treat obesity by changing gut bacteria.

There is preliminary evidence that some strains of bacteria, provided as probiotic supplements, may be of benefit in weight management, but there is still much to learn in this area. There is also a lack of regulation in the supplement industry and a huge variation in what different probiotic supplements provide, so it can be hard to know what you're getting.  Some studies suggest that some fibres with prebiotic like effects may be beneficial as well.

Interestingly, metformin, which is an antidiabetic medication, has been shown to alter gut bugs in rodent studies in favour of a gut bacteria that is associated with less adiposity. (While metformin is considered to be weight neutral, some people do lose weight with it.) Also, metformin loses efficacy in animals when pretreated with antibiotics - could this be because of an alteration in gut bacteria? 

We also know that bariatric surgery changes the gut bug composition, and may play a role in the weight loss effect of surgery, by altering gut bugs in favour of those that are not so good at helping us harvest calories from food. 

Fecal transplant (yes, you read that correctly!) is also being considered as a possible treatment strategy for obesity.



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New Obesity Medication Approved In Canada

>> Monday, February 19, 2018





Last week, Health Canada approved a new medication for weight management in Canada. This medication is actually a combination of two medications that have been around for years, called naltrexone and bupropion.

Bupropion is an antidepressant medication (called Wellbutrin), and is also used as a smoking cessation agent (called Zyban). It works by stimulating the fullness center of our brains, thereby suppressing appetite (specifically, it increases POMC activity in the hypothalamus by inhibiting reuptake of dopamine and norepinephrine).

Naltrexone is an opioid antagonist, which has been used for many years in the treatment of alcohol dependence and prevention of relapse to opioid dependence.  Naltrexone works by preventing the fullness center of our brains from shutting itself off, further contributing to appetite suppression (specifically: POMC releases B endorphin that creates a negative feedback loop by binding to the mu opioid receptor on POMC neurons; naltrexone blocks this negative feedback loop). 

Naltrexone and bupropion are also thought to have an effect on the mesolimbic reward center of our brains as well, which may result in decreased motivation for, desire for, and sense of reward/satisfaction from tasty foods. 

The weight loss at 1year with naltrexone/bupropion (trade name is Contrave) is about 4% of body weight compared to placebo, with people continuing to take the medication through a year (i.e. excluding those who dropped out of the study) losing 8.1% body weight in combination with lifestyle modification.  With an intensive weekly behavioural modification program, people who continued the medication and lifestyle program lost 11.5% weight after a year, again about 4% more than the behavioral modification group alone, who lost 7.3% body weight.

In a study of people with type 2 diabetes, overall weight loss was 3.7% body weight (5.9% in those who completed the trial) vs 1.7% in the placebo group (2.2% in trial completers). In addition, diabetes control improved, with a 0.5% greater reduction in hemoglobin A1C (a diabetes report card test) than placebo.

The dose of naltrexone/bupropion for weight management is gradually escalated from the starting dose of one 8mg/90mg tablet once a day, to the full dose of two tablets twice per day, over about 4 weeks.

The most common side effects of naltrexone/bupropion are nausea (in 32% of people vs 7% on placebo), constipation, dizziness, vomiting, and dry mouth.  Gastrointestinal side effects tend to abate after about 4 weeks on treatment.

In terms of rare but serious side effects, there is a slightly increased risk of seizures with bupropion (0.1% of people in the weight loss studies vs 0% on placebo), so this medication should not be used in people at risk of seizures.   It is advised not to take Contrave with a high fat meal, as this increases absorption of the medication to more than what was intended.  Also, if doses are missed, they should not be taken later (just skip it completely).

Though it is an antidepression medication, bupropion can temporarily worsen depression or suicidal thoughts (there were no suicide attempts in any of the naltrexone/bupropion weight loss studies).

Contrave should not be used in people who are on opioid pain medications.  There are also a number of other potential medication interactions that must be assessed before starting the medication.

Heart rate and blood pressure can increase slightly; what is usually seen is actually a very small decrease in blood pressure with the weight loss, but not as much blood pressure decrease as one would usually expect with the amount of weight loss seen.  A cardiovascular safety trial was begun but halted about halfway through because interim data had been released, with the concern being that this data release could impact the integrity of that trial.  Naltrexone/bupropion appeared to have cardiovascular safety at the halfway mark, but this is not sufficient data to answer the question – thus, another cardiovascular safety trial is being planned.

Note that this is not a comprehensive list of all considerations in prescribing naltrexone/bupropion – the full Canadian product monograph is available here

Naltrexone/bupropion was approved in USA in 2014 - interested readers can consult the American product monograph here.  

It is encouraging that we now have three medications in Canada that are approved for weight management.  We know that obesity is very heterogeneous (different in causes, contributors, and health consequences from person to person), and thus, the best approach will be unique to each individual.  We also know that the response to antiobesity medication differs from person to person.  The general principle is that a 5% weight loss after 3 months on treatment is the best predictor of long term success with a particular medication (though in my opinion,  maintaining weight after a significant dietary-induced weight loss with the help of medication is an important success as well).  

Disclaimer: I receive honoraria as a continuing medical education speaker and consultant from the makers of naltrexone/bupropion (Valeant). 

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018



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