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Will Bariatric Surgery Help Me Control My Diabetes?

>> Sunday, February 19, 2017





One of the major reasons why we might suggest bariatric (obesity) surgery to our patients with obesity and type 2 diabetes, is that studies have shown bariatric surgery to be very effective in improving diabetes control, or even putting diabetes into remission.  However, it has been slow to grow the body of research data in this area, as it is difficult to conduct high quality, long term studies in this field.

Now, just published, we have 5 year data showing that bariatric surgery (gastric bypass surgery and sleeve gastrectomy) are superior to medical therapy to treat type 2 diabetes in people with obesity.

I blogged on the 3 year data in this trial, called the STAMPEDE trial, when it came out in 2014 - where you can read about the structure, goals of the study and the results at that time.

Now, published in the New England Journal of Medicine, the extended results of the STAMPEDE study show that 5 years after bariatric surgery, 29% of patients who had gastric bypass surgery had tight control of their diabetes, vs 23% of those who had sleeve gastrectomy, vs only 5% of those who had intensive medical treatment alone.  A duration of diabetes of less than 8 years before surgery was the main predictor of achieving tight control of diabetes, suggesting that earlier intervention with bariatric surgery may give the maximum benefit in glycemic control.

There were also greater improvements in body weight, several measures of cholesterol, need for insulin, and quality of life in the surgical groups.  No late major surgical complications were reported except for one person in the sleeve gastrectomy group who underwent gastric bypass at year 4 to treat a gastric fistula.  Follow up at the 5 year mark was 90%, which is excellent.

While I still take issue to the target for diabetes control being too tight in this study at an A1C of 6.0%, this study does now give us good 5 year data to support that bariatric surgery can be an effective tool to help treat type 2 diabetes in people with obesity.

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www.drsue.ca © 2017

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Benefits of Continuous Glucose Monitoring With Insulin Injections in Type 1 Diabetes

>> Saturday, February 11, 2017






In people with diabetes, continuous glucose monitoring (CGM) is an alternative to checking sugars with frequent finger pokes.  CGM is available as a stand alone tool, or can be integrated with an insulin pump system.  Most studies showing the benefits of CGM were done in people using insulin pumps.  Now, two studies show the benefits of CGM in people with type 1 diabetes using insulin injections to treat their diabetes.

The first study, published in JAMA, randomized 158 people with type 1 diabetes using insulin injections to use of either the usual form of self blood glucose monitoring (finger pokes) vs CGM.  At 6 months, the hemoglobin A1C (a marker of diabetes control) was 0.6% lower in the people using CGM compared to those using finger pokes.   People using finger pokes to check sugars during the study were also wearing a CGM during the study, but they could not access the readings on the CGM, with the purpose being for researchers to analyze what the CGM showed in the people using finger pokes during the study.  Importantly, this analysis found that people using CGM spent 37 minutes less per day with low blood sugar (43 minutes per day, compared to 80 minutes per day for people using finger pokes).

The second study, also published in JAMA, compared the effect of CGM vs finger poke monitoring in the same person, using a crossover design.  Patients were randomized to use either CGM or finger pokes for 6 months, then did the reverse for the next 6 months (with a 17 week break in between).  Amongst these 161 patients with type 1 diabetes, hemoglobin A1C was 0.43% lower during the time of CGM use, and they also reported less fear of hypoglycemia, greater well being and greater treatment satisfaction while using CGM. Patients were hypoglycemic 4.79% of the time while using finger pokes (using data from masked CGMs), vs 2.79% of the time with use of CGM.

One thing that I found particularly disturbing about these studies was the amount of time patients spent with low blood sugars.  While CGM improves upon this, we would ideally like patients with diabetes to have zero hypoglycemia.  CGM units have alarms that alert a patient when blood sugar is low, which can be lifesaving, especially for people who don't feel their low sugars and are at risk of sleeping through a low.  Hopefully improved glucose monitoring technology, as well as better insulins being developed, will help us to reduce lows further.  CGMs are unfortunately quite expensive, though some people are able to get the expense covered - talk to your insurance provider (if you have one) and/or your diabetes educator to find out about your options.

These studies clearly support the potential benefits of continuous glucose monitor (CGM) use in people with type 1 diabetes using insulin injections.


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www.drsue.ca © 2017

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Bariatric Surgery - Can We Predict Remission Of Diabetes?

>> Sunday, January 29, 2017




One of the most important benefits of bariatric surgery (especially gastric bypass and sleeve gastrectomy) is its ability to improve the control of type 2 diabetes, often to the point where type 2 diabetes actually goes into remission after surgery.  Not everyone with type 2 diabetes who has bariatric surgery will experience remission - about 70-80% of patients having gastric bypass and about 50-60% of patients having sleeve gastrectomy will experience remission.  Ideally, we would be able to predict the likelihood of diabetes remission before the surgery is done, as this is arguably one of the most important potential benefits of bariatric surgery.

