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The Global Impact of Diabetes

>> Saturday, December 17, 2011








Though the prevalence of diabetes is alarming in every country, the Middle East has come on the radar more recently, and is in fact home to six of the top 10 countries for diabetes rates worldwide.  It is thus very fitting that this year's World Diabetes Congress, hosted by the International Diabetes Federation, was held last week in Dubai, United Arab Emirates.  I had the pleasure of hearing diverse speakers from around the globe at the conference, and what I would like to share with you this week are some hard numbers and facts about the impact of diabetes around the planet (with reference to the excellent speakers, as well as the International Diabetes Federation's Diabetes Atlas, 5th edition).

Did you know that:

1.  There are currently 366 million people in the world with diabetes (including about 8.3% of the world's adult population).   By 2030, this number will be 552 million.

2. There is little gender difference in diabetes rates, with 185 million men and 181 million women affected worldwide.

3. All nations are suffering the impact of the diabetes endemic; there is no country in the world where diabetes rates are not increasing.

4. Fifty percent of people who have diabetes - don't know it.  In Africa, 78% of people with diabetes are undiagnosed.

5. There are more people with diabetes living in urban areas compared to rural areas.  (The reasons why are probably several: urbanites tend to have more access to fast/Western unhealthy food choices, and tend to be less active, to name two.)

6. The greatest number of people with diabetes are in the 40-59 age group.

7. In addition to the people who already have diabetes, an additional 6.4% of the world's adults are estimated to have impaired glucose tolerance (a form of prediabetes).  That's a total of nearly 15% of the world's adults who currently have prediabetes or diabetes.

8. Rates of gestational diabetes (diabetes in pregnancy) are on the rise worldwide as well; further, women who have had gestational diabetes are at very high risk of developing type 2 diabetes.

9.  80% of people with diabetes live in low and middle income countries, who often have little or no access to medications needed for control of blood sugars.

10. The country with the highest diabetes prevalence is the Pacific island nation Kiribati, at a staggering 25.7%.

Food for thought.  (pun intended)



Dr Sue Pedersen www.drsue.ca © 2011 

drsuetalks@gmail.comFollow me on Twitter for daily tips! @drsuepedersen  

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The Vote is In, but the Jury is Out - Is Bariatric Surgery an Appropriate Treatment Option for Type 2 Diabetes?

>> Thursday, December 8, 2011






At this week's World Diabetes Congress in Dubai, hosted by the International Diabetes Federation, I had the opportunity to listen to a fantastic debate as to whether bariatric (weight loss) surgery is an appropriate treatment option for Type 2 Diabetes.

The argument in favor of bariatric surgery was presented by Dr Francesco Rubino, a bariatric surgeon and leading authority on the issue from Cornell University, in New York.   He highlighted key points of evidence regarding the benefits of bariatric surgery in terms of improving diabetes, noting that bariatric surgery provides a powerful potential opportunity to reverse the course of an otherwise progressive disease.  While the current criteria for bariatric surgery in diabetics include a Body Mass Index (BMI) ≥35, he presented for us the International Diabetes Federation position statement on the role of bariatric surgery, which suggests that surgery should also be considered in people with BMI 30 to 35 when diabetes cannot be adequately controlled by medical therapy, especially in the presence of other cardiovascular risk factors.  (BMI can be calculated here)

Dr Rubino noted that bariatric surgery stands apart from some other medical treatments of diabetes, in that many medications cause weight gain, whereas bariatric surgery can result in substantial weight loss.  He noted that patients who are most likely to have the greatest improvement (or complete remission) of diabetes include those with a shorter duration of diabetes, and lower preoperative medication requirements; in other words, earlier intervention appears to produce the best results.  He noted that not only does bariatric surgery improve diabetes, but can also be very effective to prevent new cases of diabetes.  Other benefits include some improvement in cholesterol profile and blood pressure, which are also risk factors for cardiovascular disease.  Gastric bypass is superior to gastric banding in achieving these effects.  (Sleeve gastrectomy was not discussed in particular - I enter my own editorial comment here, that sleeves are proving to be quite effective to treat type 2 diabetes as well, somewhere between gastric bypass and banding in terms of efficacy, but so far appearing to be closer in efficacy to gastric bypass).

