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Peeing At Night? Could Be Sleep Apnea

>> Saturday, May 30, 2015

Many people get up to pee at night.  This could simply be a reflection of drinking water before bedtime, caffeine, or alcohol, or it could be a symptom of a medical problem, one of which is sleep apnea.

Obstructive sleep apnea (OSA) is a condition where the upper airway is obstructed during sleep, causing pauses in air intake despite an effort to breathe.  The severity of OSA is determined by the number of apnea (no airflow) or hypopnea (decreased airflow) events during an hour, measured during overnight testing:
  • mild OSA: 5-15 events per hour
  • moderate OSA: 15-30 events per hour
  • severe OSA: over 30 events per hour

Obesity is a common cause of OSA, but it can also be caused by decreased muscle tone of the upper airway (due to neurologic conditions or substances such as alcohol, sedatives, or muscle relaxants), or variance in the structure of the upper airway. 

So how does OSA cause a person to pee excessively at night?  Research has shown us that the negative pressures generated in the chest by trying to inhale against a blocked airway cause increased blood return to the right side of the heart.  This, in combination with other pressures placed on the heart by OSA, cause the heart to release a hormone called atrial natriuretic peptide (ANP) that tells our kidneys to excrete more sodium and water.  

Other common symptoms of OSA include daytime sleepiness, morning headaches, difficulty concentrating, restless sleep, and snoring. OSA is not thought of or tested for enough, and as a result, many people suffer from OSA but don't know that they have it. 

There are many other medical problems that can cause a person to pee at night, ranging from bladder issues, to prostate problems, to uncontrolled diabetes, to congestive heart failure, to several others.   For health care providers, it's important to consider obstructive sleep apnea on this list when a patient tells us they are urinating often at night.   If you are a patient urinating excessively at night, be sure to speak to your doctor about it.

Follow me on twitter! @drsuepedersen © 2015


Could Artificial Sweeteners Cause Diabetes?

>> Sunday, May 24, 2015

Artificial sweeteners are commonly touted as a healthy alternative to natural sugar. Sweeteners contain low to no calories (read about the types of sweeteners here), and they do not make blood sugars spike in diabetics.   However, a growing body of research lends a growing amount of concern to possible negative side to artificial sweetener use. 

A fascinating set of studies was collected and published recently in Nature, looking at how artificial sweeteners affect the bacteria in our intestines, and how these effects in turn may actually increase the risk of developing diabetes or pre-diabetes.  For the scientist with a couple of hours and a day with a good attention span may want to read the article for themselves – it’s heavy but super.  Here are the key results of their studies:

Both lean and obese mice who were fed artificial sweetener (saccharin, sucralose, or aspartame) were more likely to develop prediabetes compared to mice fed glucose or sucrose. (read more about different types of sugar here).

They showed that the development of prediabetes in these mice was caused by a change in the types of bacteria in the mice’s intestines.  These altered bacteria are better at making calories from food accessible for absorption, meaning that mice (or humans) more readily absorb these calories, thereby contributing to higher blood sugars (and probably weight gain as well).

In humans, survey type studies have shown that people who use artificial sweeteners are more likely to be people with weight struggles and diabetes, but whether the artificial sweeteners cause these problems, or whether it is simply that people who have these problems are more likely to consume artificial sweeteners to help fix these problems, is difficult to separate.    The authors therefore looked at a very small group of seven study participants who didn’t normally consume artificial sweeteners, and they found that when they ate artificial sweeteners for a week, four of the seven participants developed an increase in their blood sugars by the end of the week.  An examination of these people’s stools (oh yes they did) showed a marked change in the bacteria growing in their intestines after a week of artificial sweeteners. When they transplanted the stool of the people who developed higher blood sugars into mice (oh yes they did), the mice then went on to develop higher blood sugars as well.

So, in summary, these elegant studies suggest that artificial sweeteners may change the types of bacteria that grow in our gut, to types of bacteria that cause us to absorb more calories from food into our bloodstream, with the increase in sugar absorption increasing the risk of diabetes.  

So what is the best solution?  Eating added natural sugar undoubtedly increases our risk of diabetes, obesity, and metabolic syndrome, and there is now emerging evidence to suggest that artificial sweeteners may not be good for our metabolism either.

