Does Earlier Menopause Mean A Higher Risk Of Diabetes?

Menopause is a major life transition for women, both psychologically and physiologically.  A number of changes occur in a woman's body that alters metabolism, unfortunately tipping the scales towards an increase in cardiovascular risk.  We know that an earlier age of menopause increases the risk of cardiovascular disease, and that a later age of menopause onset seems to be protective.

Whether earlier age of menopause increases the risk of developing type 2 diabetes has been somewhat controversial; a new study sheds additional light on this question.

The study, published in the journal Diabetologia, evaluated 3639 postmenopausal women from the population based Rotterdam study.  They followed these women for a median of 9.2 years, with the goal of assessing how the risk of developing type 2 diabetes may vary depending on the age of menopause.

They found that the risk for developing type 2 diabetes, compared to women with late menopause (at more than 55 years old), is:

• 3.7 times higher for women with premature menopause (at less than 40 years old)
• 2.4 times higher for women with early menopause (at 40-44 years old)
• 1.6 times higher for women with normal age of menopause (at 45-55 years old)

They found that for every year later that menopause occurred, the risk of developing diabetes decreased by 4%.

So why would the risk of diabetes go up with earlier menopause? With menopause comes a natural decrease in our reproductive hormones (estrogen, progesterone, and testosterone).   These changes promote a loss of muscle and an increase in fat, especially the visceral fat that sits around our abdomen and internal organs - this is the fat that has negative effects on our metabolism.  A loss of progesterone, and hot flashes from having lower estrogen levels, can impair sleep, which is a known risk factor for obesity and metabolic syndrome.  The emotional challenges of menopause may bring out an increase in emotional eating for some women, which can promote weight gain and increase diabetes risk as well.

Interestingly, this study looked at several reproductive hormone levels at the start of the study, and showed that earlier menopause was associated with an increase risk of diabetes, independent of these hormone levels, and also independent of body mass index at baseline or shared genetic factors.

The authors hypothesize that earlier menopause and type 2 diabetes may be a consequence of epigenetic changes, which are changes that alter the physical structure of our DNA.  Epigenetic changes can be caused by a number of factors, including poor diet, smoking, and many other environmental factors. 

Further studies need to be done looking at epigentic changes to determine if these may be responsible for the association between earlier menopause and diabetes risk. If epigentic changes are at play here, living well and healthily throughout life is more important than ever!

After menopause, we can combat cardiovascular and diabetes risk by:

• Keeping active - engage those muscles! This helps to combat the decrease in muscle mass. 
• Making healthy permanent lifestyle changes 
• Having good sleep hygiene
• Getting help from your doctor if you are struggling with menopausal symptoms.

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Dexcom G5 Continuous Glucose Monitor - New Glucose Monitoring Technologies Part 2

The traditional way of monitoring blood sugars is with finger pokes, but there are other newer technologies out there that make it not only easier to check, but provide more data as well.

Two new technologies have recently arrived in Canada: the Freestyle Libre (see last week's post on this), which is a poke free glucose monitor, and the Dexcom G5 continuous glucose monitor, which allows you to broadcast sugars wirelessly to family or caregivers.   This week, we’ll review the Dexcom G5.  

The Dexcom G5 is a continuous glucose monitor (CGM). This consists of a sensor that you apply to your abdomen (lasts 7 days) which measures glucose in the interstitial fluid that surrounds your cells under your skin, as an estimate of blood glucose levels.  There is a transmitter that fits onto the sensor (lasts 3 months), which transmits continuous sugar readings to the reader that comes with it.  It has alarms for low or high sugars.  It needs to be calibrated against finger poke readings every 12 hours, so while the CGM can decrease the number of finger pokes, it doesn’t eliminate them entirely.  

While CGMs are not new to Canada, the exciting new feature of this model is that it transmits glucose values not only to the reader, but also to smartphones, iPads, and some smart watches.  Also, the Dexcom5 has been approved in Canada and the USA for making treatment decisions (the previous model, the Dexcom G4, is not).  Though there have been reports of inaccuracies, the FDA concluded that 'the benefits of additional information gained from this device outweigh the inaccurate results, rates of change, and false negative and positive alarms and alerts'.  As far as the clinical trials go, the accuracy is reported to be within about 9% of actual blood sugar.  The cost is about $3100 per year (ouch!).