In discussion of the very limited accessibility to bariatric surgery, Dr Rubino provocatively noted:

"If there were a pill or a shot that can control blood sugars, improve body weight, cholesterol and blood pressure, and improve survival, would it be acceptable that >99% of people do not have access to the treatment? "

He concluded with the comment that we should not be using BMI as the most important criteria or cutoff in choosing the right patient for bariatric surgery; rather, we should be considering the metabolic disease (in particular, diabetes) that each patient carries, and stratify our decision re surgical candidates based on cardiovascular risk profile, as the BMI does not tell the whole story.

The negatives for bariatric surgery in the treatment of type 2 diabetes was presented by Dr John Pinkney, professor of diabetic medicine from Plymouth, UK.

Dr Pinkney opened with a discussion of the treatment goals for type 2 diabetes, including increasing life expectancy, reducing cardiovascular disease, reducing small vessel complications of diabetes (eye, kidney, and peripheral nerve complications), and improving quality of life, using treatment modalities where the benefits exceed the risks.   Many of these health goals are achieved by optimizing control of vascular risk factors (diabetes control, blood pressure, and cholesterol).

In terms of treatment targets for diabetes, Dr Pinkney notes that several recent diabetes trials have suggested that tight glucose control may not actually prevent cardiovascular events, compared to slightly less tight glycemic control.  He wondered, then, whether getting diabetes into excellent control with bariatric surgery would really be of that much benefit (and worth the risk?) in patients who had reasonable control of their diabetes in the first place.

He noted that while the improvements in blood pressure and cholesterol with bariatric surgery are statistically significant, that the absolute improvements are not that big.  From the prevention of small vessel diabetes complications perspective, he noted that there is not yet much study in this area, and the question as to whether bariatric surgery prevents these diabetes complications in the long term remains unanswered.

While improvements or remission of diabetes is certainly impressive, the long term durability of diabetes remission was discussed, in that the most recent literature is now suggesting that a substantial proportion of diabetes that initially goes into remission, recurs years down the road.

The downsides of bariatric surgery require very serious consideration, and the risks vs benefits must be weighed carefully.  The risk of death due to the surgery itself was discussed, though Dr Rubino noted that this risk is approximately that of a gall bladder removal surgery (ie, fairly low as far as surgeries are concerned).  Although the need for diabetes medications may decrease with surgery, these treatments are 'traded in' for the need for a new array of lifelong nutritional supplements (the exact array of supplements needed depends on the type of surgery).  Not taking these supplements or not having them monitored carefully can result in life threatening complications.  The removal of the freedom to 'eat as I wish' and the potential impact on quality of life was also noted.

Dr Pinkney noted that type 2 diabetes is a complex disease that is very common, and suggested that it may not be feasible or productive in general to consider a treatment (surgery) that is very expensive, requires lifelong follow up, and is therefore not accessible for any but a small sliver of the people with diabetes worldwide.

Both presenters were grateful for the opportunity to present this important topic, noting that the topic of bariatric surgery has only been taken seriously as a potential therapy for diabetes in the last few years.

At the conclusion of the presentations, a show of hands of the audience was requested as to how many people were in favor vs against the use of bariatric surgery to treat type 2 diabetes (this was an auditorium containing several hundred diabetes health care professionals from around the world) - to my eye, the vote was roughly evenly split.

My feeling on this issue is reflected in an underlying theme to both of these presentations: the decision for bariatric surgery is a highly patient specific decision.  Each patient must be considered on a case by case basis, with the benefits and risks carefully weighed and discussed in exquisite detail.  For the right diabetic patient, bariatric surgery can provide an appropriate treatment option.


Dr Sue Pedersen www.drsue.ca © 2011 

drsuetalks@gmail.comFollow me on Twitter for daily tips! @drsuepedersen  

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Does Your Genetic Background Result In Your Diabetes or Weight Struggles being Unmodifiable?

