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Skinny Slow Cooker Chicken Marinara

>> Sunday, March 29, 2015

Love this slow cooker permutation of chicken marinara - SkinnyMom wins the award for an awesomely healthy recipe that didn't need any 'doctoring' to make it approved.  Imagine how much you'll love coming home from work, cracking open the front door to find the delicious scent of your dinner wafting out to great you....

  • 2 pounds boneless, skinless chicken breasts
  • 4 cloves garlic, peeled and crushed
  • 4 tomatoes, chopped or one 14.5-ounce can low-sodium tomatoes, drained
  • 4 medium ribs celery, diced (1 cup)
  • 2 small zucchini, diced (2 cups)
  • 1 bell pepper, cored, seeded, and diced
  • One 18-ounce jar low-sodium marinara sauce
  • 1 tsp dried basil
  • 1 tsp dried thyme
  1. Place the chicken in the slow cooker; add the garlic, tomatoes, celery, zucchini, and pepper.
  2. Pour the marinara sauce over all, and sprinkle the basil and thyme on top.
  3. Set the slow cooker on low and cook for 6 to 8 hours (make sure the chicken is cooked through!).
  4. Before serving, shred the chicken with a fork.

Makes 8 servings.  Nutritional Info per serving (approximate): 
  • calories: 172
  • fat: 3.6g
  • protein: 27g
  • carbs: 7g
Follow me on twitter: @drsuepedersen © 2015


Testosterone Treatment in Men - Risk To The Heart?

>> Sunday, March 22, 2015

At the Endocrine Society’s recent ENDO 2015 meeting in San Diego, I managed to score a seat in a packed-to-overflowing symposium discussing some of the controversies surrounding testosterone therapy in men.

At the heart of the discussion ws the fact that testosterone prescribing in men has dramatically increased over the last several years, primarily due to an increase in prescribing of this hormone to men who do not have a medical reason for failure of testosterone production (ie a testicular or pituitary problem), but rather, are men who have a low-ish testosterone due to aging or obesity, in hopes that they may feel better with testosterone therapy.   The prescribing of testosterone in men without a true failure of testosterone production has raised a number of safety concerns – in particular, whether testosterone may increase the risk of heart attacks or stroke.

The first point that was made in the symposium by Dr Alvin Matsumoto is that men may be labelled as having low testosterone, when, in fact, they don’t.  The problem here lies with a number of concerns with the accuracy of measurement of testosterone levels in men:

  • First of all, testosterone needs to be measured in the morning, as levels are highest in the morning and fall later in the day; 'normal' ranges have been developed based on the early morning measurements.  
  • Second, there are a lot of problems with the accuracy of testosterone measurement - one study looked at over 1000 different labs and found that testosterone levels on the same sample varied by 6 fold (ranging from very low to well within the normal range).  
  • Third, testosterone levels are not the same from day to day in one particular man - in fact, in men who have a low testosterone measured initially, about a third will have a normal level on repeat testing.  

Dr Shehzad Basaria then took us through an excellent review of the conflicting data around the effect of testosterone on cardiovascular (CV) risk.  Population studies suggest that testosterone treatment decreases the risk of CV events, but it is possible that it is men more concerned about/interested in their health that were taking the testosterone, so these results may just reflect that healthier men were tending to take testosterone in the populations studied.  Other retrospective studies, on the other hand, have suggested that testosterone treatment increases the risk of CV events – these studies suggested that it is older men, and those with pre-existing heart disease, who had the highest risk.  This is highly relevant to the discussion of whether it is safe to prescribe testosterone to men with age- or obesity-related decline in testosterone, as this is a group of men who are older and more likely to have pre existing heart disease.

We always look to randomized, controlled clinical trials for the answers to these questions if at all possible – and in fact, a recent study called the TOM study was stopped early because they saw a higher risk of CV events in the group of men receiving testosterone treatment.   The TOM study results have been criticized because they were studying muscle strength as their primary endpoint of interest and not CV events per se – but the results are what they are.

