Dental Disease and Diabetes: What's the Connection?

It is well known that diabetics are at an increased risk of vascular complications, and that control of blood sugar, cholesterol, and blood pressure are important to prevent these complications from developing. One often overlooked risk factor in diabetics is periodontal disease, a chronic bacterial infection affecting the gums and bone that support the teeth.

Periodontal disease is known as gingivitis in its mildest form, presenting as tenderness, redness, and swelling of the gumline. If untreated with proper oral hygiene (adequate brushing and flossing), this can evolve to a chronic condition with gum recession, plaque accumulation and bone loss, called periodontitis.

The relationship between periodontal disease and Type 2 Diabetes is something of a vicious cycle. First of all, it is known that diabetics are at higher risk of developing periodontal disease, and that it is more severe than in non diabetics. The elevated blood sugars increase the susceptibility to infection - bacteria thrive on the excess sugar that is available.

On the other side of the coin, having periodontal disease is associated with an increased risk of developing diabetes, and is also associated with poor blood sugar control in patients with diabetes.

A key factor responsible for the relationship between periodontal disease and diabetes appears to be inflammation. As discussed by Dr Tenenbaum and colleagues in a recent publication by the Canadian Diabetes Association, periodontal disease produces a low grade inflammatory state, with increased levels of inflammatory chemicals in the blood stream. These inflammatory mediators are known to be associated with increased risk of vascular disease, and true to that, an increased prevalence and incidence of cardiovascular disease has been observed in patients with periodontal disease. We also know that Type 2 Diabetes and the complications that develop are partially mediated by inflammatory changes in the blood vessel wall, so this may be part of the link between the two conditions.

To minimize your risk of periodontal disease, follow these important tips from the Canadian Dental Association:

1. Brush your teeth and tongue twice a day with toothpaste and floss once a day to remove plaque between teeth. When choosing oral health care products, check for the Canadian Dental Association (CDA) Seal of Recognition.

   Products bearing this Seal have been reviewed by CDA and have demonstrated specific oral health benefits.

2. Check your gums regularly. Look for the warning signs of gingivitis and report them to your dentist right away.
   
3. See your dentist for regular check ups, and schedule a professional cleaning to remove stains and built-up tartar.
   
4. Eat healthy foods for your oral health as well as your overall health. Eating excess sugar is one of the primary causes of dental problems. With the proper nutrients that come from healthy eating and proper oral hygiene, you can fight cavities and gingivitis.
   
5. Don't smoke. Smoking is a major contributor to dental problems and may cause oral cancer.

Dr Sue Pedersen www.drsue.ca © 2010 drsuetalks@gmail.com

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Video Blog: Test Tubes Illustrate High vs Normal Blood Sugars

In this video blog, Dr Sue shows you two mock test tubes, illustrating what normal blood looks like and how it flows, compared to blood when blood sugar is high. It is important to control blood sugars (keeping levels as close to normal as possible) to prevent or delay the complications of diabetes over time, including damage to the eyes, heart, kidneys, nerves in the feet, and blood vessels throughout the body.



Dr Sue Pedersen www.drsue.ca © 2010 drsuetalks@gmail.com

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Benefits to Barley and Buckwheat? The Low Glycemic Index Diet

Amongst the plethora of weight loss strategies that abound out there, the Low Glycemic Index Diet is touted as yet another way to 'guarantee' substantial weight loss. Let's debulk the mystery - is this fact or fiction?

The Glycemic Index of a particular food refers to the rapiditiy with which the sugars (carbohydrates) in that food are absorbed into our bloodstream. Technically speaking, it is defined by the incremental rise in blood sugar after ingestion of 50 grams of a particular carbohydrate, compared to 50 g of a reference food, which is usually white bread. White bread has arbitrarily been set to have a glycemic index (GI) of 100. A low GI food has a GI of less than 55, while a high GI food has a GI of more than 70.

There has been much controversy as to whether a low GI diet actually results in weight loss. Overall, studies show that a low GI diet is NOT particularly effective, resulting in a 2 lb weight loss over the course of 6-12 months, with a 10-15 GI difference between diets. As low GI diets are usually also high fiber diets, it may actually be the higher fiber content of the low GI diet that is responsible for any weight loss that is seen, as fiber helps to keep us feeling fuller longer, therefore resulting in a lower caloric intake overall.

For diabetics, however, glycemic index is a very important consideration, as a lower GI diet helps to control the rise in blood sugar that is often seen after eating. Having said that, however, the glycemic index has its limitations, as it tells us nothing about the quantity of carbohydrate, only about the quality of carbohydrate.