This can be a useful tool for parents (it’s approved down to age 2) or caregivers who want to keep an eye on their loved one’s sugars.  Also, CGMs with alarms have helped to keep many a patient of mine who have lost their ability to feel low blood sugars safer, waking them up at night when sugars are going low.   As for all of the interstitial glucose monitoring technologies - if in doubt about the glucose reading - check with a finger poke.

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Poke Free Glucose Monitor Has Arrived In Canada! New Glucose Monitoring Technologies Part 1

The traditional way of monitoring blood sugars is with finger pokes, but there are other newer technologies out there that make it not only easier to check, but provide more data as well.

Two new technologies have recently arrived in Canada: the Freestyle Libre, which is a poke free glucose monitor, and the Dexcom5 continuous glucose monitor, which allows you to broadcast sugars wirelessly to family or caregivers.   Today, we’ll review the Libre, and I’ll follow up with a separate post on the Dexcom5.

Finger pokes are uncomfortable, and can be a barrier to checking blood sugars.  As blogged previously, the Freestyle Libre system (pictured above) is an entirely new technology, consisting of a tiny monofilament sensor that you apply to your arm every 14 days.  It measures glucose in the interstitial fluid that surrounds the cells under your skin, as an estimate of blood glucose levels. Hold the reader near the sensor and Ding! - it will tell you your current glucose level, which direction your sugar is heading (up, down, or steady), a message on the screen if glucose is going low or high, and – get this – it will show you your last 8 hours of glucose readings in a graph. 

The Libre sensor is calibrated right out of the box, so there is no need for finger poking to calibrate it.  It is approved by Health Canada for making treatment decisions, provided that you take into account all of the info on the screen when you scan the reader.

You DO need to check with a finger poke (built into the reader) if:

• sugar reads low or going low (very important, as the Libre may inaccurately indicate hypoglycemia)
• during a time of a rapid blood sugar change (for example during exercise, after eating, or after taking a bolus of insulin; the reason being because interstitial glucose changes lag behind blood glucose changes); or
• if your symptoms do not agree with the number you see when you scan (remember, though, that some people with diabetes are not able to feel it when their sugars go low - in that case, confirming with a finger poke may be needed more often) 

It’s less accurate on the first day you wear it, so I would suggest more reliance on finger pokes on day 1.  The accuracy improves to within about 9-11% of actual blood sugar after that. (Standard finger poke monitors have varying accuracy, and the analysis method for accuracy is different, but Diabetes Canada accepts within 15% accuracy for those monitors.)   It costs about $50 for the reader (one time cost), and about $90 for each sensor (replaced every 14 days).  There is a built in ketone meter as well, which is handy if there is a need to check ketones (more on this here).

The Libre provides the opportunity to decrease the need for finger pokes, and scanning just 3 times a day (every 8 hours) is enough to give a full 24h glucose profile, which can help you and your diabetes care providers understand your blood sugars in even more detail.

Stay tuned for info on the Dexcom5 continuous glucose monitor!


Disclaimer: I have received honoraria as a continuing medical education speaker and consultant from the makers of the Freestyle Libre (Abbott).

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Anemia, Mortality, and Type 2 Diabetes

Health care providers out there may have noticed that anemia is a not-infrequent finding amongst patients with type 2 diabetes.

It turns out that there are multiple reasons for anemia in type 2 diabetes - and the health consequences may be severe.

A study was recently published evaluating the prevalence, risk factors, and prognosis of anemia in two groups of Australian patients.  They found that the prevalence of anemia was double to triple in people with type 2 diabetes, compared to people without diabetes.

They found multiple risk factors independently associated with a higher risk of anemia, including:

• impaired kidney function: related at least in part to reduced erythropoeitin production by the kidneys, which is a hormone that stimulates red blood cell production
• longer duration of diabetes: 5% increased risk of anemia per year of having diabetes - may be due to decreased red blood cell production and/or increased destruction, as consequences of chronically elevated blood sugar
• metformin use: likely related to vitamin B12 deficiency, but other mechanisms such as low magnesium are considered
• thiazolidinedione use [pioglitazone (Actos) or rosiglitazone (Avandia)]: likely related to fluid retention
• peripheral arterial disease: possibly related to higher oxidative stress, inflammation, atherosclerosis

Other risk factors were identified as well, such as low iron, and low testosterone in men.