A recent study tried to answer this question using a scoring system called the DiaRem Score, which looked at at 4 preoperative variables amongst a group of 407 patients who underwent gastric bypass surgery:
  • age
  • need for insulin 
  • diabetes medication use (points assigned varied by type of medication)
  • hemoglobin A1C (a blood test which is a 3 month report card of diabetes control)

They found that this score, which is based on the above 4 variables, was highly predictive of who went into remission from their type 2 diabetes and who did not.

Other scoring systems and variables have been looked at as well.  Other variables that stands out in the literature are a shorter duration of diabetes, and preoperative serum C peptide level, which is a marker of a person's ability to produce insulin.

It is exciting to know that as we learn more about bariatric surgery, that we can become better at predicting who may benefit from a diabetes standpoint.  However, a word of caution - longer term studies suggest that for people who do enjoy diabetes remission after bariatric surgery, the diabetes recurs in about 50% of these people by 5 years post op.  While there is still certainly a health benefit to being free of diabetes for a number of years, it is important to remember that the diabetes can return and must be screened for regularly and lifelong.


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www.drsue.ca © 2017

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Marijuana and Diabetes Risk - Friend or Foe?

>> Sunday, January 22, 2017




In follow up to my blogs about the increased risk of diabetes associated with smoking (read more here), some of my colleagues have asked me to comment on whether there is also an increased risk of diabetes associated with marijuana use.  With the advent of medical marijuana, and the plans to legalize marijuana use in Canada, this is definitely an excellent question.

A question, which it turns out, we have very little data on which to base an answer.

One study examined body fat, insulin sensitivity, and various aspects of beta cell function (the pancreatic cells that make insulin) in 30 cannabis smokers, and compared them to people matched for age, gender, ethnicity, and body mass index. They found that cannabis smokers had a higher percentage of abdominal visceral fat (the fat around the organs that is the metabolically dangerous (diabetes inducing) fat).  Good cholesterol (HDL) was a little lower, and carbohydrate intake a little higher, but otherwise, there was not much difference between groups.

Another study evaluated metabolic parameters in 4657 adults from the American NHANES (National Health and Nutrition Examination Survey), 579 of whom were current marijuana users. They found that current users had a 16% lower fasting insulin level, and had less insulin resistance as well  (17% lower HOMA-IR, for the scientists in the audience), suggesting a lower risk of developing type 2 diabetes. Use of marijuana in this study was associated with smaller waist (a crude way to measure abdominal visceral fat - which contrasts with the findings in the first study above).

Other than these studies, there is very little data on marijuana and its effect on diabetes risk.

At this point, the available data does not suggest that marijuana carries the increased risk of developing diabetes that cigarette smoking does, with one study suggesting that it may even be protective of developing diabetes. However, the data is extremely limited, and further study of the effects of marijuana is much needed.


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www.drsue.ca © 2017

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Diabetic Neuropathy

>> Saturday, January 14, 2017





One of the main reasons why long term blood sugar control is so important in diabetes is the prevention of diabetes complications.   Diabetic neuropathy, which is damage to nerves caused by chronic elevation in blood sugars, is one of the complications we are trying to prevent.   Diabetic neuropathy affects a lot of people (you may be surprised by just how many - read on!), can be present in people who don't even have diabetes yet, can take many different forms, and can have a profound impact on the quality of life of people living with diabetes.

The American Diabetes Association has recently released a Position Statement (download is free) to help guide clinicians in understanding, diagnosing, preventing, and managing this complication of diabetes.

Some key points from this article:

1.  Diabetic neuropathy (DN) is a diagnosis of exclusion.  In other words, just because a patient with diabetes has findings of neuropathy, doesn't mean that the diabetes is necessarily the cause.  Other causes of neuropathy (discussed in the article) need to be ruled out before the nerve problem is attributed to diabetes as the cause.

2.  There are many types of diabetic neuropathy.  Distal symmetric polyneuropathy usually starts with symptoms in the feet, including numbness, tingling, pain, and burning, especially at night.  Autonomic neuropathies can affect/include the heart, ability to maintain blood pressure when standing up (orthostatic hypotension), the gastrointestinal tract, urinary tract, sexual dysfunction, or dysfunction in sweating. There are also forms of diabetic neuropathy that can affect specific nerves (cranial or peripheral), or bundles of nerves as they exit the spinal column.

3.  Diabetic neuropathy is common. Distal symmetric polyneuropathy affects 50% of people with type 2 diabetes after 10 years, and 20% of people with type 1 diabetes after 20 years.  Autonomic neuropathy involving the heart may affect up to 60% of people with type 2 diabetes after 15 years, and up to 30% of people with type 1 diabetes after 20 years.