>> Friday, November 11, 2011









In my post last week, I discussed the large and important contribution of genetic background towards the tendency to develop type 2 diabetes or obesity.  Since that time, I've had a couple of people ask me whether there is any point to undertaking lifestyle intervention (ie changes in eating patters and/or activity) if their genetics have already dictated that they are going to have a lifelong struggle with these conditions. 


As I noted last week


While it is true that eating well and exercising are the cornerstones of the management of type 2 diabetes, and can certainly improve diabetes control, it is not possible for most people with diabetes to make it go away with these lifestyle changes.


This week I would like to bring the focus to the first part of this statement - ie, that lifestyle changes can certainly improve diabetes control, and improve obesity as well.  Just about everyone with type 2 diabetes or weight struggles can see some improvement with permanent lifestyle change.  How much improvement that is seen is going to depend on several factors, including: 

  • For those who struggle with their weight or eating patters: Have the root causes of that  struggle been addressed? (emotional eating, depression, medications causing weight gain, untreated sleep apnea.... the list of possibile contributors is long)
  • What is the degree of motivation to change? 
  • What permanent lifestyle interventions have been undertaken, and are they in line with the genetically determined tendencies and ethnic/cultural considerations of the patient? 
On the last two points - yes, it's true - our genetic makeup plays a part in determining which lifestyle changes will work best for us, and may even play a role in our levels of motivation to do so.  For example, studies have shown genetic differences in the natural tendency to exercise than others, so for some, exercise will play a greater part in the success of their permanent lifestyle changes than for others. As another example, each of us has our own unique balance point of hunger and satiety hormones, such that some of us need more food or a higher body weight to feel full than others.  For those people, medications that are directed towards modifying these hormone balances may be a great leap forward in helping them lose weight (such medications are available to treat type 2 diabetes, but not to treat obesity per se).  


Again on the line of genetics, it is important that practical goals are set, with regards to controlling type 2 diabetes or managing obesity with lifestyle changes.  For diabetics, there may be only a certain amount of glucose control that can be obtained by making lifestyle change - the pancreas gets tired over time (genetics and stress on the pancreas caused by overweight both play a role here), and for many, medications need to be started despite the very best efforts on the part of the patient. 

From a weight stance, the goals must be practical as well.  Remember that even a 5% body weight reduction (in those who are overweight or obese) decreases the risk of a whole host of complications associated with excess body weight. 


The key in maximizing lifestyle success is in finding the form, or forms, of permanent lifestyle change that work for you - the bulk of this blog is dedicated to just that, in an attempt to help provide you lots of different lifestyle options to try on your journey towards permanent lifestyle change.   And don't be afraid to ask your healthcare providers for help - remember, there is no shame. 




Dr Sue Pedersen www.drsue.ca © 2011 drsuetalks@gmail.com

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There Should Be No Shame in Having Diabetes

>> Friday, November 4, 2011






I came across this excellent article online yesterday on msnbc.com, which discusses the stigma often associated with having diabetes.  The personal stories made me sad, then made me mad, and then I decided to take matters into my own hands and discuss this very important topic as this week's blog.

Mary's story is one that I hear from my patients on a regular basis - there is often a feeling of shame associated with having type 2 diabetes.   Because type 2 diabetes is often seen in association with overweight, there is a stigma upheld by many members of the general public that people who have diabetes are lazy, eat too much, don't exercise, and are not interested in their health.

What people need to realize, is that it is not the fault of the individual that they have diabetes.   There is a very strong genetic basis for developing diabetes (as blogged previously), and a very strong genetic basis for obesity as well (read more here), which we are learning more about every day as new genes involved are continuously being discovered.  Furthermore, there are many people out there with type 2 diabetes who are not overweight or obese - this speaks to the very strong genetic tendency towards developing diabetes in these individuals.   While it is true that eating well and exercising are the cornerstones of the management of type 2 diabetes, and can certainly improve diabetes control, it is not possible for most people with diabetes to make it go away with these lifestyle changes.

