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Should Fertility Clinics Deny Treatment To Women With Obesity?

>> Monday, July 16, 2018








As blogged previously, due to concerns about poor clinical outcomes and maternal/fetal risks, many fertility clinics in Canada impose an upper body mass index (BMI) cutoff of about 35-40 kg/m2, above which they will not offer fertility treatments.  Is this the right thing to do?

The new Canadian Clinical Practice Guideline for the delivery of fertility care to women with obesity reviews the evidence on this very controversial topic.

Based on survey studies of fertility clinics, whether a BMI cutoff is used, and what BMI cutoff is used if so, is highly variable and not based on any specific or clear evidence.  Most clinics that have an upper BMI cutoff beyond which they will not offer fertility treatments cite anesthesia risk as the main reason for the cutoff.

Not only are BMI cutoffs arbitrary and without consensus, getting below the BMI cutoff goals may be very difficult for many women with obesity to achieve.  Furthermore, one study suggested that over half of the fertility clinics with a BMI cutoff did not offer any weight loss instructions or guidance to their patients - sounds to me like telling a person to row a boat but not showing them how to use the oars.

Denying fertility care to women with obesity is highly stigmatizing and discriminatory, and can worsen feelings of low self esteem, social isolation, anxiety, and depression. Denying older women fertility care until they have lost weight may cost them valuable time and any chance of pregnancy.

There is no doubt that there are risks of obesity to both the mother and the unborn child, and weight loss should be encouraged and supported.  However, as the guidelines point out, the risk of obstetrical obesity-related complications does not clearly exceed the risk of complications with other pre-existing medical conditions like hypertension, diabetes, or epilepsy. In addition, obesity related health status is a better predictor of pregnancy with fertility treatment than BMI, and also a better predictor of overall health outcomes in general, so why is there so much focus on the numbers on the scale in the first place?

As the Guideline states:

In the absence of simple, safe, and effective strategies that reliably help patients with obesity lose weight in a timely fashion, it is difficult to advocate for a universal BMI cut-off in place of careful counselling, screening for metabolic abnormalities and informed consent. 

Programs that impose BMI cut-offs should offer resources for patients to help them lose weight, and should inform patients about both the risks and benefits of delaying fertility treatment.


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Fertility Care For Women With Obesity

>> Monday, July 9, 2018






Obesity has a profound impact on reproductive health from many perspectives. We now have a brand new Canadian Clinical Practice Guideline which provides us evidence based recommendations for fertility care for women with obesity.

The Guideline, published in the Journal of Obstetrics and Gynecology of Canada, provides 21 key recommendations that answer the following questions (highlights discussed here - please see the full article for details):


What is the impact of obesity on female fertility?

Women with obesity have a risk of infertility due to a lack of ovulation that is more than twice that of women without obesity.   Even if ovulating, the physiologic ability to reproduce is still reduced.


What is the impact of obesity on MALE fertility?

While men with obesity have lower testosterone levels, it is unclear whether obesity has an impact on sperm quality and semen parameters. Men with obesity do have a higher risk of erectile dysfunction, which may be improved with weight loss.


What is the impact of female obesity on fertility treatments?

There is a lower oocyte (egg) yield with IVF. Implantation, pregnancy and live birth rates decline with increasing severity of obesity.  Live birth rates decline by 0.3-0.4% for every 1 increase in BMI over 25 kg/m2.


What is the impact of obesity on mum's health risk in pregnancy?

There is an increased risk of gestational diabetes, high blood pressure, prolonged labor, need for instrument assistance for delivery, shoulder dystocia, and C-section.   These risk increase with higher BMI.


What is the impact of obesity on baby's risk during pregnancy?

The risk of having a large baby or a baby with a congenital abnormality is increased.


What screening tests are appropriate for women with obesity seeking fertility care?

Screening should include testing for diabetes, cholesterol levels, high blood pressure, cardiovascular disease, breast cancer, and endometrial cancer.   These screenings should be done before starting fertility treatment.


What are the most effective treatments to help infertile women with obesity lose weight?

Modest weight reductions (5-10%) improve metabolic risk. Help should be offered for lifestyle modifications.  Medications to treat obesity, or bariatric surgery, should be considered for those who do not have success with lifestyle changes.

Women in their late reproductive years who have had bariatric surgery should be advised that the possible benefits of waiting for 1-2 years after surgery to conceive should be balanced against the decline in fertility related to advancing age. 

Bariatric surgery lowers the risk for large babies, gestational diabetes and hypertension, but increases risk for small babies.


Is there data demonstrating a difference in fertility outcomes for women who lose weight before pregnancy, compared to women who proceed directly to fertility treatment?

Yes - weight loss improves spontaneous fertility rates.


Should there be a national BMI cutoff for access to fertility care?

In Canada and around the world, concerns about poor clinical outcomes and maternal/fetal risks have resulted in many fertility clinic medical directors imposing an upper BMI cutoff to their program, above which they will not offer fertility treatments.  Stay tuned on this one - I am going to dedicate a whole blog post to discuss this very important and hotly debated topic.