4.  Diabetic neuropathy can be present in people with prediabetes.  Distal symmetric polyneuropathy may be present in 10-30% of people with impaired glucose tolerance, and autonomic neuropathy affecting the heart has been found in people with impaired glucose tolerance as well.

5.  Prevention of diabetic neuropathy is key, as there is no effective treatment available for established nerve damage.  Prevention is achieved primarily through optimizing blood sugar control. Lifestyle interventions are recommended for prevention in people with prediabetes or type 2 diabetes, and a multifaceted approach including targeting of cardiovascular risk factors is recommended for prevention of cardiac autonomic neuropathy in people with type 2 diabetes.

6.  Management of established diabetic neuropathy is directed towards the particular type of neuropathy each patient has.  This can include pain control medication, fall prevention, and specific treatments to manage symptoms of the autonomic neuropathies.


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www.drsue.ca © 2017

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The Bugs In Your Gut - Could They Cause Obesity or Diabetes?

>> Friday, December 30, 2016




Did you know that you have more bacterial cells inside your intestines than you have human cells in your entire body?  Not only that, but they house somewhere between 250 to 800 times more genes than we have human genes in our body.   Perhaps it's not so far out, then, for us to learn that these bacteria (called the 'microbiome') play an important role in our metabolism, and are very likely to contribute to the risk of both obesity and type 2 diabetes.

A wonderful Viewpoint article in JAMA (free to read online here) outlines what we know about this topic so far.

The microbiome has many important functions, including the production of important amino acids (protein building blocks) and vitamins, and they also help to degrade toxins.  The genes in these bacteria also produce hormones and inflammatory molecules that enter our circulation and effect our health.

These bacteria also play a role in how many calories we absorb from food, because they make enzymes that help us to digest polysaccharides, a type of carbohydrate.  Some types of gut bacteria are better at this than others, and studies have shown that people with obesity carry more of the carb-digesting bacteria (called Firmicutes) than people without obesity.  Interestingly, some studies have shown that when a person with obesity loses weight, particularly after bariatric surgery, the proportion of 'good' bacteria (called Bacterioides) increases relative to the 'bad' Firmicutes. Overall, the studies suggest that the gut bacteria may be both a cause and a consequence of obesity.

Along with the increased capacity to absorb carbs in people who carry more Firmicutes bacteria, so comes an increased risk of having not only obesity, but also type 2 diabetes.  Altered production of short chain fatty acids by gut bacteria, as well as low grade gut inflammation caused by chemicals made by the microbiome, also contribute to insulin resistance and diabetes risk.

So how does this play out in terms of treatment of obesity or diabetes? Well, some studies (mostly done in rodents, but some in humans too) have shown that manipulation of the gut microbiome by way of stool transplants (yep, transplanting poo), or perhaps by other modalities such as change in diet or probiotics, may be able to have an effect on the type of bacteria we have, but we are far from developing concrete treatment approaches.   However, as we learn more about our gut bugs and the genes they carry, we come steps closer to learning how we may ultimately be able to incorporate microbiome modification into our treatment options for obesity and metabolic syndrome.


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www.drsue.ca © 2017

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New Canadian Diabetes Association Clinical Practice Guidelines Update

>> Saturday, December 3, 2016




While the full Canadian Diabetes Association (CDA) Clinical Practice Guidelines are formally updated every 5 years (with the next edition due in 2018), interim updates are published if new evidence emerges that is considered to be practice changing.  As such, the CDA has just released an interim update with revised recommendations, in light of the new cardiovascular outcome trial of a diabetes medication called liraglutide.

As blogged previously, in people with type 2 diabetes who were at high risk of cardiovascular disease, the liraglutide cardiovascular trial (called the LEADER trial) demonstrated that liraglutide reduced the risk of cardiovascular events by 13%.  Put another way: if 66 people are treated for 3 years with liraglutide, one cardiovascular event would be prevented.

In the LEADER trial, 81% of patients had a past history of established cardiovascular disease, while 19% of patients did not (but they were still considered to be at high risk of CV events due to their risk factors).  Subgroup analyses suggested that it was patients who had a history of established cardiovascular disease who had the reduction in risk with liraglutide. As patients had to be age 50 or older to be included in the study, we do not know if these findings apply to a younger population.

In the revised CDA Guidelines, liraglutide now joins another medication called empagliflozin, as medications to consider after metformin, in patients with type 2 diabetes and established cardiovascular disease, who are not at target blood sugar control.  As ongoing cardiovascular outcome trials of diabetes medications are completed and published, the CDA Guidelines will be updated accordingly.

I have pasted the new algorithm below, but the resolution isn't great - it's a little friendlier on the eyes here.





Disclaimer: I am a member of the Expert Committee for the writing of the Canadian Diabetes Association 2018 Clinical Practice Guidelines. 



Follow me on twitter! @drsuepedersen

www.drsue.ca © 2016

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