Therefore, it is not only the glycemic index, but also the Glycemic Load that is important. The Glycemic Load is defined as the GI of a food, multiplied by the number of grams of carbohydrate in a serving of that food, thereby capturing both the quality AND quantity of carbohydrate intake. In other words, if you consume a low GI food (eg brown rice, GI=50) but a large quantity of it (resulting in a high Glycemic Load), the quantity of carbohydrates can contribute not only to a post meal glucose rise, but also to significant weight gain. Thus, it is important to exercise portion control in order to limit the Glycemic Load of a meal.

To improve diabetes control, and to assist in weight maintenance, a few important tips are as follows:

1. Switch up your high Glycemic Index foods for lower GI foods. Examples are to exchange white bread, pasta, or rice, for brown. Try incorporating some interesting carbohydrate alternatives such as pearl barley (pictured above, GI=25-33), lentils (GI 21-30), or buckwheat (GI=50-54).

2. Exercise portion control to limit your Glycemic Load!

3. Balance your meal: including protein, a small amount of fat, or a more acidic content to your meal decreases the Glycemic Index of your meal overall, and can decrease post meal blood sugars by as much as 20%!


Dr Sue Pedersen www.drsue.ca © 2010 drsuetalks@gmail.com

Follow me on Twitter for additional tips and pearls! drsuepedersen

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Protecting You and Your Baby: Diagnosing Diabetes Before, During, and After Pregnancy

In parallel with the explosion of type 2 diabetes in recent years, so too are we seeing a marked increase in gestational diabetes, or diabetes which is diagnosed in pregnancy. Because of the critical importance of diagnosing and appropriately treating these women, consideration is currently being undertaken for changing the way we approach the diagnosis. These changes would result in a much broader group of pregnant women being identified as diabetic.

The impetus for considering a change in the diagnosis of gestational diabetes (GDM) is that an important study demonstrated that increasing maternal blood sugars were associated with increased birth weight and high insulin levels in the newborn baby, at levels below current Canadian diagnostic blood sugar thresholds for GDM. The International Association of Diabetes and Pregnancy Study Groups has therefore proposed a new set of blood sugar criteria for the diagnosis of GDM which are lower than our current thresholds.

The implications are enormous: as many as 18% of pregnant women would be considered to have gestational diabetes, compared to only 8% with current criteria.

Another important change being proposed is that certain blood sugar criteria would result in the diagnosis of Type 2 Diabetes while pregnant. Currently, when a woman is found to have high blood sugars in pregnancy, we make a diagnosis of Gestational Diabetes, which by definition is a state of elevated blood sugars that would be anticipated to resolve postpartum. However, it is increasingly recognized that many of these women were likely undiagnosed Type 2 Diabetics prior to pregnancy, and in these women, their blood sugar elevation will persist after delivery.

Though there is much ongoing debate as to whether these new criteria should be adopted, the opportunity to underline the importance of diagnosing and treating elevated blood sugars before, during, and after pregnancy must not be missed. The following steps are of crucial importance:

1. Blood sugars should be checked before pregnancy, such that diabetes before pregnancy can be detected and treated to control before conception. This is critically important, as high blood sugars in the first trimester is associated with increased risks including congenital malformations (birth defects), miscarriage, and high blood pressure in the mother.

2. Aggressive screening for diabetes in pregnancy, starting as early as at the time of diagnosis of pregnancy. The screening strategy is more aggressive in women with risk factors for diabetes, which include overweight, family history of diabetes, previously giving birth to a large infant, presence of metabolic syndrome, and certain ethnic backgrounds (such as Aboriginal Indian, South Asian, African ancestry). Remember that a woman who does not have diabetes before pregnancy can develop diabetes even in the very beginning of pregnancy, as several hormonal changes occur in pregnancy that can predispose towards development of diabetes.

3. Diabetes must be carefully checked for after delivery, so as to identify women who have diabetes that persists beyond pregnancy. Checking blood sugars after delivery is not enough; a glucose challenge test (performed under the care of your doctor) must be undertaken.

4. Breast is best: in addition to numerous benefits to the baby, breastfeeding also helps to control blood sugars postpartum in the woman who is persistently diabetic. Breastfeeding is also a great method to help shed pounds after pregnancy, as about 300 calories are expended in breast milk each day (including 50 g of carbohydrates)!

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

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Nine Percent of Canadians to be Newly Diagnosed with Diabetes over Ten Years

It is not new news that a diabetes epidemic is upon us. Currently, nearly 6% of Canadian adults (about 2 million people overall) are diagnosed with diabetes. Most of these cases are Type 2 diabetes, which is caused by a state of insulin resistance, and often brought on by overweight or obesity.

Predicted rates of diabetes in the near future in Canada are even more starggering.

An investigative report was undertaken by Canada's Institute for Clinical Evaluative Sciences, to try to predict how many new cases of diabetes we are going to see in Canada over the next few years.