The best answer is to avoid adding added sweetener period, be it sugar or artificial sweeteners. 

Thanks to my friend and colleague, Pam, for the heads’ up on this article.

Follow me on twitter! @drsuepedersen © 2015


Eating Disorders and Obesity

>> Sunday, May 17, 2015

As regular readers will know well, obesity is much more than just an imbalance between calories in and calories out.  Amongst the list of possible contributors are a number of eating disorders which often go overlooked, and are important to identify so that a person suffering from these conditions can be helped and treated.  Two of the most common eating disorders associated with obesity are Binge Eating Disorder and Night Eating Syndrome.  Let's take a look at each of these in more detail.

Binge Eating Disorder (BED) is defined by eating a large amount of food within 2 hours, at least once a week for at least 3 months.  These episodes of eating are accompanied by a feeling of a loss of control.  In addition, three of the following must be present:
  • eating rapidly
  • eating even though there is a lack of hunger or eating until uncomfortably full
  • feeling shame, disgust or guilt
  • eating alone due to embarrassment
Binge Eating Disorder is quite common, affecting 10-20% of people seeking obesity treatment.  Men and women are equally at risk.  

Night Eating Syndrome (NES) is defined as eating 25% of food after the evening meal and/or at night, at least once a week for at least three months, and is associated with distress or impairment of function in daily life.  At least three of the following must also be present:
  • not hungry in the morning
  • there is an urge to eat between dinner and bedtime, or during the night
  • difficulty getting to sleep at least 4 nights per week
  • a belief that eating is necessary to help you get to sleep
  • a worsening of mood in the evening
NES is also common, affecting 10-15% of people with obesity.  Again, men and women are equally at risk.

(Note that NES is distinct from another less common eating disorder called Sleep Related Eating Disorder, where the person is eating at night but has no memory of doing so.)

Treatment options are available for both BED and NES.  These treatments include behavioral strategies, helping people to find ways to replace the binging/eating behaviors with other more healthful strategies, using techniques like mindfulness thinking.  Some medications have also been shown to be of benefit in treating these conditions. 

Be sure to talk to your health care providers if you feel these symptoms resonate with you.

Follow me on twitter! @drsuepedersen © 2015


What Determines Our Daily Energy Burn?

>> Sunday, May 10, 2015

Whether we gain, lose, or maintain weight depends on the balance between calories in, which is what we eat and drink, and calories out, which is the energy that we burn.
So, what exactly determines the calories out side of the equation? 

Our daily calorie burn, also called energy expenditure, is divided into several components: 

1.  Resting Metabolic Rate (RMR)

The RMR is the energy that we use while at, well, rest!  This includes the energy it takes to run our daily functions like breathing, heart pumping, and brain function, and all of the functions of maintenance and repair that go on inside all of our cells on a 24/7 basis.  Believe it or not, this comprises 50-80% of our total daily calorie usage.

The RMR varies greatly from one person to the next, due to differences in lean body mass, age, gender, and genetics.  The RMR is also determined by thyroid hormone levels and the baseline activity of each person's sympathetic nervous system, which produces a baseline level of adrenaline and a tendency towards usage of body fat as an energy source (called lipid oxidation).

2.  Spontaneous Activity

Spontaneous activity refers to everything that we do to move around in a day, from daily living activities to purposeful exercise.  Although one might think this is the biggest part of our daily calorie usage,  it accounts for only 10-25% of our total calorie burn in most people.  
The calorie burn from spontaneous activity varies a lot from person to person, with the biggest variance between individuals actually being due to all of the spontaneous activity excluding purposeful exercise, hence the name non exercise activity thermogenesis or NEAT.  NEAT includes everything from the calories burned during work activities, transport from place to place (eg walking vs driving), and even the amount we fidget!  Interestingly, our tendency for fidgeting behaviors seems to be largely genetically determined.  So, a person who is less inclined to be 'fidgety' will burn less calories in NEAT than a person who is more inclined to be fidgety.    People who have a higher sympathetic nervous system drive tend to have higher NEAT as well. 