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Should I Be Tested For Diabetes?

>> Tuesday, July 3, 2018





Diabetes is common, and it is on the rise.  It is estimated that 9.3% of Canadian adults have diabetes, and about 22% have pre diabetes.  You read that right - that's almost one third of Canadians that do not have normal blood sugar.

It is important to know if you have diabetes, as diabetes can lead to many health issues and complications, especially if it goes undiagnosed and/or untreated. Diabetes can go on for many years without any symptoms, so just because a person feels well doesn't mean they don't have it.  Prediabetes (when blood sugars are between the normal and diabetic range) can also be associated with health complications even before diabetes develops.


As per the 2018 Diabetes Canada Guidelines on screening for diabetes in adults,  you should be tested if you are:

  • Age 40 or older - and retesting at least every 3 years
  • If you have risk factors that increase the likelihood of developing type 2 diabetes, you should be tested more frequently and/or start screening earlier. Some of these risk factors including having a family history of type 2 diabetes; a history of pre diabetes or gestational diabetes; being a member of a high-risk population; or having overweight or obesity.  

You can use the Canadian Diabetes Risk (CANRISK) Calculator to assess your risk for diabetes.


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Diabetes Canada Guidelines 2018 - Complementary And Alternative Medicine

>> Monday, June 25, 2018






Many people turn to natural health remedies in an effort to improve their health, and diabetes is no exception.  There is a lot of confusing information on the internet about these products, so I'm thrilled that the 2018 Diabetes Canada Clinical Practice Guidelines has systematically updated their review of the available medical literature on herbal remedies for diabetes, and summarized this in a fantastic chapter that also includes evaluation of other therapies such as yoga, acupuncture, and reflexology.

People with diabetes: if you are taking a natural approach as part of your diabetes management, read on!

Health care providers:  anywhere from 25% to 57% of people with diabetes report using complementary medicine or alternative medicine - so this discussion will be highly relevant to anyone's practice.


Check out the lists in the chapter to look for data on a particular remedy.  Here's a summary:

  • About 30 natural health products have been shown to improve type 2 diabetes control - but - noting that these are mostly single and small trials, it is premature to recommend their widespread use, and further research is needed.  This includes ginger, nettle, and a list of Chinese herbs, amongst others.
  • A list of supplements that did NOT show improvement in type 2 diabetes control, or had studies less than 3 months, or were non randomized or non controlled.  This includes ginseng, flaxseed oil, soy phytoestrogens, vitamin C, vitamin E, vitamin D, and others.
  • A list of supplements that have shown conflicting results for diabetes control, including cinnamon, coenzyme Q10, omega 3, probiotics, and zinc
  • Chromium gets special attention due to its popularity - with studies being small, short, with most not showing a benefit to improve diabetes control. Studies of vanadium are too short to tell if it improves diabetes control or not.

The chapter goes on to review data on natural products for treatment of complications of diabetes and other cardiovascular risk factors like cholesterol and blood pressure. While there is some interesting data, the studies are again short and small, making strong conclusions difficult.

Importantly, the Guidelines warn us that side effects and toxicities have been reported with some natural remedies, giving examples ranging from diarrhea to liver failure to inducing abortion.  Concerns exist about standardization and purity of these compounds. Some natural health products contain pharmaceutical ingredients, and even toxic substances. Herbs can also interact with prescription medications, which can be dangerous. Again, the theme is that studies are too small and short to really understand safety of natural remedies in general.

Yoga has shown some benefit in diabetes control, but acupuncture and tactile massage have not. The chapter also reviews a smattering of data that exist looking at tai chi and reflexology - have a read of the whole chapter to get into these details.

Key Messages: 

Some natural products have reported a lowering of A1C of 0.5% or more in trials lasting at least 3 months in adults with type 2 diabetes, but most of these are single, small trials that require further large scale evaluations before they can be recommended for widespread use in diabetes.

A few more commonly used natural health products for diabetes have been studied in larger randomized controlled trials and/or meta analyses, and have refuted the popular belief of the benefits of these compounds.

Health care providers should always ask about the use of complementary and alternative medicine as some may result in unexpected side effects and/or interactions with traditional medicines.

Key Messages For People With Diabetes: 

Although some complementary and alternative medicines may have the potential to be effective, they have not been sufficiently studied, and others can be ineffective or even harmful.

It is important to let your health care provider know if you are using complementary and/or alternative medicines for your diabetes.


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Diabetes Canada Guidelines 2018 - Vaccinations

>> Monday, June 18, 2018





The 2018 Guidelines have expanded the vaccination chapter to now include recommendations for not only the flu shot and the pneumococcal vaccine, but also information regarding hepatitis B and shingles.


Key Messages For People With Diabetes:

You should receive routine vaccinations as recommended for anyone with or without diabetes.
Check if you are up to date with your vaccinations.