As far as how exactly testosterone treatment could increase the risk of heart attacks, we don’t know, but several possibilities have been suggested, including increase in clotting tendency/inflammation, driving testosterone levels too high with treatment, and fluid retention.

Because of the concerns that testosterone treatment may increased the risk of cardiovascular events, the FDA has now stated that testosterone treatment is only approved for men with true failure of testosterone production caused by certain medical conditions (these would include a primary problem with the testicles such as previous injury, mumps, or chromosomal issues; or the pituitary gland such as a pituitary tumor or radiation damage). They go on to state that the benefit and safety of testosterone has not been established for the treatment of low testosterone due to aging, even if a man's symptoms seem related to low testosterone.  The FDA also now mandates that the labeling for testosterone treatments includes a warning that it may increase the risk of heart attack or stroke.

Clearly, much more research is needed to answer our questions in this controversial area.

Follow me on twitter! @drsuepedersen © 2015


Bariatric Surgery for Diabetes Prevention?

>> Sunday, March 15, 2015

Over the last decades, many modalities to prevent type 2 diabetes have been studied.  Lifestyle changes, particularly if they result in weight loss, can be very powerful to prevent this condition.  Of all of the medications studied, only metformin has so far been recommended to decrease the risk of developing diabetes in people who have prediabetes.  Now, studies are coming out, showing that bariatric (obesity) surgery can be very powerful to prevent type 2 diabetes.

One such study, published recently in The Lancet (Diabetes & Endocrinology),  looked at over 2000 patients who had bariatric surgery, and compared them to a group of matched patients who had not had obesity surgery.  They found that, over a median of 2.8 years and a maximum of 7 years of follow up, patients who had bariatric surgery had an 80% lower risk of developing diabetes compared to people who had not had bariatric surgery.

Another recent study was a systemic review and meta-analysis that looked at the power of different interventions to prevent diabetes. In examination of studies of physical activity +/- diet, anti diabetic medications, obesity medications, and bariatric surgery, they found all of these strategies to be of benefit.  Bariatric surgery stood out as being the most effective to prevent diabetes, with a 90% reduction in risk.

So the question then becomes, should we advocate for obesity surgery for the purpose of prevention of diabetes?  Well, as for any treatment or prevention of any medical condition, it's important to balance the benefits vs risks.  Bariatric surgery is invasive, and the most successful modalities (gastric bypass and sleeve gastrectomy) are permanent procedures.  These procedures have a long list of possible complications that need to be taken into consideration.

While bariatric surgery may be the best treatment option for some patients with obesity and existing type 2 diabetes, obstructive sleep apnea, severe high blood pressure, or severe osteoarthritis, it seems that using surgery solely to prevent these conditions may be outweighed by potential risks.  That being said, a marked reduction in risk of developing type 2 diabetes is certainly an added bonus to the patient having bariatric surgery who is having bariatric surgery for other reasons.

Thanks to my friend Gord for the inspiration for this blog post!

Follow me on twitter! @drsuepedersen © 2015


ENDO 2015: Fun In San Diego!

>> Sunday, March 8, 2015

It's been an amazing week!  I always leave the ENDO conference feeling so inspired and passionate about endocrinology, and I look forward to returning home to my patients with new pearls of information to guide my practice.

The ENDO2015 organizers asked me to publish at least one post this week about fun things I did while in San Diego (to make sure I actually got away from my computer for a little while? ;).

During the week in San Diego, I have taken the opportunity to ponder my new pearls of knowledge while enjoying some great sunrise seaside runs (a great treat for this mountain girl!) - I'm looking forward to putting the skis back on at home, but I must admit the warm sunshine and ocean breeze was a wonderful repose from the Canadian winter.

Lots of interesting things to see on these morning sojourns... the Naval Base:

A sculptural display called Our Silences, described as "an invitation to emotively reflect - or get excited with intelligence - about one of the fundamental human rights: the freedom of expression."