The calorie burn from spontaneous activity also depends on body weight, as it requires more calories to carry a higher body weight through life's daily activities.  

3.  Thermic Effect of Food

The thermic effect of food refers to the calories it requires to actually digest the food that we eat, and comprised about 10% of our daily calorie burn.  This can vary somewhat, depending on the types of food eaten (protein requires more calories to digest than carbs or fat), and by sympathetic nervous system activity.  However, the jury is still out as to whether differences in the thermic effect of food plays a role in obesity or not.  

So, a few tips to take away in terms of weight management: 

  • With weight loss, the daily calorie burn in resting metabolism and spontaneous activity actually decreases, because there is less weight to maintain and carry around in a day. (Think of a 20 lb weight loss like taking off a 20lb backpack - less weight to carry around means lower calorie burn).  Our metabolism actually slows when we lose weight as well, further decreasing the calories that we need to eat.  So, the 'calories in' side of the equation needs to be scaled back as a person is losing weight, to stay in tune with the decreased calories burned with weight loss. 
  • Think about being NEAT!  In other words, try to put more movement in your day.  Rather than being still after dinner, go for a walk instead.  Take the stairs instead of the elevator.  Look for a further parking spot instead of a closer one. 
  • Use an exercise program to burn calories, but also to gain muscle mass (as a higher muscle mass increases your RMR). 

Follow me on twitter! @drsuepedersen © 2015


Obesity Management In Canada - A Long (But Promising!) Road Ahead

>> Saturday, May 2, 2015

At this week's Canadian Obesity Summit meeting, I have had the great pleasure of chairing, speaking, and participating in a diverse array of educational sessions, ranging from studies of lifestyle alterations, to government policies, to medications treating obesity, to bariatric surgery.

One of the themes that rang strong is this:

Canada needs more resources dedicated to the management of obesity.

I can give you many examples of how this point came out, but I'll give you one that rings out in particular.  One session which discussed bariatric surgery included a fabulous presentation by bariatric surgeon, Dr Mary-Anne Aarts, regarding barriers to post operative follow up of bariatric patients.  An interesting discussion ensued with comments from bariatric care providers across the country, and most agreed that follow up appointment attendance is often not good, particularly the further a patient gets in their post op journey (after 6 months post surgery, patients are usually requested to come to appointments every 6 months until 2 years post op).   One point that was made was that follow up may be perhaps too infrequent to keep patients interested and motivated to continue to come. (Studies do show that bariatric surgery patients enjoy greater success with more frequent follow up.)  Dr Aarts pointed out that in the Netherlands, bariatric patients have appointments scheduled every 3 months for 2 years postoperatively, which shocked most of the audience... who in Canada has the resources for that?!  

Here is our problem.  Obesity is a chronic disease, just like, for example, diabetes - yet, we don't treat obesity like a chronic disease.  The Canadian Diabetes Guidelines recommend that diabetics see a physician every 3 months at least, to have an A1C (diabetes report card) and other elements of their health checked as needed.  Why don't we have the same resources available to treat obesity in the same long term, longitudinal way?  If we asked our patients with obesity to follow up every 3 months with a health care provider on an ongoing basis to help them manage this disease, perhaps they might feel more supported and weight management success might be better.

What we need is to:

1.  Break down the stigma against obesity amongst the general public and health care providers, such that obesity is accepted as a chronic disease and not a lifestyle problem.

2.  Have more resources available in health care such that we are able to manage obesity with a long term, team based approach that engages multiple disciplines including dietitians, nurses, pharmacists, psychologists, exercise therapists, and doctors.

3.  Teach health care providers how to best approach the discussion and treatment of obesity with their patients. (See the 5As of obesity as a great way to start!)

So what's the 'Promising' part in all of this?   We (as the Canadian Obesity Network) are 11,000 members strong, and passionately dedicated to achieving these goals.  Together, we continue to make a difference one step at a time, with the above goals in mind.   This week's Summit has gone a long way to breaking down the obesity stigma in the public eye, and we continue to redouble our efforts as our numbers and voice grow.

PS - the Canadian Obesity Network membership is open to anyone with a professional stake in obesity - and it's totally free to join!  Check it out here!

Looking forward to the last day of the Summit today.

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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