You should receive:
  • the flu shot, every year
  • the pneumococcal vaccine initially when you are over age 18; and again, when you are over age 65 IF your first vaccination was given under age 65 and it's been more than 5 years since you had it

It is now recognized that people with diabetes are at a higher risk of hepatitis B infection compared to people without diabetes.  Outbreaks can happen in places where there is assisted glucose monitoring if hygiene protocols are not adhered to - for example, there have been cases of outbreaks reported in long term care facilities.   The Guidelines do not officially recommend Hepatitis B vaccinations, but do go through some of the pros and cons to consider. 

Though the data is scarce, the existing information suggests that people with diabetes are at an increased risk of getting shingles (herpes zoster), which is a reactivation of the chicken pox virus.  The Diabetes Canada Guidelines list the recommendations for Canadians as a whole for shingles vaccination, with the point of making sure that people with diabetes are vaccinated according to these recommendations. 



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Diabetes Canada Guidelines 2018 - Driving Safety

>> Sunday, June 10, 2018





Yes, it’s finally here!  The Diabetes Canada Guidelines now has a full chapter dedicated to the important topic of driving safety in people with diabetes.  

Diabetes can affect driving performance because of the risk of low blood sugars with some medications (see below), because low blood sugars can delay reflexes, cause confusion, or loss of consciousness.  Complications of diabetes can also affect driving safety, including eye complications affecting vision; nerve complications (can affect sensory and/or muscle function); amputation;  and vascular disease (heart disease or history of stroke). 


Here are some of the Key Messages For People With Diabetes from this chapter: 

1. If you take insulin, or a diabetes medication that can cause low blood sugar [sulphonylureas: eg. gliclazide (Diamicron), glyburide; or meglitinides (repaglinide (Gluconorm)], check your blood sugar: 

  • immediately before driving
  • if you develop symptoms of low blood sugar while driving (pull over immediately in a safe location)
  • at least every 4 hours while driving, or more frequently if there are factors that may increase your risk of low blood sugar (eg recent activity, missing a meal)
  • at least every 2 hours while driving if you have a history of recurrent severe hypoglycemia or if you have hypoglycemia unawareness (you don't feel it when your sugars are low)
2.  Do not drive if your blood sugar is less than 4 mmol/L.  If your sugar is less than 4, do not start driving until you have ingested 15 grams of carbohydrate, retested, and blood sugar is at least 5.  Wait 40 minutes before driving as it takes time for judgement and reflexes to the brain to fully recover from a low blood sugar. 

An easy way to remember (it rhymes!): ABOVE 5 BEFORE YOU DRIVE


3.  If a low blood sugar develops while driving:
  • STOP the vehicle in a safe location
  • REMOVE the keys from the ignition
  • TREAT the low blood sugar and WAIT before driving again (see above)

4.  Always keep a glucose meter, supplies, and a source of fast acting carbohydrate (eg dextrose tabs) with you, and within easy reach, if you take any of the above medications or insulin.

5.  On longer journeys, take regular meals, snacks, and periods of rest.


There are also important messages about notifying your doctor and your driving licensing body if you've had severe hypoglycemia, frequency of assessments for fitness to drive, reporting procedures for health care professionals when patients have conditions that impair their driving abilities, and special considerations for commercial drivers.

For health care providers, there is also excellent information on how, when, and what needs to be assessed for fitness of people with diabetes to drive.  This includes a discussion of hypoglycemia risk, glycemic control, and assessment of diabetes complications to identify whether any of these factors could significantly increase the risk of a car accident for your patient.

This entire chapter is a must-read for any health care professional who has patients in their practice with diabetes treated with insulin, sulfonylureas, or meglitinides.


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Diabetes Canada Guidelines 2018 - Diabetes In Older People

>> Sunday, June 3, 2018






The goals of diabetes management in older people (defined by the Guidelines as about age 70 or older) is distinct from diabetes in younger people, especially for those who are frail or dependent on others for care.

One of the highest priorities in the older person with diabetes (as for all people with diabetes) is the avoidance of hypoglycemia (low blood sugars), which can be a side effect of some diabetes medications.  Older people are less likely to feel symptoms of low sugars, and their bodies are less able to respond to low sugars (due to reduced glucagon secretion), putting them at even higher risk of severe hypoglycemia.  

Many of the recommendations in this chapter of the 2018 Guidelines are focused on the principle of avoiding low sugars in older people with diabetes, upping the emphasis on this even above what was already stated in the last edition of the Guidelines.  

Here are some highlights from this chapter

NEW: There is now more guidance as to what A1C target may be considered, depending on a patient’s level of independence and frailty. 

The recommended targets for older people with diabetes are: 
  • Functionally independent: A1C 7% or less, premeal sugars 4-7 mmol/L, post meal 5-10
  • Functionally dependent: A1C less than 8%, premeal 5-8, post meal less than 12
  • Frail and/or with dementia: A1C less than 8.5%, premeal 6-9, post meal less than 14
  • End of life: avoid low sugars, and avoid symptomatic high sugars
The 2018 Guidelines continue to advise caution in using sulphonylureas in the elderly because of risk of hypoglycemia.  Now, there is a NEW Key Recommendation that DPP4 inhibitors should be used over sulphonlyureas because of a lower risk of hypoglycemia.