And naturally, lots of fabulous people watching en route - especially impressed by the active lifestyle of both tourists and residents.  It seemed as though there was never a shortage of people going for walks, rolls, runs, laps of stairs of the convention centre.... And I even got to be a faux-participant of today's San Diego Marathon!

It's been a pleasure being a blogger for ENDO2015 - thanks to all my readers for taking the journey with me!  Moving forward, feel free to join me in my now 7th year of blogging - check back for my weekly post, enjoy the search box in the right hand margin, or subscribe to receive my posts automatically.

Follow me on twitter! @drsuepedersen © 2015


ENDO 2015: Medications To Treat Obesity

>> Saturday, March 7, 2015

At the ENDO 2015 meeting this week, I had the great pleasure of sitting in on a session about medications to treat obesity, a presentation provided by Dr Caroline Apovian.  Dr Apovian is the lead author of the Endocrine Society's Clinical Practice Guideline for the Pharmacological Management of Obesity (published in January 2015).

It's an exciting time in the US for treating obesity, as the FDA has now approved a total of 6 medications for the treatment of obesity.   The six medications available are (ordered as they appear in the guidelines):

  • phentermine
  • topiramate + phentermine
  • lorcaserin
  • orlistat
  • naltrexone + bupropion
  • liraglutide (approved, not yet available on shelves)

Most other countries in the world do not have access to so many options to treat obesity with medications - for my Canadian readers, we have only two (orlistat, and liraglutide, which has just been approved by Health Canada but is not yet on shelves).

In her discussion of these medications, Dr Apovian made some poignant points about the use of medications to treat obesity - specifically, that we are far behind in approving and accepting the use of medications to treat obesity, compared to other chronic medical conditions like diabetes or high blood pressure, where we have many different medications to choose from.  While the reasons for this are complex, it stems at least in part from the stigma that still surrounds obesity - the reluctance by both health care professionals and the general public to accept obesity as a chronic disease and not just a symptom or a lifestyle 'problem'.

These medications are intended for use in addition to lifestyle changes, in people who have had unsuccessful attempts at lifestyle changes to lose weight.  Dr Apovian pointed out another contrast in our approach to obesity with other chronic health issues: specifically, that it is interesting that we do not categorically require a patient with high blood pressure to 'fail' a low salt diet before starting medication, and we do not require a patient with high cholesterol to 'fail' a low fat diet before recommending cholesterol lowering medication.

These new Clinical Practice Guidelines (where you can read the details about these medications) is the first of its kind - it recommends that we look at obesity as the central problem to address and treat, rather than focussing only on the complications of obesity, as we have traditionally tended to do.

I couldn't agree more.  We are in need of a Revolution in our thinking – namely, to consider the obesity as the central fulcrum of clinical attention and treatment.  In other words, we need to treat the obesity itself, while simultaneously addressing the complications of obesity that are present.  By targeting treatment towards the obesity, we often see an improvement in many of the complications associated with obesity, thereby improving the overall health of our patient. 

Follow me on twitter! @drsuepedersen © 2015


ENDO 2015: Performance Enhancing Drugs

>> Friday, March 6, 2015

Late yesterday at the Endocrine Society's ENDO 2015 conference, I attended a fascinating session about performance enhancing drugs given by Dr Shalender Bhasin.  

When we think about performance enhancing drugs (PEDs), we tend to associate their use with elite athletes who are using them to get an edge to win a game or a race (with the cycling scandals being an example).  While this certainly does occur, the far more common abuse of PEDs is actually amongst recreational weight lifters, who use PEDs to improve their aesthetic appearance (ie to looked as cut and ripped as possible).  Those that use PEDs for muscle appearance may be at an even higher risk of adverse health effects than the elite athlete, because recreational body builders are more inclined to use these drugs for many years continuously, whereas elite competitive athletes tend to use them more intermittently, usually limited to a few years, and usually supervised by sports med physicians.  (That being said, let's be clear: any use of PEDs can be very dangerous, 'monitored' or not.)

