Are Low Blood Sugars a Normal Part of Having Diabetes?

Diabetes is a condition that is diagnosed on the basis of elevated blood sugars.  We know that high blood sugars over time can cause damage to the heart, kidneys, eyes, nerves, and other organs, so an important part of diabetes treatment is to keep blood sugars as normal as possible.  Some medications used to treat diabetes can cause low blood sugars if more is taken than what is needed.  So, is having low blood sugars a normal part of being treated for diabetes?


(for THE BOTTOM LINE, skip to below)

As I discussed at this weekend's Rocky Mountain Internal Medicine conference in Banff, Canada, my first point on this important topic is that having low blood sugars in diabetes is more common than we think.  Several studies have demonstrated that if blood sugars in diabetics are continuously monitored for 24 hours, a significant proportion of people are having low blood sugars - and don't know it.  There are a couple of reasons why you may not know you are having lows:  symptoms of lows (shakes, sweats, heart pounding, etc) decrease after 10-15 years of having diabetes, and older people may not get these symptoms even early in their diabetes.   Low sugars can have some atypical symptoms as well, such as nightmares.  A fall in the middle of the night in an older individual could be due to a low blood sugar, so if this is happening, it's important to check.

My second point is that low blood sugars have many negative effects.  A low sugar can be dangerous if it happens behind the wheel of a car or while operating machinery - this is why it's mandatory to check sugars before doing these things, if you are on medications that can cause low blood sugars.  A severely low sugar can cause a seizure or heart rhythm problems, though fortunately, severely low sugars are not common, especially if diabetes is managed well.

An important aspect of having low blood sugars that is sometimes overlooked is the effect that low sugars has on quality of life.  Having a low sugar is a scary feeling, and people who have had lows often fear - a lot - the possibility that it could happen again, and their family does too.  Seven to 10% of people who have a low blood sugar while at school or work will go home and miss the rest of the day, and some will miss the next day too.  Having a low sugar requires taking in carbohydrate calories to correct it, which can make it harder for overweight people to lose weight.   Having low sugars is expensive too, as it ends up costing in lost time at work, extra meter strips to check sugars, and so on.

The good news is that not all medications to treat diabetes cause lows.  Insulin and two classes of oral medications for Type 2 diabetes called sulfonylureas (includes glyburide, gliclazide, and others) and meglitinides (includes repaglinide) are the ones that can cause low blood sugars.  There are many other classes of medications to treat Type 2 diabetes that do not cause low blood sugars.

As far as insulin goes, insulin is required to treat Type 1 diabetes, and it is also required for many Type 2 diabetics, depending on how advanced their diabetes is.  However, there are different kinds of insulins available, some with lower risk of low sugars than others.

Some diabetes medications can also be adjusted depending on what you feel like eating.  For these medications, lower doses can be taken if less food is eaten to avoid a low blood sugar, rather than having to eat a regimented meal pattern every day to avoid your diabetes medication causing a low blood sugar.     Some diabetes medications can also be decreased for days that you are more active, rather than having to eat more on active days to avoid having a low sugar.

THE BOTTOM LINE:  Low blood sugars do NOT have to be a normal part of having diabetes.  I'm a big believer in adjusting diabetes medications to fit a person's lifestyle, rather than a patient having to alter their lifestyle to fit their medications (and avoid lows).   If you are struggling with low blood sugars as part of your diabetes treatment, speak to your doctor to find out what can be done to decrease the risk of lows, or possibly eliminate the risk entirely.


Dr Sue Pedersen www.drsue.ca © 2012 

Follow me on Twitter for daily tips! @drsuepedersen

Read more...

Lower Vitamin D Increases Risk of Gestational Diabetes

Included the long list of possible actions of vitamin D in humans is the possibility that it has a role in the regulation of blood sugar.   A new study supports that this may be true in pregnant women, as it has shown that women who have lower levels of vitamin D in the first trimester of pregnancy have a higher risk of developing gestational diabetes during that pregnancy.

At the European Association for the Study of Diabetes (EASD) meeting in Berlin last week, lead author Dr Lacroix from Sherbrooke University in Quebec, Canada, presented the study.  They looked at vitamin D levels in 558 pregnant women in the first trimester of pregnancy who did NOT have diabetes in the first trimester, and then tested them for gestational diabetes (ie, diabetes that develops during pregnancy) in the second trimester (which is the standard time to test for gestational diabetes).