When I am discussing optimization of diabetes control with my patients, they often tell me that they feel embarrassed to check their blood sugars in public, or to administer medications or insulin in front of other people.  As a result, they may choose to forgo checking sugars or administering medications at times like lunch, when they are often out in public.   It breaks my heart each time I hear this - how can our society be so cruel and judgemental?

It's high time that our society gets a grip on what it actually means to have type 2 diabetes.  This disease has a strong genetic predisposition; our extremely toxic, fast food, sedentary enviroment is conducive to bringing it out in many people who are genetically prone.

People with diabetes who are seen checking blood sugars or administering insulin in public are showing committment and motivation to watch their numbers, and to do everything they can to optimize their glycemic control and their health - they deserve a HIGH FIVE! from all of us!


And a High Five to msnbc.com for writing this fabulous article - I hope their far reach will do well to get this message out to many.  Feel free to pass on this article as well, to everyone you know!


Dr Sue Pedersen www.drsue.ca © 2011 drsuetalks@gmail.com

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Smoking and Diabetes Risk: A Deadly Combination

>> Sunday, January 30, 2011



It comes as no surprise to anyone reading this blog that smoking is bad for your health. Interestingly, the risk goes far beyond cancer risk and heart disease - smoking has an important impact on diabetes as well.

As reviewed by Patasi and Hall, several studies have demonstrated that smoking increases the risk of developing type 2 diabetes 2- to 3- fold. The likely reason behind this fact is that smoking decreases the body's ability to use insulin. In fact, smoking 1 cigarette reduces the body's ability to use insulin by 15% for an entire day! We also see that amongst patients with type 2 diabetes, smokers have higher blood sugars than nonsmokers.

Vascular disease is a complication of both smoking and diabetes, so it should come as no surprise that having both risk factors compounds the risk. Smoking diabetes are more than 10 times more likely to develop peripheral vascular disease than nonsmoking diabetics, and also have a higher risk of small vessel diabetic complications such as nerve, eye, and kidney damage. Smoking can also lead to impotence amongst diabetic men. And that's not all - the list goes on.

Given that we know that smoking increases the risk of several cancers as well as the risk of vascular disease, and that 80% of diabetics will die as a result of heart disease or stroke, smoking and diabetes are truly a deadly combination.

Dr Sue Pedersen www.drsue.ca © 2011 drsuetalks@gmail.com

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Are Genetics Important in Diabetes?

>> Saturday, January 22, 2011






In a world where the epidemic of diabetes threatens to spiral out of control, our understanding of the influences that put people at risk of developing the disease is crucial.  As a second part to my recent blog about the important genetic influence on the development of obesity, it is also very important to consider the genetic contribution towards diabetes.

In North America, approximately 80% of diabetes is caused by Type 2 Diabetes, which is a condition of elevated blood sugars caused by resistance of the body's organs and tissues to the effects of insulin, to the point where the pancreas is not able to produce sufficient insulin to overcome this state of insulin resistance.  Insulin resistance and Type 2 Diabetes worsen with weight gain and improve with weight loss; however, there are a subset of people with Type 2 Diabetes who are normal weight.   About 10% of diabetes is Type 1 diabetes, where the immune system attacks the pancreas and causes it to fail to produce insulin.  The final 10% of diabetes is causes by various rare genetic disorders.

The evidence for a strong genetic tendency towards developing Type 2 Diabetes is strong.  For example:

  • some ethnic groups residing in North America (such as Hispanic, South Asian, and Aboriginal) are at 2-6 fold higher risk of developing Type 2 Diabetes compared to North American Caucasians
  • a twin of a person with Type 2 Diabetes is at 90% risk of developing the disease (as compared to Type 1 diabetes, where the risk is lower at 50%)
  • nearly 40% of patients with Type 2 Diabetes have at least one affected parent (whereas in Type 1 Diabetes, the risk of the child of a Type 1 Diabetic parent getting the disease is only 6%)
  • the lifetime risk of a person getting Type 2 Diabetes is 5-10 times higher if they have a first degree relative with the disease, compared to not having a relative with the disease