The use of PEDs by men with the goal of enhancing their aesthetic appearance sheds light on an important issue that doesn't get enough attention: namely, that it is not only women, but also men, that are at risk of body image disorders in our current society.  While women may feel a social pressure to emulate the wafer thinness of some celebrities or models, men may also feel pressure to emulate their Hollywood counterparts, to be more chiseled and buff than may be obtainable under normal physiologic circumstances.  A term called Muscular Dysmorphic Syndrome has been coined to describe the condition where an individual (usually a man) is preoccupied with muscularity and leanness, causing dissatisfaction with the person's own body size and shape to the point where it results in impaired function in occupation and social life. 

Muscular Dysmorphic Syndrome with resultant abuse of performance enhancing drugs (PEDs) can be difficult to detect.  This group of individuals typically do not come to doctors for help, and if they do, may not admit that they are using PEDs.  This is a grave concern, because there are multiple (including some life threatening) risks of PED use, with the particular list of risks depending upon the drug or drugs being used.  (PEDs can vary from testosterone derivatives, to growth factors, to hormone modulators, to diuretics, to Beta-2 agonists, to peptides, to stimulants - or any combination of the above).  

As Dr Bhasin eloquently pointed out, the best diagnostic tool that we as health care professionals have to diagnose both Muscular Dysmorphic Syndrome and resultant PED abuse is a good conversation - ie, to proactively ask our patient about it if suspected; and, the ability to have an empathetic, compassionate discussion with our patient about it.

Follow me on twitter! @drsuepedersen © 2015


ENDO 2015: Diabetes and Bones

>> Thursday, March 5, 2015

And....we're off!!! ENDO 2015 is off to a fabulous start.  I'm excited to share with you our learnings about diabetes and bone disease from a symposium held this morning.  You'll need a few extra minutes to read this post - it's a little longer than my usual blogs - so much to cover and share!  Grab a cuppa and get comfy. :)

We were first provided an overview of the impact of type 1 diabetes (T1DM) and type 2 diabetes (T2DM) on the skeleton, by Dr Ann Schwartz.  We learned that diabetics are at an increased risk of fracture (broken bones) than people without diabetes. In T1DM, bone density is lower than in non diabetics, suggesting a moderately increased risk of hip fracture.  However, studies have shown that a type 1 diabetic is actually at over a 6 times higher risk of a hip fracture compared to a non diabetic (much higher than differences in bone density would suggest), suggesting that there is much more to the story than a lower bone density.

In type 2 diabetics, the situation is different.  As 90% of T2DM patients struggle with overweight or obesity, bone densities are higher, a result of the higher body weight that the skeleton supports. Despite this, T2DM patients are at 40% higher risk of hip fracture; after adjusting for body mass index (BMI), there is a 70% increased risk of hip fracture compared to non diabetics.  

While diabetics are at a higher risk of falls (see below for more thoughts on this), studies that controlled for falls still show a higher fracture risk – again suggesting that there is something going on in the bones themselves that increase fracture risk.

So why are diabetics at a higher risk of fracture for a given bone density?  Many possibilities have been suggested in terms of differences in bone structure at the microarchitectural level, but as Dr Mary Larsen Bouxsein pointed out, there is little that is currently understood about exactly what is happen at the microscopic level in terms of the damage that high blood sugars could be doing to bone.  Dr Josh Farr showed us data suggesting that cortical bone microarchitecture in women appears to be compromised in T2DM due to decreased bone formation and turnover, but these studies are limited by size and data are not available in men.

As diabetics have a higher fracture risk for a given bone density, our traditional means of evaluating fracture risk may not be appropriate.  It has been shown that bone density testing (using the T score) does predict risk of hip fracture in diabetics, but at a particular T score, the fracture risk is higher than a non diabetic with the same T score.  The FRAX score, which we often use to predict risk of fracture in our patients, underestimates the risk of fracture in T2DM.

