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New ‘Real-World’ Obesity Clinical Practice Guidelines

>> Thursday, June 23, 2016

It is an unfortunate fact that despite the high prevalence of overweight and obesity in our society, most health care professionals receive little training in obesity medicine.  I am asked by colleagues just about every day: ‘How do I treat my patient who struggles with excess weight?’  Health care providers often feel lost in this arena.  

There are a number of obesity management guidelines that try to guide the care of people with obesity, but they often do not provide a consensus on a clear and concise approach to management or treatment goals.

Good news! The American Association of Clinical Endocrinologists and American College of Endocrinology have produced a new set of Clinical PracticeGuidelines for obesity that they describe as an evidence based, real-world approach, that gives health care providers practical, straightforward, and tangible algorithms for diagnosis, assessment, and management of people with excess weight.

The theme of these guidelines (which I fully agree with) is that management of obesity is not about the numbers on the scale, but about improving overall health and well being.

The approach to diagnosis and management in these guidelines are nicely packaged into a handful of algorithms and tables that you can access here.  Some of the highlights:

1.  The diagnosis of obesity is not just about the numbers on the scale.  They break down the obesity diagnosis into two components: the anthropometric component (numbers: BMI, waist circumference), and the critically important clinical component (complications of the excess weight, of which they have included a convenient checklist of things to look for and how to screen for them).

2.  There is a beautiful table that lists how much weight loss is recommended to improve any particular complication of obesity (eg 5-15% for type 2 diabetes, 5-15% or more for polycystic ovary syndrome, 7-11% or more for obstructive sleep apnea).

3.  They break down lifestyle treatment into three components: meal plan, physical activity, and behavior modification.  They review pros and cons to different types of diets and where evidence exists for improvement of parameters of health (while emphasizing that the dietary approach needs to be individualized to each patient).

4.  They review pros and cons of medications to treat obesity (note that only two of the medications reviewed are available in Canada – namely, liraglutide and orlistat), along with clinical features that may favor the use of one antiobesity medication over another.

In the spirit of focusing on treating to improve weight-associated health complications rather than focus on numbers on the scale, they suggest more intensive treatment approaches (eg medication or bariatric surgery) in situations where complications of obesity already exist.  Personally, I am inclined to favor a more proactive approach, not only looking at these treatment options to improve upon existing complications of obesity, but also to prevent these complications from developing in the first place.

Overall, these guidelines and nicely packaged tables and algorithms provide a great framework to help health care professionals with a real-world approach to obesity management.  Check it out!

Follow me on twitter! @drsuepedersen © 2016


Diabetes Medication Liraglutide Saves Lives

>> Friday, June 17, 2016

In follow up to my recent blog post – as promised - the hotly anticipated LEADER trial results became available this week, in a simultaneous release at the American Diabetes Association meeting, as well as published in the New England Journal of Medicine.

The LEADER trial examined the effect of a type 2 diabetes medication called liraglutide (trade name Victoza) on cardiovascular events, in a group of people with type 2 diabetes who were deemed to be at high cardiovascular risk (age 50 or more with at least one existing cardiovascular condition such as a history of heart attack or stroke; or age 60 or more with at least one cardiovascular risk factor (for example, hypertension).

The goal of this study, as for all hard outcome studies of diabetes medications, was to prove cardiovascular safety of liraglutide.  

Not only did liraglutide prove to be safe in people at high cardiovascular risk – it actually REDUCED cardiovascular events.  Amongst 9,340 patients from 32 countries, followed for a median of 3.8 years, there was a 13% reduction in the risk of (a composite endpoint of) death from a cardiovascular causes, non fatal heart attack, and non fatal stroke. Cardiovascular deaths were reduced by 22%, and death from any cause was reduced by15% compared to placebo.  The benefit of liraglutide was particularly pronounced in people who had established cardiovascular disease at baseline, and in those with moderate reduction in kidney function at baseline.

To put the results another way:  
  • 66 people would need to be treated for 3 years to prevent one of (cardiovascular death or heart attack or stroke)
  • 98 people would need to be treated for 3 years to prevent one death of any cause.

These numbers needed to treat are similar to the protective effects of statins (cholesterol medications) and ACE inhibitors (blood pressure medication).

Now that we know that liraglutide has a distinct cardiovascular benefit, a question that arises is whether this is an effect shared by other medications in this class, called GLP-1 receptor agonists.  The ELIXA trial, a study of lixisenatide (not available in Canada), did not show a cardiovascular benefit.  Studies of other medications in this class (eg dulaglutide, exenatide) are still underway, so for these, we don’t know the answer yet.  

We also don't know if the cardiovascular benefit of liraglutide exists in people with type 2 diabetes who aren't in these high risk groups, or in people with obesity without type 2 diabetes (liraglutide is also available as an obesity treatment, called Saxenda).  However, this trial gives us additional confidence in the safety of liraglutide, given that the LEADER trial was conducted in the highest cardiovascular risk population.

The effect of liraglutide to reduce cardiovascular events is important, as we know that cardiovascular disease is the leading cause of death in people with type 2 diabetes.  So far, other diabetes medications that have shown a cardiovascular benefit are metformin (with somewhat scanty data) and empagliflozin (based on the EMPA-REG trial, which you can read about here). Thus, in Canadametformin is considered the first line treatment for type 2 diabetes, with empagliflozin to be considered in patients with existing cardiovascular disease who are not at target blood sugar control with metformin.  

Liraglutide will likely join the ranks of empagliflozin as a second line treatment option, with the decision making process as to which to choose based not only on the characteristics of each medication, but most importantly, on the characteristics and desires of each individual patient.

Follow me on twitter! @drsuepedersen © 2016

Disclaimer: I have been involved in research trials of liraglutide, other GLP-1 receptor agonists, and SGLT2 inhibitors like empagliflozin.  I receive honoraria as a continuing medical education speaker and consultant from the makers of liraglutide (Novo Nordisk) and empagliflozin (Boehringer-Ingelheim/Eli Lilly).  


How Does Cortisol Affect Metabolism?

>> Monday, June 6, 2016

Cortisol is a hormone that is essential for human life. It is released in response to stressors on the body, and has an integral role in our metabolism, including keeping our blood sugars from going low when fasting (eg overnight).  Cortisol also stimulates fat cells to grow and mature, particularly the fat cells around the organs (called visceral fat).

Some people who struggle with excess weight may be more sensitive to the effects of cortisol, resulting in a higher tendency to accumulate fat around the organs, called visceral fat.  This visceral fat is much more dangerous to health than the fat that collects under the skin (called subcutaneous fat), as it is the visceral fat that is associated with a higher risk of metabolic complications such as diabetes, high blood pressure, and heart disease.

If cortisol is actually being overproduced, this can lead to a lower resting metabolic rate because it leads to a breakdown in muscle mass (muscle mass is an important determinant of resting metabolic rate - read more about this here).    Cortisol also stimulates hunger, resulting in increased desire for highly saturated fat and sweet foods in particular.

During stress, cortisol is released and snacking often increases, but it's unclear whether the increased snacking is due to the cortisol increase or the stress itself. This stress can be psychological stress, but also physical stress such as untreated obstructive sleep apnea.

While pathologic overproduction of cortisol by an adrenal or pituitary gland tumour is rare (called Cushing's syndrome), it is likely that stress (psychological or physical) may contribute to differences in cortisol production, which may in turn have an effect on body weight.

So, understanding cortisol physiology teaches us that managing both psychological and physical stressors are key to successful weight management.

Follow me on twitter! @drsuepedersen © 2016



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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