The study found that 1.9 million Canadians are predicted to develop diabetes in the ten year period between 2007-2017. This will nearly double the number of currently diagnosed cases. Although the risk of developing diabetes is higher with a higher weight or higher Body Mass Index (with 'obesity' being defined as a Body Mass Index >30), most of the new cases of diabetes will be in the 'overweight' category (with BMI 25-30), because there are more overweight than obese people in the country. Another concerning trend that is being seen is that younger Canadians are becoming affected by Type 2 Diabetes, due to higher rates of childhood obesity. The youngest Canadian with Type 2 Diabetes currently on record is only six years old. Risk factors for developing type 2 diabetes in Canada were identified, and include:

• higher Body Mass Index (you can calculate your own BMI here, in the right hand column)
• increasing age
• being male (vs female)
• people who have immigrated to Canada (compared to people born in Canada)
• being a lower-income woman, or a higher-income man
• ethnic background
  
• having lower levels of education
  

In this report, a Diabetes Population Risk Tool has been constructed, with which the risk of a particular individual developing diabetes can be generated, taking into account various risk factors and demographic data (BMI, age, gender, and other factors). They provide two profiles for comparison:

Profile 1: Female, 33 years old, BMI=22 kg/m2, no hypertension, white, not immigrant, post-secondary education.

Ten-year risk of being diagnosed with diabetes: 1.2%.


Profile 2: Male, 55 years old, BMI=38 kg/m2, hypertensive, white, does not have heart disease, smoker, less then secondary school education.

Ten-year risk of being diagnosed with diabetes: 44%.


The report has some good news too - and that is related to the predicted benefits in prevention of diabetes that could be achieved with simple lifestyle intervention. Based on Ontario population data, for example, it is estimated that by providing individuals at highest risk for diabetes with lifestyle therapy (and provided they adhere), only eleven people would need to be treated to save one person from developing diabetes.

The bottom line: Prevention is Key!!

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

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Diabetes Treatment: Is Weight Loss Surgery the Answer?

Canada, like the rest of the world, is caught in a diabetes epidemic. Over 2 million Canadians are diagnosed with the disease, and by the year 2020, those numbers are expected to rise to 3.7 million. This epidemic is paralleled by the high prevalence of obesity, which currently affects 25% of Canadian adults and 10% of Canadian children. One of the treatment options that is being increasingly considered to treat type 2 diabetes in the setting of severe obesity is weight loss surgery.

I attended the First Canadian Diabetes Surgery Summit in Montreal this week, hosted by McGill University, to discuss this very issue. Over two very intense and productive days, a collection of international leaders in the area presented their research and clinical experience to a diverse group including Canadian surgeons, family physicians, endocrinologists, health care professionals, and policy makers. A wealth of learning, sharing, and ideas were generated from this summit, of which I am going to discuss over the course of several articles in the coming weeks. Here are the highlights.

In short, bariatric surgery is a very effective treatment for type 2 diabetes. The results depend on the type of surgery done, but remission rates of diabetes of over 80% have been documented, and sustained for at least 2 years. Much of this success is related to the impressive weight loss that is seen with bariatric surgery, but gut hormone changes with certain types of surgery (such as gastric bypass surgery) play an important role as well.

It must be emphasized that bariatric surgery is only appropriate for a very select group of people. The current guidelines recommend bariatric surgery as a potential option for patients with a BMI >40, or a BMI >35 with at least one serious medical complication (such as diabetes), who have failed intensive attempts at weight loss with conventional treatments (lifestyle alteration, medications, etc). Bariatric surgery has a long list of potential side effects and complications that must be seriously considered, and which vary depending on the type of surgery performed. On balance, however, bariatric surgery has been shown to decrease mortality by 28-40% in this population, and as such, may be the most appropriate option for some people.

In Canada, we struggle with very limited accessibility to bariatric surgery. As Dr. Nicolas Christou, one of Canada's leaders in bariatric surgery, pointed out:

• Based on very conservative estimates that 5% of the 1 million Canadians who fit criteria for bariatric surgery would actually be appropriate candidates for surgery, 50,000 Canadians would currently be candidates for the procedure.
  
• Approximately 3,000 bariatric procedures will be done in Canada this year.
  
• According to these numbers, then, Canada currently has in excess of a 15 year back log of patients who could benefit from these procedures.
  

What can we do about this? The problem of course, is funding. Funding for bariatric surgery is extremely limited in Canada, though accessibility does vary greatly by province. Cost analyses suggest that for patients with diabetes, the costs of bariatric surgery to the government are recouped by 26-30 months post operatively, and after that, there are only savings to be had by the health care system due to the decreased rate of diabetes related complications, hospitalizations, and medication requirements of these patients.