They found that lower vitamin D levels in the first trimester were associated with a higher risk of developing gestational diabetes, with 37% of gestational diabetic women having had a lower vitamin D in the first trimester, and only 26% of non-gestational diabetic women having had a lower vitamin D in the first trimester.   (Scientists: lower vitamin D was defined as less than 50 nmol/L; also note that this difference remained statistically significant after adjusting for potential confounding factors including age, BMI, and body fat percent).


The bottom line:  Vitamin D levels may be one of many factors to consider in minimizing the risk of developing gestational diabetes.  If you are pregnant or considering becoming pregnant, speak to your doctor about vitamin D.

Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

Read more...

New Data on Type 2 Diabetes and Obesity Surgery

At the European Association for the Study of Diabetes (EASD) meeting in Berlin today, I had the pleasure of sitting in on a session discussing the effects of obesity surgery on type 2 diabetes.  Whereas previous years of diabetes meetings have seen very sparse attendance at bariatric surgery talks, this session was absolutely packed. 

At this session, a number of fascinating studies were
presented.  Highlights included: (be warned - it's a very science-heavy blog this week!)

A study by S. Steven and colleagues (UK) looked at a group of 92
patients who had type 2 diabetes prior to having gastric bypass
surgery, with the aim of determining which factors were associated
with a greater chance of diabetes remission after surgery. One of
their findings was that the degree of weight loss achieved post op was
the main determinant of diabetes remission - controversial, as the
bulk of currently available evidence suggests that remission of
diabetes is independent of weight lost.

A study by Pournaras and colleagues found that a nifty removable liner placed
inside of the first 60cm of small intestine (called a duodenal-jejunal
bypass liner) improved type 2 diabetes control over a 1 year trial period.
This introduces the question as to whether, in the future, we can
consider less invasive alternatives to bariatric surgery (such as
these) to help control type 2 diabetes.


A couple of elegant studies out of Denmark (including colleagues Jens Juul Holst and Sten Madsbad who I collaborate with on research studies personally) and Sweden were presented, designed to give us a better understanding of just how obesity surgery improves type 2 diabetes (with a lot of arrows pointing to the increase in the hormone GLP-1 that is seen after surgery).

Finally, there was a neat study from Finland showing that the insulin resistance of fat in femoral bone marrow improves with bariatric surgery (I personally had not previously thought about bone marrow being insulin resistant!).  

Overall, a very exciting day, and a very exciting meeting!

Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

Read more...

Women, Sex, and Diabetes

It is well known that men with diabetes are at risk of erectile dysfunction (ED).  We are now learning that it is not only diabetic men that are at risk of sexual challenges - a new research study reveals that women with diabetes can struggle with several aspects of sexual function too.

The study, which was done in California, administered questionnaires to well over 2,000 women aged 40-80, asking questions about sexual function.  They found that:

• women with diabetes were more likely to report low sexual satisfaction;
• insulin treated diabetic women were more likely to have problems with lubrication and orgasm than women without diabetes.
• women with serious complications of their diabetes (eg heart disease, kidney complications, stroke) reported less sexual satisfaction and activity than diabetic women without these complications.

So what is the link between diabetes and lower sexual health?  Just like for men, several possibilities exist, including:

• blood flow to the genital organs may be impaired (in the same way that blood supply to other organs can be damaged over time, especially if blood sugar control is poor);
• the nerve supply can be damaged over time (just like nerves to the feet can be affected, again, especially if blood sugar control is poor over the long term);
• some medications can affect sexual function;
• sex drive can be decreased if a person is not well because of their diabetes, or diabetes-related complications.  

A note on the finding that insulin treated women had more problems with lubrication and orgasm -  this probably reflects the fact that the women using insulin had more advanced complications of their diabetes (eg nerve damage), and should NOT be interpreted to mean that insulin itself decreases sexual satisfaction.  That being said, if a woman on insulin is having frequent problems with low blood sugars, this could certain dampen the sex drive - the solution here would be to adjust the insulin dosing with the help of health care providers so that the lows are no longer occurring.   The psychological issues that are sometimes associated with starting insulin could have an effect on the libido as well, which can certainly take time to work through - I want to emphasize that the solution is not to stop the insulin, as not taking insulin when it's required can have truly devastating effects on health.   I always encourage my patients to think of starting insulin in a positive light, as it provides the opportunity to get good control of diabetes!


BOTTOM LINES:

1.  Diabetic women are at risk of having sexual health issues - both patients and health care providers need to ask about it, and talk about it.