Medications that treat type 2 diabetes may have variable effects on bone as well, as reviewed by Dr Christian Meier.  Metformin, our first line treatment for type 2 diabetes, seems to be protective of the bones.  We know that the group of medications called thiazolidinediones increase the risk of fracture in postmenopausal women and older men, and with longer duration of treatment. There is some evidence to suggest that the group of type 2 diabetes medications called incretin therapies may be protective of bone, but much further study needs to be done.  A newer class of medications called the SGLT2 inhibitors may slightly increase fracture risk, but again, much more study is needed in this area.

A few important points that I would like to highlight (from this session, as well as my own thoughts):  
  • It is crucially important to avoid low blood sugars in patients with diabetes.  A low blood sugar can cause a fall that can result in a fracture.  
  • Prevention of diabetic nerve damage is also crucial, as fall risk increases in those who have loss of sensation to their feet.  
  • Being fit and strong is also important to prevent falls. 
  • Finally, checking vitamin B12 in patients on metformin is important as well, as low vitamin B12 can cause nerve damage, and metformin can rarely cause vitamin B12 levels to be low.

Follow me on twitter! @drsuepedersen © 2015


Proud To Be An Official ENDO 2015 Blogger!

>> Wednesday, March 4, 2015

This morning I'm on my way to ENDO 2015, the annual conference hosted by the Endocrine Society, in San Diego, CA.   I'm always enthusiastic to be a part of this dynamic meeting, which brings together endocrinology experts from around the world, to provide updates on a wide range of clinically relevant topics.

I'm extra excited this year, as has been selected as an official blog to cover ENDO 2015!

So, this week, you're in for a treat - I'll be posting daily blogs, covering a highlight of each academic day (and maybe a little San Diego fun too....)

Stay tuned!

Follow me on twitter! @drsuepedersen © 2015


Health Canada Approves New Obesity Treatment

>> Monday, March 2, 2015

Hot on the heels of the FDA's recent approval, Health Canada has now also approved the use of a diabetes medication called liraglutide as a weight loss medication for people with or without diabetes.

Liraglutide is a medication that has been in use in Canada to treat type 2 diabetes for several years (called Victoza).  As an obesity treatment, it will have a different name, Saxenda; the medication is the same, but the dose to treat obesity is a little higher (based on clinical trials, which you can read more about here).  

Liraglutide can now be used as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of:
-      30 kg/m2 or greater (obesity), or;
-      27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes, or high cholesterol);

and who have failed a previous weight management intervention.

Liraglutide is a derivative of a human hormone called GLP-1, which is released in response to meals.  It works to tell the pancreas to release insulin, and suppresses another hormone involved in blood sugar regulation, called glucagon.  It helps with weight loss by sending a message to the satiety (fullness) centre of your brain, and it has an effect, particularly in the early weeks of treatment, to slow down the stomach.

As for any medication, there are potential risks with using liraglutide.  Common side effects include stomach upset, particularly nausea as the stomach is slowed initially, but this usually improves in the first weeks on the medication.  As for more severe side effects, the question has been raised as to whether this class of medications could cause inflammation of the pancreas (called pancreatitis), but to date, a causative connection has not been established (see more from the FDA and European Medicines Agency on this here).  Liraglutide has been shown to cause a rare form of thyroid cancer in rodents; this has not been seen in humans but is being monitored.  (For further discussion of side effects, see the FDA press release on Saxenda). 

My take on this? The approval of liraglutide for obesity is a landmark, in that this is the first time that a human gut hormone has been approved for obesity treatment.  There are many gut hormones involved in the feeling of fullness, many of which are being actively studied; combinations of these hormones look promising as well.   This is also a landmark decision for Health Canada, in that it has been almost twenty years since a medication was approved for the treatment of obesity in Canada.    

Please refer to my blog post on the FDA's approval last month for my further thoughts on this topic.  

Disclaimer: I was involved in the research trials of liraglutide as an obesity treatment.  I receive honoraria as a continuing medical education speaker and consultant from the makers of liraglutide (Novo Nordisk). I am involved in research of medications similar to liraglutide for the treatment of type 2 diabetes. 

Follow me on twitter! @drsuepedersen © 2015



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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