As reviewed by Dr McCarthy, the search for genes connected to Type 2 Diabetes has really taken off with the ability to search the entire human genetic makeup (called the 'genome') in recent years.  In fact, there are at least 40 genetic spots (called 'loci') in the human genome that have been found to be associated with a susceptibility to developing Type 2 Diabetes.  These genetic variants are associated with a variety of disturbances that affect the risk of developing Type 2, including alterations in the development of the pancreas, insulin synthesis, and insulin secretion.  The genes that contribute to development of obesity (as blogged previously) likely contribute to the risk of type 2 diabetes as well, as the insulin resistance that characterizes type 2 diabetes worsens with weight gain.

In terms of the influence of these genetic variants on the risk of Type 2 Diabetes, it appears that in some cases, having two abnormal copies of these genes may as much as double the risk of getting diabetes, compared to having two normal copies of these genes. 

For some individuals, the eventual development of Type 2 Diabetes may be unavoidable, due to their genetic makeup.    However, many cases of Type 2 Diabetes are preventable, as many people develop sufficient insulin resistance to generate full blown diabetes only when they reach a state of overweight or obesity.  While obesity in itself has some genetic predisposition as well, both obesity and type 2 diabetes can be improved with dedicate attention towards a healthy lifestyle.

As for obesity genetics, our understanding of the genetic basis for Type 2 Diabetes is essential, as it will help us in better understanding the disease, finding new targets for treatment, and hopefully allowing us to improve individual strategies towards treatment and prevention.


Dr Sue Pedersen www.drsue.ca © 2011 drsuetalks@gmail.com

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After Gestational Diabetes: What's Next?

>> Sunday, January 9, 2011








Gestational diabetes, or diabetes diagnosed for the first time during pregnancy, is a common condition, affecting approximately one in 25 pregnant women in Canada. After the baby is born, women who had gestational diabetes may be eager to leave their blood sugar concerns behind, but beware: women who have had gestational diabetes are at high risk of developing type 2 diabetes.


In pregnancy, there are several factors that contribute to the development of gestational diabetes, including increased food intake, weight gain, decreased exercise, and the production of several hormones by the placenta that make the mother more resistant to the effects of insulin. As the development of gestational diabetes identifies women whose pancreas is not able to keep up in the face of the stress of pregnancy, it also identifies women who are at future risk of developing full blown type 2 diabetes (outside of pregnancy). In fact, having had gestational diabetes increased the risk of developing type 2 diabetes later in life by up to 12 fold. Further, some cases of gestational diabetes were likely type 2 diabetics before the pregnancy started, but they did not come to medical attention until the pregnancy began.


Because the impact of undiagnosed type 2 diabetes postpartum is of serious consequence to the mother's health, and also has implications for future childbearing, it is essential that these women undergo screening for type 2 diabetes postpartum. Blood sugars will be checked following delivery in the hospital, but this alone is not enough, as diabetes can return after discharge home when normal life and eating patterns resume.


All women who have had gestational diabetes must undergo a glucose tolerance test within 6 weeks to 6 months postpartum. This involves drinking a glucose containing drink, with measurement of blood sugar before and 2 hours after the drink is taken. Checking fasting blood sugars is not enough, as this will miss 40% of type 2 diabetes in the postpartum population.


Additionally, women with previous gestational diabetes must be screened for type 2 diabetes:

* before any future pregnancies
* every 3 years, or more often, depending on other risk factors


Unfortunately, as few as 25% of women who have had gestational diabetes complete this important postpartum testing. Having undiagnosed type 2 diabetes can cause injury to blood vessels supplying vital organs including the heart, kidneys, and eyes. Having undiagnosed type 2 diabetes at the time of the next pregnancy can have devastating consequences to the fetus, including congenital malformations and miscarriage.


If you have or have had gestational diabetes, speak to your doctor to be sure that you have undergone, and continue to undergo, the appropriate screening.



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


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