Other highlights from the Key Recommendations

NEW DETAILS: Functionally independent older people with diabetes who have a life expectancy of greater than 10 years should be treated to achieve the same glucose, BP and lipid targets as younger people with diabetes. 

NEW: BP targets should be individualized for older adults who are functionally dependent, or who have orthostasis, or who have a limited life expectancy.  (may wish to target a slightly higher BP than the usual target of less than 130/80)


NEW: In older people with type 2 diabetes with no other complex comorbidities but with clinical cardiovascular disease, and in whom glycemic targets are not met, consider a diabetes medication that decreases the risk of cardiovascular events (same as for the type 2 diabetes population in general, see here)


There are new Key Messages For Older People With Diabetes, which reflect the above points: that every older person with diabetes needs a customized diabetes care plan, and that your diabetes health care team will work with you to set blood sugar control targets, choose appropriate glucose lowering medication, and a program for screening and management of diabetes related complications. 

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Diabetes Canada Guidelines 2018 - Diabetes And Pregnancy

>> Monday, May 28, 2018





With no less than 42 (!) recommendations, this is the longest chapter in the 2018 Diabetes Canada Clinical Practice Guidelines.  That's because there is a lot to say about management of not only diabetes predating pregnancy, but also gestational diabetes (diabetes that develops in pregnancy).

As a summary of this chapter is beyond the scope of a blog post due to its length,  I have picked out some of the key pearls to share here.


1.  Key Messages for women with diabetes who are pregnant or planning a pregnancy - this is a completely new section, and a must read not only for women with diabetes, but also women at risk for gestational diabetes.

2.  Contraception for women with diabetes is ESSENTIAL, until both the woman and her health care providers agree that she is safe and ready for pregnancy. There are many steps to be taken that must be in place before any attempts at pregnancy. This includes having good and stable blood sugar control, ensuring no unsafe medications are on board, vitamin supplementation, and eye checks.

3.  A1C target pre pregnancy should be 7% or less, and ideally 6.5% or less if it can be achieved safely (without low blood sugars).

4.  A1C target during pregnancy should be 6.5%, and ideally 6.1% or less if it can be achieved safely (without low blood sugars).

5.  Folic acid 1mg should be started 3 months pre pregnancy, and continued until at least 12 weeks of pregnancy (the 2013 Guidelines recommended more)

6.  Women on metformin or glyburide for type 2 diabetes with good control can continue these medications until pregnant.  Once pregnant, it is recommended to switch to insulin. (the previous guidelines recommended that all women with type 2 diabetes should be switched to insulin and stabilized on insulin prior to pregnancy). Metformin use during pregnancy in women with type 2 diabetes is currently under active study.

7.  Recommendations for appropriate weight gain in pregnancy are based on pre pregnancy BMI.

8.  Screening for gestational diabetes is recommended for all women at 24-28 weeks of pregnancy, with the preferred method being a 50g glucose challenge as the initial test.  Women who are at increased risk of gestational diabetes should have blood testing for diabetes at the first pregnancy visit.

9. For women with gestational diabetes, testing for diabetes after pregnancy remains essential.

10.  New recommendations for fetal surveillance and timing of delivery are provided.

I emphasize again that there are many other changes and expansions of recommendations in this chapter of the guidelines - anyone practicing in this area of diabetes care is encouraged to embrace the chapter in its entirety.


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Sudden Death During Triathlons

>> Tuesday, May 22, 2018




Ever think that a triathlete seems invincible? They can swim, they can ride, they can run….

Well - think again. It turns out that the risk of sudden death during a triathlon is higher than the risk of sudden death in the general population. 

A recent study is the first to collect data on sudden deaths during triathlons.  (Triathlons consist of a swim, followed by cycling, followed by a run.)  The study reviewed race related deaths during 30 years of triathlons in USA, with data from over 9 million participants.  They identified 135 deaths, for a risk of death of 1.74 per 100,000 participants.  

Perhaps surprisingly, most of the sudden deaths and cardiac arrests (90) occurred during the swim (which starts the race), with 7 during cycling, 15 during the run, and 8 during the post race recovery.  Men age 60 and older were at the highest risk of death at 18.6 per 100,000.  There were also 15 trauma related deaths during cycling. 

Of the 135 deaths, 61 autopsies were performed.  At least 18 of these deaths were due to narrowing of the arteries of the heart.

Why do so many of these sudden deaths occur during the swim, which is at the start of the race?  This may be due to the adrenaline rush at the start of the race increasing the risk of heart arrhythmias, crashes in the water, and/or difficulty in identifying events and initiating rescue, defibrillation and CPR in the water.  This contrasts with data in marathoners (a race of running only), which suggests that sudden deaths in marathons most commonly occur at the end of the race.  Cardiovascular disease accounts for the the majority of marathon-related cardiac arrests.

