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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.  


Follow me on twitter! @drsuepedersen

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.



Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017







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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!



Follow me on twitter! @drsuepedersen

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.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017








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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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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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