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Protecting You and Your Baby: Diagnosing Diabetes Before, During, and After Pregnancy

>> Saturday, June 26, 2010

In parallel with the explosion of type 2 diabetes in recent years, so too are we seeing a marked increase in gestational diabetes, or diabetes which is diagnosed in pregnancy. Because of the critical importance of diagnosing and appropriately treating these women, consideration is currently being undertaken for changing the way we approach the diagnosis. These changes would result in a much broader group of pregnant women being identified as diabetic.

The impetus for considering a change in the diagnosis of gestational diabetes (GDM) is that an important study demonstrated that increasing maternal blood sugars were associated with increased birth weight and high insulin levels in the newborn baby, at levels below current Canadian diagnostic blood sugar thresholds for GDM. The International Association of Diabetes and Pregnancy Study Groups has therefore proposed a new set of blood sugar criteria for the diagnosis of GDM which are lower than our current thresholds.

The implications are enormous: as many as 18% of pregnant women would be considered to have gestational diabetes, compared to only 8% with current criteria.

Another important change being proposed is that certain blood sugar criteria would result in the diagnosis of Type 2 Diabetes while pregnant. Currently, when a woman is found to have high blood sugars in pregnancy, we make a diagnosis of Gestational Diabetes, which by definition is a state of elevated blood sugars that would be anticipated to resolve postpartum. However, it is increasingly recognized that many of these women were likely undiagnosed Type 2 Diabetics prior to pregnancy, and in these women, their blood sugar elevation will persist after delivery.

Though there is much ongoing debate as to whether these new criteria should be adopted, the opportunity to underline the importance of diagnosing and treating elevated blood sugars before, during, and after pregnancy must not be missed. The following steps are of crucial importance:

1. Blood sugars should be checked before pregnancy, such that diabetes before pregnancy can be detected and treated to control before conception. This is critically important, as high blood sugars in the first trimester is associated with increased risks including congenital malformations (birth defects), miscarriage, and high blood pressure in the mother.

2. Aggressive screening for diabetes in pregnancy, starting as early as at the time of diagnosis of pregnancy. The screening strategy is more aggressive in women with risk factors for diabetes, which include overweight, family history of diabetes, previously giving birth to a large infant, presence of metabolic syndrome, and certain ethnic backgrounds (such as Aboriginal Indian, South Asian, African ancestry). Remember that a woman who does not have diabetes before pregnancy can develop diabetes even in the very beginning of pregnancy, as several hormonal changes occur in pregnancy that can predispose towards development of diabetes.

3. Diabetes must be carefully checked for after delivery, so as to identify women who have diabetes that persists beyond pregnancy. Checking blood sugars after delivery is not enough; a glucose challenge test (performed under the care of your doctor) must be undertaken.

4. Breast is best: in addition to numerous benefits to the baby, breastfeeding also helps to control blood sugars postpartum in the woman who is persistently diabetic. Breastfeeding is also a great method to help shed pounds after pregnancy, as about 300 calories are expended in breast milk each day (including 50 g of carbohydrates)!

Dr. Sue © 2010


Nine Percent of Canadians to be Newly Diagnosed with Diabetes Over 10 Years

>> Saturday, June 19, 2010

It is not new news that a diabetes epidemic is upon us. Currently, nearly 6% of Canadian adults (about 2 million people overall) are diagnosed with diabetes. Most of these cases are Type 2 diabetes, which is caused by a state of insulin resistance, and often brought on by overweight or obesity.

Predicted rates of diabetes in the near future in Canada are even more starggering.
An investigative report was undertaken by Canada's Institute for Clinical Evaluative Sciences, to try to predict how many new cases of diabetes we are going to see in Canada over the next few years.