Bottom Lines:  

1.  Screening for cardiovascular disease when appropriate is important, and triathletes are no exception.  

2.  Organization of races to reduce risk is important: eliminating mass swim starts, and having coordinated safety responses to identify and help people in trouble are key.

PS  - Regular readers - never fear ! I still have several chapter reviews of the Diabetes Canada 2018 Guidelines coming up over the next several weeks.  Stay tuned!

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Diabetes Canada Guidelines 2018 - Physical Activity

>> Monday, May 14, 2018




There is a ton of great, new information in the 2018 Diabetes Canada Physical Activity guidelines chapter.  Here are some of the highlights:


1. Avoid prolonged sitting. Try to get up briefly every 20 to 30 minutes.  Bluntly put, this is because we now know that habitual, prolonged sitting is associated with an increase risk of death and major cardiovascular events (eg heart attack).

2. While it is still recommended to engage in 150 minutes per week of aerobic exercise and at least 2 sessions per week of resistance exercise if possible, it is now recognized that smaller amounts of activity still provides some health benefits. Something is better than nothing!

3.  Make use of strategies that increase motivation, such as setting specific physical activity goals, and using self monitoring tools (eg a pedometer that counts steps). (My editorial comment - some of these devices can also remind you to get up if you've been sitting for too long.)

4.  Medical clearance: It was previously recommended that anyone with diabetes who is about to begin a program more vigorous than walking should have medical clearance first.  This has been relaxed a little - now, this need for clearance is more focussed on middle aged and older people who wish to undertake prolonged or very vigorous exercise, and of course, anyone with symptoms suggestive of cardiovascular disease.

People with more advanced diabetic eye disease should be treated and stabilized before vigorous exercise, and people with severe diabetic nerve disease in their feet/legs should inspect their feet daily and wear appropriate footwear.   It is also recommended to ideally see a qualified exercise specialist before starting strength training (eg weights) to avoid injury.

5.  There is a great list of suggested strategies to help people with type 1 diabetes reduce the risk of lows with exercise.


Bonus Practical Stuff: 

Resources for people with diabetes: (scroll down to Exercise) - including info on how to plan and maintain physical activity, videos on resistance exercises, and more!

Resources for health care providers: under 'Management' - scroll down to 'Physical Activity and Diabetes' - tools including how to write an exercise prescription


Enjoy - and have fun!





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New 2018 Diabetes Canada Guidelines - Nutrition Therapy

>> Monday, May 7, 2018





It's hard to know how to eat right - there is a lot of conflicting information out there, and unfortunately lots of claims that have no scientific backing nor evidence of long term success.
Eating well with diabetes is no exception.

Thankfully, we have the Diabetes Canada Clinical Practice Guidelines to give us evidence based recommendations on healthy eating with diabetes.

The updated Nutrition Therapy chapter in the 2018 Guidelines contains a lot of great information.   I really encourage interested readers to snuggle up with a cuppa to read the whole chapter, but let's go through some of the key points here:

1.  Nutrition therapy can reduce hemoglobin A1C (the diabetes report card) by 1-2% (that's as much as 1-2 diabetes medications!)

2.  The proportion of carbs vs protein vs fat should be flexible within the recommended ranges, and will depend on individual treatment goals and preferences.

3.  Eating low glycemic index foods instead of high glycemic index foods helps to improve diabetes control.

NEW: Aim for a fibre intake of 30-50g per day, with 10-20g coming from soluble fibre, to improve blood sugars and cardiovascular risk.

4.  Added sugars should be MAXIMUM 10% of total daily caloric intake.

5.  Intensive health behaviour interventions in people with type 2 diabetes can improve weight, fitness, diabetes control, and cardiovascular risk factors.

6. NEW: People with diabetes should be encouraged to choose the dietary patterns that best align with their values, preferences, and treatment goals. (check out the new sections on ethnocultural diversity in Canada, and on Ramadan, as well!)


Here are some of my favourite Key Messages For People With Diabetes: 

1.  Try to prepare more of your meals at home, using fresh and unprocessed ingredients.

2.  Prepare meals together and eat as a family. This is a good way to model healthy food behaviours to kids and teens, which can help reduce their risk of developing overweight or diabetes.

3.  The best strategy is one that you can maintain long term.

4.  With prediabetes and newly diagnosed type 2 diabetes, weight loss is the most important and effective dietary strategy if you have overweight or obesity.  A weight loss of 5-10% may help to normalize blood sugars.