After adjustment for other independent predictors of mortality, anemia was associated with a 57% increased risk of mortality over the mean of 4.3 years of study, compared to people with diabetes but without anemia.

The good news is that many of these risk factors for anemia are treatable, and even preventable.  For example: optimizing blood sugar control; checking vitamin B12 in people on metformin; checking iron levels in people who are anemic and investigating for the cause of low iron if so.

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How Successful is Gastric Bypass Surgery 12 Years Later?

We know that gastric bypass surgery is a powerful tool in the management of obesity and metabolic syndrome.  However, there is not a lot of data available following patients out over the very long term.  A recent study is the first prospective study looking only at Roux-en-Y gastric bypass surgery, to give us data out as far as 12 years.

The study, published by Adams and colleagues in the New England Journal of Medicine, enrolled 418 patients in Utah, USA who underwent gastric bypass surgery, and compared them over the long term to 417 patients who wanted surgery but did not have surgery (primarily because of lack of financial insurance coverage), and a third group of 321 patients with obesity who were not interested in surgery. They had an excellent rate of follow up of over 90% of patients at 12 years.

Here are some of the key findings: (skip to take home messages below for the short version)

1.  Weight loss:

• Two years after gastric bypass surgery, the mean weight loss was 45 kg. 
• At 6 years postop, the mean weight loss was 36.3kg (so there was about 20% weight regain, which is very consistent across studies).
• At 12 years postop, the mean weight loss was 35kg – so weight was overall stable from 6 years to 12 years after surgery.

 [At 12 years, people who wanted surgery but didn’t have it had lost 2.9 kg (probably because they were part of this study), and people with obesity who did not want surgery had lost 0 kg (also notable for no weight gain over the long term).]

2.  Type 2 diabetes:

Among patients in the surgery group who had type 2 diabetes before surgery:

• At 2 years postop, 75% of diabetes had gone into remission.
• At 6 years postop, 62% of diabetes cases were in remission
• At 12 years postop, 51% of diabetes cases were in remission.
• The likelihood of diabetes being in diabetes remission at 12 years was 8.9 times higher for those who had had surgery compared to those who wanted but did not get surgery, and 14.8 times higher than those who did not want surgery in the first place.
• At 12 years, the likelihood of being in diabetes remission was highest in people who had diet controlled diabetes before surgery (remission rate 73%), less for people who needed pills to treat their diabetes before surgery (remission rate 56%), and lowest for people who required insulin to treat their diabetes before surgery (remission rate 16%). 
• At 12 years, there was a 91-92% lower risk of having new type 2 diabetes develop in patients who had had bariatric surgery, compared to the non surgery groups.

3.  Mortality rates:

At 12 years, mortality in people who had gastric bypass surgery was lower than those who wanted surgery but didn’t get it, but there no different between those who had gastric bypass surgery than those who didn’t want surgery in the first place, likely because the group not wanting surgery was healthier at baseline. There were 5 suicides in the group that had bariatric surgery, compared to 2 suicides in the non surgical group.  (see here and here and here for discussion of suicide risk after bariatric surgery ) 

Take home messages from this study:

• On average, weight loss is stable over the long term after gastric bypass surgery – though the results can be different for different people, and certainly lifelong dedication to permanent lifestyle changes are essential for continued success.

• Gastric bypass surgery can be a powerful tool to not only put diabetes into remission, but also to decrease the risk of developing diabetes later on.  Earlier intervention is better, because the longer a person has diabetes, the more tired their pancreas gets (ie decreased beta cell function, which are the cells that produce insulin), and a tired pancreas may be too tired to control blood sugars after bariatric surgery without help from medication.  Thus, considering bariatric surgery early in the course of diabetes, or even in the prediabetes phase, may have the most powerful impact.

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Could Antacid Medications Affect Blood Sugar Control in Diabetes?