2.  Preserving sexual health is one more important reason to have good control of blood sugars, as poor control increases the risk of damage to nerves and blood vessels that are important for good sexual function.

Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

Read more...

Obesity Surgery to Treat Type 2 Diabetes?

At the recent inaugural meeting of the Canadian Association of Bariatric Physicians and Surgeons in Toronto in June, I was asked to review the recent consensus statement released by the International Diabetes Federation on the use of bariatric (obesity) surgery to treat patients with obesity and type 2 diabetes.

(Skip to MY BOTTOM LINES below for a summary, or read through for the nitty gritty!)

The International Diabetes Federation consensus states:

1.  Bariatric surgery is an appropriate treatment for people with type 2 diabetes 
and obesity not achieving recommended treatment targets with medical 
therapies, especially when there are other major co-morbidities.

2.  Surgery should be an accepted option in people who have type 2 diabetes 
and a body mass index (BMI) of 35 or more.  (note - you can calculate your BMI in the right column here)

3.  Surgery should be considered as an alternative treatment option in patients 
with a BMI between 30 and 35 when diabetes cannot be adequately controlled 
by optimal medical regimen, especially in the presence of other major 
cardiovascular disease risk factors.


As I reviewed at the meeting, the literature shows that most patients with obesity and poorly controlled type 2 diabetes experience an improvement in their diabetes with obesity surgery (especially gastric bypass and sleeve gastrectomy).  We have more data for patients with a BMI ≥35 than we do for patients with a BMI of 30-35 at this point in time, but the literature for the latter group is growing.

A large proportion of patients with type 2 diabetes will go into remission from their diabetes (meaning their diabetes goes away) after bariatric surgery, which of course sounds like a very attractive possibility to the person who has to deal with diabetes on a daily basis.


HOWEVER: 

• Based on the data we have currently available, about half of these cases of diabetes that went into remission after gastric bypass surgery come back by 5 years after surgery (called 'recurrence'). 
• Almost all of the long term data for diabetes remission rates is in patients with a BMI ≥ 35; there is almost no data to help us understand what the long term recurrence rate of type 2 diabetes is in the BMI 30-35 group.  People who have diabetes with this lower BMI may have a stronger genetic predisposition towards having diabetes, so it is plausible that these people would be less likely to have their diabetes stay away over the long term.
• There is little data to help us understand long term recurrence rates of diabetes after sleeve gastrectomy (which is becoming increasingly popular - read more about the types of surgeries here).
• The definition of diabetes 'remission' was previously quite loose and has now become much stricter; therefore, the remission rates reported in the literature are overinflated.

MY BOTTOM LINES on this controversial topic are:

1.  For people with a BMI of ≥ 35, with POORLY CONTROLLED diabetes:   Bariatric surgery is an option that provides a good opportunity to improve diabetes control.

2.  For people with BMI 30-35, with POORLY CONTROLLED diabetes:  There is very little information to guide us in this group of patients, but so far, it appears that bariatric surgery could provide a good opportunity to improve diabetes control.

3.  For people with BMI of ≥ 35 with GOOD CONTROL of their diabetes: Bariatric surgery can offer an opportunity to make diabetes go away - but for at least half of these patients (and possibly more over the longer term), the diabetes will come back.

4.  For people with BMI of 30-35 with GOOD CONTROL of their diabetes: Bariatric surgery can make diabetes go away, but we don't yet know what percentage return to diabetes.  Due to genetics, their risk of return to diabetes may be higher than those with BMI ≥35.

5.  Any patient whose diabetes goes into remission after bariatric surgery MUST be followed for the rest of their life for screening for the possible return of diabetes.

And of course, for ALL people who are thinking about having bariatric surgery, the risks and benefits of the procedure as a whole must be carefully weighed by both patient and their health care providers, to decide if this intervention is the right thing for them.



Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

PS - Bariatric surgery has been shown to PREVENT development of Type 2 diabetes as well (scientists - recent follow up to the SOS study published in the New England Journal of Medicine) - a story for another day's blog!

Read more...

Top 10 Advantages of Being Diabetic

This week, I want to share with you a truly inspirational blog - an amazing example of how a very positive light can be shed on having diabetes, or any chronic medical condition for that matter.

My friend Tim (not my patient) happens to be a Type 1 Diabetic, and he's written a truly inspiring post on his blog, about his perspective on how he sees his diabetes being an advantage in his life.  This blog brought tears to my eyes, from laughter (he's funny!), yes, but mostly from being so moved and heart warmed that he can find so many positive things in the challenges that he faces ever day.  