5.  Diabetes friendly eating habits can improve blood sugars and decrease the risk of cardiovascular disease, including:

  • select whole foods instead of processed
  • avoid sugar sweetened beverages
  • pay attention to both carbohydrate quantity, and quality (low glycemic index instead of high)
  • considering learning how to count carbs
  • preferred dietary fats are unsaturated - maximum saturated fats has now been increased to 9% of total calorie intake (previously 7%) - and avoid trans fats completely
  • choose lean animal protein, and eat more vegetable protein


The data for many different diets/patterns of eating is reviewed, with many different types of diets being suggested for an improvement in type 2 diabetes control, including Mediterranean, vegetarian, and DASH diets, as well as diets that include pulses (eg beans), vegetables, fruits, and nuts.  The details of what is in these diets is provided in the chapter, and available data in type 1 diabetes is reviewed as well.  At the end of the day, the key is to choose a healthy way of eating that is in keeping with individual preferences, as this gives the greatest likelihood of being able to follow it long term.


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New 2018 Diabetes Canada Guidelines - Weight Management

>> Monday, April 30, 2018




As an author of the Weight Management chapter of the new 2018 Diabetes Canada Clinical Practice Guidelines, I'm thrilled to share with you some key points and exciting changes!

So what is new since the last guidelines in 2013?

1.  People first language.  We have made an important change in the entire 2018 Diabetes Canada guidelines in the way we talk about obesity.  Obesity is a diagnosis, and not a way to describe a person.  Thus, instead of the terminology 'overweight or obese people', the correct terminology is 'people with overweight or obesity'.  This is a critical step in breaking down the stigma against obesity!


2.  New information on medications for weight management in type 2 diabetes.  Liraglutide (Saxenda) is a new medication available for weight management in Canada since the last guidelines.

(note: Naltrexone/Bupropion (Contrave) is now approved in Canada as well, but this approval occurred after the literature reviews for the Guidelines were completed, so is not included in this iteration)

Medications for weight management have not been adequately studied in people with type 1 diabetes.


3.  Updates on bariatric surgery:

  • Gastric banding is not as effective as other bariatric procedures for type 2 diabetes control or remission.  
  • Predictors of who is more likely to enjoy type 2 diabetes remission after bariatric surgery include a shorter duration of diabetes, younger age, not needing insulin preoperatively, and higher preoperative serum C-peptide (a marker of insulin production). 
  • An update on the effect of bariatric surgery on complications of diabetes is discussed as well.
  • The BMI criteria for bariatric surgery remain unchanged.  Evidence of risk and outcomes of bariatric surgery for people with a BMI of 30-35 is limited and cannot be recommended at this time. 
  • Bariatric surgery has not been adequately studied in people with type 1 diabetes. 



KEY MESSAGES: 

1. Sustained weight loss of 5% or more can improve diabetes control and cardiovascular risk factors.

2.  In people with diabetes and obesity, weight loss and improvement in diabetes control can be achieved with healthy behaviour interventions.  Weight management medications can improve diabetes and metabolic control.

3.  Bariatric surgery may be considered appropriate for people with diabetes and obesity.

4.  When selecting the most appropriate diabetes medications, the effect on body weight should be considered.



KEY MESSAGES FOR PEOPLE WITH DIABETES: 

1. When you have diabetes, having overweight or obesity increases your risk for complications.

2.  Healthy behaviour modifications, including regular physical activity and eating well can help with your blood sugar control, and reduce your risk for other health problems associated with diabetes.

3.  Your diabetes health care team can help you with weight management.  For some people with diabetes, weight management medications and bariatric surgery may be helpful.



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New 2018 Diabetes Canada Guidelines - Cardiovascular Protection

>> Tuesday, April 24, 2018





We know that reducing the risk of heart attacks and strokes in people with diabetes includes much more than just having good blood sugar control.

So what's new in the Cardiovascular Protection chapter of the Diabetes Canada Guidelines since the last Guidelines in 2013?  Well, as for every chapter, there are now...


KEY MESSAGES FOR PEOPLE WITH DIABETES: 

Ask your doctor about the ABCDEs to reduce your risk of heart attack and stroke:

A = A1C - blood sugar control (the target is usually 7% or less)

B = BP - blood pressure control (less than 130/80)

C = Cholesterol - LDL cholesterol less than 2.0 mmol/L.  Your health care profider may advise you to start cholesterol lowering medication.

D - Drugs to protect your heart - these include blood pressure pills (ACE inhibitors or ARBs), cholesterol lowering medication ('statins'),  and in people with existing cardiovascular disease, certain blood glucose lowering medications, which can protect your heart even if your BP and/or LDL cholesterol are already at target

E = Exercise/Eating - Regular physical activity, healthy eating, and achievement and maintenance of a healthy body weight.

S = Stop smoking and manage stress.


The recommendations for ACE/ARB have loosened a little bit.  While it was recommended in 2013 that anyone over the age of 55 with diabetes should be on an ACE or ARB provided no contraindications, this recommendation has now been modified, as no studies have clearly demonstrated CV benefit for people with diabetes over 55 without any additional cardiovascular risk factors.  However, ACE/ARB is still recommended for:

  • anyone with clinical cardiovascular disease
  • anyone with microvascular complications
  • age 55 or older with an additional cardiovascular risk factor or organ damage (protein in the urine, retinopathy, left ventricular hypertrophy)
So, since most people with diabetes age 55 or older have at least one additional cardiovascular risk factor, the vast majority of people over age 55 will still be recommended to take an ACE or ARB.