The study found that 1.9 million Canadians are predicted to develop diabetes in the ten year period between 2007-2017. This will nearly double the number of currently diagnosed cases. Although the risk of developing diabetes is higher with a higher weight or higher Body Mass Index (with 'obesity' being defined as a Body Mass Index >30), most of the new cases of diabetes will be in the 'overweight' category (with BMI 25-30), because there are more overweight than obese people in the country.
Another concerning trend that is being seen is that younger Canadians are becoming affected by Type 2 Diabetes, due to higher rates of childhood obesity. The youngest Canadian with Type 2 Diabetes currently on record is only six years old. Risk factors for developing type 2 diabetes in Canada were identified, and include:

  • higher Body Mass Index (you can calculate your own BMI here, in the right hand column)
  • increasing age
  • being male (vs female)
  • people who have immigrated to Canada (compared to people born in Canada)
  • being a lower-income woman, or a higher-income man
  • ethnic background
  • having lower levels of education
In this report, a Diabetes Population Risk Tool has been constructed, with which the risk of a particular individual developing diabetes can be generated, taking into account various risk factors and demographic data (BMI, age, gender, and other factors). They provide two profiles for comparison:

Profile 1: Female, 33 years old, BMI=22 kg/m2, no hypertension, white, not immigrant, post-secondary education.

Ten-year risk of being diagnosed with diabetes: 1.2%.

Profile 2: Male, 55 years old, BMI=38 kg/m2, hypertensive, white, does not have heart disease, smoker, less then secondary school education.

Ten-year risk of being diagnosed with diabetes: 44%.

The report has some good news too - and that is related to the predicted benefits in prevention of diabetes that could be achieved with simple lifestyle intervention. Based on Ontario population data, for example, it is estimated that by providing individuals at highest risk for diabetes with lifestyle therapy (and provided they adhere), only eleven people would need to be treated to save one person from developing diabetes.

The bottom line: Prevention is Key!!

Dr. Sue © 2010


Normal Weight Obesity Part II

>> Saturday, June 5, 2010

Thanks to all of my readers who provided feedback, comments, and questions regarding last week's blog on Normal Weight Obesity. The questions generated were important, and I'd like to share some of these key issues with you this week!

One of my readers enquired as to whether everyone in the normal BMI range (18.5-25) is at risk of Normal Weight Obesity (NWO). The answer is that the higher your BMI is within the normal range, the higher the risk of NWO. In other words, an individual with a BMI of 19 is extremely unlikely to have NWO, whereas an individual with a BMI of 24 has a higher likelihood of NWO. (Stay tuned for a little more detail on this one - I've just submitted a research article for publication along with my colleague Dr. Arne Astrup in Copenhagen, looking at our own DEXA scan data and BMI misclassification rates.) Women are also at higher risk of NWO than men.

Another important issue to point out is that the opposite classification problem can occur as well: that is, that some people are classified as being overweight by BMI, but do not have excess body fat. Men are at higher risk of this type of misclassification than women (though it can happen in women as well). Picture, for example, a male hockey player with lots of lean muscle mass, and a BMI of 27. This individual is overweight by BMI criteria, but his fat mass may be only15%, well under the 25% fat mass cutoff that defines excess body fat in men. It would be entirely inappropriate to recommend to this hockey player to lose weight!

This example highlights the importance of having other estimates of body fat than just BMI. Waist circumference can be helpful as well: you could imagine that the ultra-fit hockey player would have a trim waist, whereas a sedentary man with a BMI of 27 may be collecting a little extra around his midline. Our ideal upper limits for waist circumference are:

  • Caucasian, Middle Eastern, Africans: men 94cm, women 80 cm
  • South Asians, First Nations, Chinese, and Japanese: men 90 cm, women 80 cm

This discussion also highlights another important issue with regards to weight struggles, and that is to remember to take pride in a change in body composition that you might be making by stepping up your exercise routine, even if you are not seeing a change in weight. Building muscle in place of fat is beneficial in terms of decreasing your risk of complications of excess body fat (cardiovascular disease, high blood pressure, and many others), and will likely also provide you with an improved sense of general well being and overall health. Changing your body composition in favor of less body fat is a victory in itself!

Dr. Sue © 2010



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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