Not to mention that he's using his blog to raise funds for the Juvenile Diabetes Research Foundation.

Check it out - and please share your thoughts!

Tim's amazing attitude is summed up in his catch line at the top of his blog about Type 1 Diabetes:
No longer a type, but more a skillset.

Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

Read more...

Sweeteners - Friend or Foe?

Artificial sweeteners have long been available, as a way to sweeten drinks and food while avoiding the calorie impact of sugar.  Recently, sweeteners have been on the hot seat, as it has been questioned whether these chemicals are friend or foe in the battle of the bulge.


There are several sweeteners currently available (as blogged previously), and the first thing that bears saying is that each of these chemicals is a very different compound, so the effects of each one could be different.   (to jump over the scientific part of this discussion, skip to The Bottom Line below)

Interestingly, in recent years, we have learned that sweeteners can activate not only the sweet receptors in our mouths, but also in our intestines and our pancreas (though it's only the receptors in our mouths that give us the feeling of eating something sweet).  It has therefore been suggested that artificial sweeteners may have an effect on the production of appetite regulating hormones, leading to weight gain.

As recently reviewed, some 'test tube' (in vitro) studies have shown that artificial sweeteners can affect the production of appetite hormones from gut cells, while other test tube studies have shown no effect.  In human and animal studies, most have NOT shown an effect of sweeteners on appetite hormones.  Thus, overall, the research suggests that sweeteners do not have an effect on appetite - though the research is far from complete, and there is still a lot of ongoing study in this area. 

In addition, several studies have shown that a higher consumption of sweeteners is linked with a higher risk of obesity.  However, what these studies are not able to separate is whether higher sweetener consumption is seen in people who are overweight because they are drinking the sweeteners in an attempt to lose the weight, or whether the sweeteners are actually causing the weight struggle.   There is much research being actively done in the area to give us an answer to this question.

The Bottom Line: As it stands now, there is not enough evidence to convince us that sweeteners lead to weight gain, while the evidence that excess sugar leads to weight gain is very clear.  There are many excellent clinical trials underway in this area, which will hopefully give us more clarity on the subject.

Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

Read more...

Bisphenol A Exposure from Canned Soup

There is mounting evidence that exposure to a widely used chemical called bisphenol A is associated with an increased risk of obesity, diabetes, and metabolic syndrome.  A recent study reveals that eating canned soup for just 5 days can dramatically increase exposure to this potentially dangerous chemical.

Bisphenol A is a widely used chemical, found in a variety of products ranging from plastics to cash register receipts.  Most of our exposure is thought to be through food; in addition to being present in many water bottles and plastic food storage containers, it is also present in the interior epoxy coatings of many canned goods used to prevent corrosion.

The study was eloquently simple.  Seventy-five students and staff at the Harvard School of Public Health were each asked to eat soup for lunch for 5 consecutive days, and were randomly assigned to eating either canned soup, versus homemade soup from scratch. The following week, they ate soup each day for lunch once again, but they ate the opposite kind of soup from what they had eaten the week previously (researchers: thereby providing a randomized, single blinded, crossover design). 

The results were, in my opinion, quite astonishing: the researchers found that the bisphenol A levels in the urine were nearly twenty times higher after a week of canned soup consumption, compared to after homemade soup consumption.  Further, the urine bisphenol A levels after the canned food week were 60% higher than the higher end of urine bisphenol A levels noted in the general population. 

The study did not test the bisphenol A levels in the blood, so we don’t know if these people quickly cleared the bisphenol A from their systems, or whether the bisphenol A levels in their blood or other tissues was also elevated, or for how long.  That being said, the study does clearly show that just 5 days of eating canned soup dramatically increases exposure to this potentially harmful compound. 

Let’s hope that this study gives an extra push towards using bisphenol A – free linings to canned goods, as well as yet another reason to cook and enjoy healthy food made at home!  

Thanks to my friend and colleague Jon for pointing out this study!

Dr Sue Pedersen www.drsue.ca © 2012

drsuetalks@gmail.com 

Follow me on Twitter for daily tips! @drsuepedersen 

Read more...

Metformin Improves Survival in Type 2 Diabetics with Cancer

There are many different treatment options available for Type 2 diabetes, ranging from several classes of oral medications, to injectable therapies including insulin.  Metformin is considered in most countries to be the first line treatment for Type 2 diabetes for a long list of reasons, and a recent study adds improved survival after a diagnosis of cancer to this list of metformin-related benefits.