As far as cholesterol medication goes, guidelines for treatment with statins are unchanged.  If LDL cholesterol goals (LDL of less than 2 mmol/L, or greater than 50% reduction from baseline) are not achieved, consideration for the addition of ezetimibe is recommended. In people with diabetes who also have cardiovascular disease, a PCSK9 inhibitor may be used.


And, as blogged last week, for people with type 2 diabetes and established cardiovascular disease, consideration should be given for using a glucose lowering medication that has been shown to reduce the risk of cardiovascular events. 

Aspirin continues to be recommended for patients with established cardiovascular disease, at a dose now of 81-162mg daily (in line with the Canadian antiplatelet therapy guidelines). 

One of the Key Messages is also that there is emerging evidence that heart failure, even in the absence of a previous heart attack, is an important (and often unrecognized) complication of diabetes.  Health care professionals should be on the lookout for heart failure in their patients with diabetes.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018


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2018 Diabetes Canada Guidelines - Medications for Type 2 Diabetes

>> Monday, April 16, 2018



It can seem daunting to consider that in the treatment of type 2 diabetes, there are now 9 classes of medications available that lower blood sugars (and several different medications within each of these classes).  Which medications to choose, and in which order, are driven by data surrounding efficacy, safety, and ability to prevent cardiovascular events (one of the major diabetes complications we are aiming to prevent).  Over the last few years, we have seen several diabetes medications emerge that reduce the risk of cardiovascular events, and with this information, we are seeing more of an algorithm emerge that guides clinicians on which order to consider these different medications.

The 2018 Diabetes Canada Clinical Practice Guidelines Pharmacotherapy chapter now provides an algorithm that not only takes into account cardiovascular risk protection, but also prioritizes the diabetes medications that do not cause two unwanted side effects that are cause by some types of diabetes medications: weight gain, and low blood sugars (hypoglycemia).

This chapter is excellent, comprehensive, (necessarily) big and the list of key messages is long - I encourage patients to read the Key Messages for People With Diabetes, and clinicians to read the entire chapter, but here are some of the highlights:

1.  In people with type 2 diabetes with A1C less than 1.5% above the individual patient's target, glucose lowering medication should be added if targets are not reached with healthy lifestyle interventions within 3 months.

2.  In people with type 2 diabetes with A1C 1.5% or more above the patient's target, medication should be initiated concomitantly with healthy behavior interventions, and consideration could be given to initiating combination therapy with 2 medications.

(note that the old guidelines used an A1C of 8.5% as the cutoffs above. The new wording reflects that the A1C target, though usually 7% or less,  can be different from one person to the next - more on this here.)


3. Insulin should be started immediately if there is syptomatic hyperglycemia or metabolic decompensation.  In the absence of metabolic decompensation, metformin is still the first choice of medication in people with new type 2 diabetes.

4.  Target diabetes control should be achieved within 3-6 months.


5.  In people with cardiovascular disease in whom A1C targets are not achieved, a medication with cardiovascular benefit should be added to existing therapy: empagliflozin, liraglutide; or canagliflozin (with a lower grade and level of evidence for canagliflozin).

6.   In people without cardiovascular disease who are not at glycemic targets, DPP4 inhibitors, GLP1 receptor agonists, and/or SGLT2 inhibitors should be considered as add on medication over sulfonylureas, meglitinides, insulin and thiazolidinedones, if lower risk of hypoglycemia and/or weight gain are priorities. (Grade A, Level 1A evidence)

7.  In people who are on insulin who are not at blood sugar targets, adding a GLP1 receptor agonist, DPP4 inhibitor, or SGLT2 inhibitor may be considered before adding or intensifying mealtime insulin therapy, with less weight gain and comparable or lower hypoglycaemia risk.


8.  Newer basal insulins (degludec and U-300 glargine) may be considered over U-100 glargine to reduce overall and overnight hypoglycaemia.


This chapter now includes an excellent table (see table 1 here) that lists the effect of diabetes medications on A1C, weight, cardiovascular outcomes, and other therapeutic considerations as well.




Follow me on twitter! @drsuepedersen



www.drsue.ca © 2018



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2018 Diabetes Canada Guidelines Are Out!

>> Monday, April 9, 2018



The Diabetes Canada (formerly Canadian Diabetes Association) Guidelines are issued in full every 5 years.   As a coauthor of the Weight Management Chapter, I can tell you that these Guidelines have truly been a labor of love for all of us - more than two years with several rounds of evidence review, drafting, re-drafting as new data comes out.... and this is what makes our guidelines one of the most respected diabetes documents in the world!

The 2018 Guidelines are exciting, with a number of substantial changes from the 2013 edition in terms of approach, rigour of methodology, and recommendations.