Proton pump inhibitors (PPIs) are medications commonly prescribed to treat heartburn and peptic ulcer disease [eg omeprazole (Losec), pantoprazole (Pantoloc), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Pariet)].    Since PPIs work by blocking acid secretion in the stomach, and since a higher acid content of food lowers its glycemic index, I was asked whether PPIs could increase the effective glycemic index of a meal and thus have a negative impact on diabetes control.

It turns out that PPIs have a very interesting relationship with pancreatic function and blood sugars.

Firstly, as PPIs work by blocking acid secretion in the stomach,  PPIs do increase the pH in the stomach and very high up in the small intestine (proximal duodenum).  However, there is little to no effect on pH in the majority of the small intestine, where carbohydrates are absorbed.

PPIs raise serum levels of a hormone called gastrin, which is responsible for stimulating acid secretion in the stomach.  This is because the gastrin secreting cells in the stomach sense that acid production is low, so more gastrin gets cranked out in an attempt to increase acid secretion.

Interestingly, gastrin stimulates glucose-induced insulin secretion from the beta cells of the pancreas.  There is also some experimental evidence that gastrin may stimulate the production of new beta cells.   Further, PPIs slow emptying of the stomach, because less acid in the stomach means that it takes longer for solid food to be broken down and be ready to pass into the small intestine.

So, based on these mechanisms, it seems that PPIs could possibly have a benefit to blood sugar levels.  While the studies on this are still quite limited, the available evidence suggests that PPIs could lower A1C (a marker of diabetes control) by 0.5% to as much as 1% - possibly as much as a diabetes medication!

PPIs are medications that have benefits but also potential risks, including increased risk of gastrointestinal infections, malabsorption of important micronutrients like calcium, magnesium, vitamin B12, and iron, increased risk of fracture, changes in gut bacteria, and others (note this list is not exhaustive), and they should not be prescribed for the purpose of blood sugar control.

That being said, I will be watching blood sugar control with extra interest the next time one of my patients with diabetes is started on a PPI for their gastrointestinal issues.

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Testing Blood Sugar - Is There A Point?

In the management of people with diabetes, we routinely equip patients with glucose meters and ask them to check sugars at home.  While the importance and utility of checking sugars at home for people using insulin is clear, there is much debate about whether this is useful for people with type 2 diabetes who are not on insulin.  A recent study, which got a lot of media hype, tackled this question.

The study, published in JAMA Internal Medicine, randomized 450 people with type 2 diabetes and not using insulin, to either a) no home glucose montoring; b) checking sugars once daily; or c) checking sugars once daily plus automated educational/motivational messages delivered to the patient from the meter.

The researchers found that there was no difference in diabetes control (A1C) nor health related quality of life after 1 year, and concluded that glucose monitoring in people with non-insulin-treated type 2 diabetes should not be routine.

I have some major beefs with this conclusion:

1.   Testing once a day does not tell a person very much about their blood sugar.   In order for home testing to be useful, I advise 'paired meal testing': checking before a meal, and checking again 2 hours later.  This can be very helpful to see how certain types of food affect your blood sugar, and can be help to eat mindfully and manage portion control.  I don't necessarily advise doing this every day: checking each of breakfast, lunch, and dinner once per week can be enough.  However, depending on what kind of medication a person is taking, I may recommend more often.  Also, if diabetes control is not great, then checks (in my opinion) should be done more frequently so that we can figure out how to bring down the sugars effectively and safely.

2.  As the authors note, the study was not powered to determine if there are benefits to checking sugars around the time of medication or dose changes.  It is very difficult for a doctor to know what the next best medication may be without knowing the pattern of blood sugars through the day.  Knowing the pattern of blood sugars is extremely important when new medications are added onto sulfonylureas and insulin in particular, because these medications can cause low blood sugar.  For example, if sugars are highest in the morning and lower later in the day, there is a risk of causing low sugars if a treatment is added that brings down sugars in the morning (as sugars later in the day will go down too).

3.  Compliance with sugar checks in the study was poor by one year, declining gradually over the year, with only about 55% of people in the monitoring groups checking sugars each day by the 1 year mark.  Interestingly, the diabetes control (A1C) was better at 3, 6, and 9 months in the glucose monitoring groups, compared to those not monitoring - perhaps the lack of difference in A1C by 1 year was due to the poor compliance with glucose checks by that point in time.