The study, recently published in the journal Diabetes Care, looked at data from over 350 primary care practices in the United Kingdom.  They examined data regarding patients who had a diagnosis of both type 2 diabetes and cancer, and then looked at what diabetes medications these people were prescribed.

The authors found that cancer mortality in this population was 9% higher amongst diabetics, compared to non diabetics.  When they looked at diabetic patients on metformin, they found that the cancer mortality rates were lower compared to patients using sulfonylureas or insulin alone to treat their diabetes, and were also lower than the cancer mortality rates in nondiabetics.  In patients using a combination of metformin + sulfonylurea, or metformin + insulin, the cancer mortality rates were the same as for non diabetics.

So what does this mean?  Firstly, these data further strengthen the position of metformin as first line treatment for type 2 diabetes, and adds to the known benefits of metformin (including improvement in blood sugars, decreased risk of diabetes-related complications, a minor amount of weight loss, doesn't cause low blood sugars, etc).  It also increases interest in the potential use of metformin as anticancer therapy in patients who don't have diabetes; in fact, metformin is currently being studied in trials with breast cancer chemotherapy, to treat breast cancer in non diabetics.

In regards to the comparison of metformin with other diabetes medications, we have to be careful of factors that can confound (confuse) these conclusions.  For example, the patient who requires insulin to treat their diabetes is metabolically different than the patient who does not require insulin - those needing insulin are often more insulin resistant, and this very likely has an impact on cancer related risk.   Furthermore, it is often necessary to use a combination of medications to treat diabetes, as metformin is often not enough to control blood sugars in many people.

Control of blood sugars is of paramount importance to the health of diabetics, and for many, multiple medications are needed to maintain blood sugar control.    The take home message from this study is that metformin remains the first line treatment for type 2 diabetes, and should be included as part of the diabetes treatment regimen, provided that the patient tolerates it and does not have any health conditions that would prohibit its use.

Dr Sue Pedersen www.drsue.ca © 2012

drsuetalks@gmail.com 

Follow me on Twitter for daily tips! @drsuepedersen 

Read more...

Are Diabetic Men At Risk of Fertility Problems?

Although diabetes is known to be associated with many complications, infertility amongst men is not traditionally thought of as being one of them.  Similarly, when a couple presents to a fertility clinic, diabetes in the man is not typically on the list of conditions to rule out.  As it turns out, diabetes in men can have an impact on fertility from several perspectives, right down to the DNA of the sperm themselves.

As reviewed by Sandro De Vignera and colleagues, the prevalence of subfertility or infertility amongst men with diabetes has been reported to be as high as 35-50% in some series, and is significantly higher than sub/infertility amongst men without diabetes.  Smoking and obesity appear to be the strongest risk factors for infertility amongst diabetic men.    

There are several mechanisms by which diabetes can be associated with fertility problems.  It is well known that diabetes can be associated with erectile dysfunction, lower testosterone levels (particularly in cases of severe insulin resistance or obesity), and retrograde ejaculation (ejaculation ‘backwards’, into the bladder). 

More recently, it has been discovered that diabetes can also be associated with damage to the DNA of sperm.  Studies suggest that diabetic men have a higher percentage of sperm with DNA damage compared to non diabetic men, and it has been postulated that this may be due to increased concentrations of ‘advanced glycation end products’ throughout the reproductive tract (proteins with sugar stuck to them, which is a consequence of elevated blood sugar over time), leading to more ‘stressed’ metabolic processes (known as ‘oxidative damage’) and thereby DNA damage.  

While several of the above mentioned elements can occur in both type 1 and type 2 diabetes, there are some differences as well.  While type 2 diabetics are more likely to suffer from the insulin resistant mechanisms of infertility (obesity, low testosterone), men with type 1 diabetes have an increased risk of concomitant autoimmunity against the developing sperm or related structures.

While this topic can be discussed in far more detail than I have presented here, the key take home message today is that diabetes may play an important role in male factor infertility.  Fertility concerns or desires should be addressed in the evaluation of the diabetic male patient, and the possibility of diabetes should be considered in a man presenting with fertility concerns.

Dr Sue Pedersen www.drsue.ca © 2012

drsuetalks@gmail.com 

Follow me on Twitter for daily tips! @drsuepedersen

Read more...