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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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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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