4.  The study team did not engage with patients after their baseline visit - meaning patients were on their own to interpret their blood sugars without help from the study team.  Their family doctors received a copy of blood sugar results, but the study did not collect info on what was done with that data, and these clinicians had minimal interaction with the study team.  

Diabetes is a team sport - an important part of the benefit of checking blood sugars is to discuss these results with your health care team for help in optimizing control.  While the setup of this study was intended to be 'real world', I would submit that what patients perceived as their 'health care team' during the study (their usual doctors plus study investigators) were not working as a team and this may have limited the best possible use of home glucose monitoring.  And perhaps compliance with checking sugars in the study would have been better if that team was working together and more engaged with the patients, as is the ideal model of care.  We are blessed in Canada to be able to say that for most people in our country, the 'real world' does consist of free access to a team to help each individual with their diabetes care.

5.  For any patient on a sulfonylurea (and of course insulin), sugars must be checked before driving.   For a paper to conclude that glucose monitoring should not be routine (in a study where 36% of patients were on sulfonylurea!) is inappropriate.

Unfortunately, the media took hold of this study and has been shouting from the rooftops that people with non-insulin-requiring diabetes do not need to check their blood sugar.    I would be most saddened if patients get the message that they should stop testing their blood sugars, and would strongly advise people to continue to follow their doctor or diabetes educator's recommendations on how frequent of sugar checks is appropriate.

I hope this blog helps to provide some balance and perspective on what I feel is a study full of limitations.

Disclaimer: I have received speaking honoraria from makers of glucose meters.

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Low Carb Diets Part II: What If I Have Diabetes?

In last week's blog post, we talked about low carb diets, definitions, and whether they work for weight management.  Today we'll discuss low carb diets in people with diabetes: Are they beneficial? Are they safe?

As far as potential benefit goes, the available data are not consistent in their findings.  In a review article published by Feinman and colleagues in the journal Nutrition, data is summarized reporting an improvement in blood sugar control, along with a reduction in medications required to control blood sugars.  However, systematic reviews and meta analyses have not consistently shown improvements in blood sugar control.  At least some of the variability likely has to do with adherence - low carb diets are not easy to stick to for many people.

If a low carb diet is going to be embarked upon, the type of medication that a person with type 2 diabetes is taking to control blood sugars is very important to consider.   Medications that can cause low blood sugars [insulin; sulfonylureas such as gliclazide (Diamicron) and glyburide; and meglitinides (eg Gluconorm)] may need to be decreased with the help of your health care provider, in order to avoid low blood sugars.

SGLT2 inhibitors are a class of medications to treat type 2 diabetes, which are associated with a risk of 1 in 1000 people per year developing diabetic ketoacidosis (DKA), which is a type of acid buildup in the blood that is life threatening. For people on these medications [canagliflozin (Invokana), dapagliflozin (Forxiga), empagliflozin (Jardiance)], low carbohydrate diets are associated with an increased risk of DKA.  As to whether a mildly low carb diet is safe is not known, as there is very little data available in this area.  One small study did show an increase in ketones in people with type 2 diabetes on an SGLT2 inhibitor on just a very mildly restricted carbohydrate diet (40% calories, as compared to people on a 55% carb calorie diet), but how much this may increase the risk of DKA is not known.

A ketogenic diet should be avoided for anyone with type 2 diabetes on insulin or SGLT2 inhibitors, because of the risk of ketoacidosis.

For people with type 1 diabetes, there is very limited data on which to guide us.  There is some data suggesting that a low carb diet may improve hemoglobin A1C (a marker of blood sugar control).   However, there is a concern that there may be a blunted response to glucagon as an emergency treatment for severe low blood sugar in people with type 1 diabetes following a low carb diet.

A ketogenic diet should be avoided for anyone with type 1 diabetes due to the increased risk of ketoacidosis.

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Will Bariatric Surgery Help Me Control My Diabetes?

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

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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Bariatric Surgery - Can We Predict Remission Of Diabetes?

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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Marijuana and Diabetes Risk - Friend or Foe?

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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Diabetic Neuropathy

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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