On balance, increased accessibility to bariatric surgery in Canada, provided in the appropriate clinical setting by a multidisciplinary, experienced health care team, should be discussed amongst Canadian health care professionals, patients, and the general public.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

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Western Bad Habits contribute to Diabetes Epidemic in China

Modern day China provides an unfortunate example of the toxic effects of adopting more western-style habits of unhealthy eating and sedentary lifestyle: according to a new study, there are now nearly over 200 MILLION people affected by either diabetes or prediabetes.

The China National Diabetes and Metabolic Disorders Study Group published an article in this week's New England Journal of Medicine that spells out the details of this metabolic disaster. They conducted an impressively large study of over 46,000 adults from across China, and tested their blood sugars. They found that based on this sample, approximately 92.4 million Chinese adults have diabetes (more than half of these being undiagnosed), and 148.2 million Chinese adults have prediabetes.

When you consider that these numbers total over six times the entire population of Canada, the implications are simply staggering to try to comprehend.

The underlying contributors to this explosion of diabetes in China are several, but one of the dominant themes is the urbanization and 'westernization' of Chinese society. With the advent of fast food to this nation, obesity has exploded in this society in a likewise fashion. Similarly, Chinese urban centres are coming more and more to resemble our own: motorized transport, increased use of the internet, less focussed exercise.... all of these elements have sunk the activity levels to an all time, Western-style, low. So, it seems that the bad habits of the western world have had a seriously negative impact on the metabolic health of our Chinese friends.

To add to the difficulty of the situation, people of Chinese ethnicity have a higher risk of developing diabetes, due to a higher genetic disposition to develop insulin resistance at a lower BMI. Diabetes onset often occurs at a lower BMI compared to people of caucasian ethnicity (though this certainly varies from person to person).

The way in which people of Chinese background manifest high sugars also presents a challenge. According to this recent study and studies before it, Chinese people have a disposition towards having high sugars after a meal even if they have normal blood sugars in the fasting state. As the first step in screening for diabetes is with a fasting blood sugar, it is possible that some of these diabetes diagnoses could be missed if sugars are not tested after a carbohydrate challenge as well.

The situation in China raises yet another red flag: the global tendency towards a progressively more unhealthy lifestyle is having a serious toll on our health, and raises potentially grim prospects for our futures unless we turn things around.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

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Getting Help in Losing Weight!

There is no question that each and every one of us is different, and our approach to weight loss is no exception. Success with one weight loss program will be variable from one person to the next, depending on how well it is geared towards that person's strengths, weaknesses, and the areas where that person needs the most support. Some people need help in gaining a better understanding of what healthy food choices are; many need a re-education on portion control (as our toxic society oversizes portions everywhere we look, making it harder to know what an actual portion size should be). Some individuals prefer to design their own weight loss diet, whereas others will excel with a diet plan that is handed to them, and which they simply have to follow without thinking further about it!

In my mission to help my overweight patients achieve a healthy weight, I've come across two fabulous resources that you might consider if you are battling the bulge:

1. Reality Bites (www.mymealplan.ca)

This is a fabulous healthy eating program designed by Canadian dieticians. There is a special emphasis on helping people with diabetes, but the diet plans can be used by anyone who wants to lose weight or simply eat healthy! When you join, you need to select the small (1200-1500 cal), medium (1500-1800 cal), or large (1800-2100 cal) diet plan. To figure out which plan you need in order to lose weight (or maintain weight if you already at appropriate weight), use the BMR calculator on my main page in the right hand column (www.drsue.ca), or talk to you health care provider. This program will then provide you with a fabulous meal plan and a grocery list that makes it very easy to adhere to!

The meal plans are carb and calorie controlled, as well as fulfilling recommendations for intake of fiber, sodium, cholesterol, fat, and saturated fat. There are a plethora of excellent recipes and diabetes information on the site as well. Membership costs $20.95 per month.


2. TOPS (www.tops.org)

TOPS (Take Off Pounds Sensibly) is a nonprofit, noncommercial, weight loss support organization based in the US, with chapters located worldwide. It operates primarily by offering group support, and by accountability with weekly weigh-ins at chapter meetings.

New members should consult with their physician to obtain a goal weight, and then report it to their chapter Weight Recorder. A private weigh in occurs at each chapter meeting, followed by a program on a wide variety of topics pertaining to the weight loss journey and healthy lifestyle. Meetings provide members with positive reinforcement and motivation in adhering to their food and exercise plans.

Cost is $30 CDN per month, plus a few dollars per month in chapter operating costs. There are lots of chapters - I counted 36 within a 25 mile radius of my own postal code! You can locate a chapter here.


These are just a couple of suggestions - there are lots of great weight loss organizations out there. Find the one that's right for you!

Dr. Sue © 2009 www.drsue.ca drsuetalks@gmail.com

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