Each chapter in the Guidelines is structured with a framework including:

Key Messages

Key Messages For People With Diabetes (this is new and awesome, and reflects that the Guidelines are intended not only for the use of health care providers, but also for people with diabetes)

Recommendations


Over the next weeks, I will be posting blogs highlighting some of the key points and changes to the guidelines, and I'll always include a link to the chapter itself if you'd like to read it in full.

Enjoy!

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018




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The Easter Waftata

>> Saturday, March 31, 2018






It's always fun to play around with a new recipe on the long weekend, when there's a little extra time!

I had never heard of a Waftata, but apparently it is a recipe reincarnated from days of yore - and super easy to cook in a modern day waffle iron! I have upped the flavour factor from the original recipe, and given options below for using eggs or egg whites in the recipe.  I think there is lots of opportunity to get creative with flavour - try adding paprika or oregano for an extra twist!

Ingredients:

  • 2 large eggs (or 1/2 cup egg white)
  • 1/3 cup part skim ricotta cheese
  • 2 tbsp onion, finely diced
  • 1 tsp minced garlic
  • 3 tsp freshly chopped parsley
  • 1/8 tsp salt
  • 1/4 tsp ground pepper
  • 1/2 cup peeled and shredded white potato
  • 1/2 cup finely diced apple (with or without skin)




Directions:

1.   Beat eggs in a small bowl.

2.  Add ricotta, onion, garlic, parsley, pepper and salt.  Whisk well.

3.  Preheat your waffle iron.

4.  Stir potato and apple into the mixture.

5.  Spray waffle iron with non stick spray and pour mixture onto it.

6.  Close lid and bake until eggs are set and golden brown.


Makes 2 servings.  Per serving:  (with whole eggs)

  • Calories: 160
  • Carbs: 12.5g
  • Fat:  6.5g
  • Protein:  11g

If you substitute 1/2 cup egg whites for the two eggs:
  • Calories: 115
  • Carbs: 12.5g
  • Fat: 2g
  • Protein: 13g


Enjoy!

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018

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How Weight Loss Affects Different Body Tissues, Fat Genes, And Inflammation

>> Monday, March 26, 2018


(this is fat tissue under a microscope)



We know that a 5-10% weight loss improves many health conditions associated with obesity.  However, it is very interesting to note that some health issues like blood sugar starts to improve with as little as 2-3% weight loss, whereas other health issues like sleep apnea require closer to 10% weight loss before we start to see improvements.  Why is this?


An eloquent study helps us to understand how different tissues in our body respond to weight loss.  This was a randomized controlled clinical trial, assigning 40 patients to a target 0%, 5%, 10%, or 15% weight loss, and then conducted an array of testing to understand the metabolic changes that occur at each of these degrees of weight loss.  Testing was extensive and included assessment of body composition, 24h blood pressure monitors, blood testing for metabolic parameters and inflammatory markers, tests of organ-specific insulin sensitivity, and even biopsies of fat tissue. Participants were weight stable for at least 3 weeks before testing was conducted.

Key findings were truly fascinating.

After a 5% percent weight loss:
  • There was a decrease blood sugar, insulin levels, triglycerides, ALT (liver test)
  • systolic blood pressure decreased (the top number), but not diastolic (bottom number)
  • NO effect on good cholesterol (HDL), bad cholesterol (LDL), glucose tolerance test (OGTT)
  • improvement in insulin sensitivity in fat, liver, skeletal muscle 
  • improvement in beta cell function (the cells in the pancreas that make insulin)

After 11% weight loss: (the 10% group ended up losing 11%)
  • continued reduction in insulin and triglycerides 
  • altered gene expression in subcutaneous fat tissue - including genes involved in fat synthesis, cholesterol flux, and inflammation
  • no additional benefit to insulin sensitivity in fat tissue or liver
  • additional improvement in insulin sensitivity in skeletal muscle
  • additional improvement in beta cell function

After 16% weight loss: (the 15% group ended up losing 16%)
  • reduction in inflammatory markers (plasma free fatty acids, CRP)
  • more marked altered gene expression in subcutaneous fat tissue - including genes involved in fat synthesis, cholesterol flux, and inflammation
  • continued reduction in insulin and triglycerides
  • no additional benefit to insulin sensitivity in fat tissue or liver
  • additional improvement in insulin sensitivity in skeletal muscle
  • additional improvement in beta cell function

So what is the BOTTOM LINE from this (rather complicated) study?   

1. A 5% weight loss has important benefits to our health, primarily related to a decrease in our body's resistance to insulin.  

2. Further weight loss continues to improve our body's insulin resistance (particularly in muscle), with additional improvements in our metabolic health.  

3.  At 11% weight loss, we start to see changes in how our fat tissue expresses genes, in favour of better health.

4.  At 16% weight loss, there is a decrease in inflammation in our bodies, and a more marked change in fat tissue gene expression.

While a smaller degree of weight loss (even just 2-3% based on other studies) has a very important impact on our metabolic health, the changes in inflammation and fat gene expression seen at over 10% weight loss may well be what it takes to see benefits in other medical conditions associated with obesity, such as obstructive sleep apnea and arthritis.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2018




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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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