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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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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Prevent Diabetes with Lifestyle: Study

An important study was published in November 14th's edition of the Lancet medical journal, which proves that diabetes can be prevented with lifestyle changes, and that this benefit can persist over the long term.

This study is called the Diabetes Prevention Program Outcome Study (DPPOS), and is a follow up to the landmark Diabetes Prevention Program initial study (DPP) that was published in 2002 in the New England Journal of Medicine.

The DPP was a study of over 3,000 prediabetics who were randomized to received either intensive lifestyle counseling, a diabetes medication called metformin, or placebo treatment, to see how effective these strategies were in preventing progression to full blown diabetes. The DPP trial was stopped prematurely, because the evidence for the superiority of the lifestyle intervention was already clear. After an average of 2.8 years, the lifestyle group had a 58% lower rate of development of diabetes than the placebo group, which was even better than the metformin treated group, who had a 31% lower rate of development of diabetes than placebo. Weight loss was also superior in the lifestyle group at 5.6kg, compared to 2.1kg in the metformin group, and 0.1kg in the placebo group.

In the DPPOS follow up study, all patients were offered lifestyle therapy, similar to the initial lifestyle group of the DPP, but in a less intense format. Placebo was stopped, and the metformin group continued their metformin.

During the 10 year follow up in the DPPOS, the original lifestyle group regained most of their weight, which may be related to the less intense nature of the DPPOS lifestyle program. Both the metformin and the original placebo groups lost a bit of weight (with the onset of the lifestyle program), but gained it back. As such, there was no significant difference in weight between the 3 groups at the end of the DPPOS.

However, despite there being no difference in weight, there continued to be a lower overall rate of onset of diabetes in the original lifestyle and metformin groups: they still had a 34% and 18% lower incidence of diabetes than the original placebo group, respectively. In other words, the original intensive lifestyle undertaken in the first 2.8 years of this study delayed diabetes onset by 4 years, and metformin delayed diabetes onset by 2 years.

Furthermore, although the diabetes incidence was highest in the placebo group overall, the rate of onset of diabetes in both the placebo and metformin groups fell to equal the rate of onset in the original lifestyle group, due to the institution of lifestyle therapy at the start of DPPOS. This points again towards the benefits of lifestyle in prevention of diabetes.

The bottom lines:

• Effectively changing your lifestyle in favor of healthy eating and increasing exercise is beneficial to prevent diabetes.

• The more intensive the support and counseling in making these changes, the more effective that program is to prevent diabetes.

• Even if an intensive support program is not feasible for the very long term, the benefits of diabetes prevention during the time of the intense program are still maintained over the long term!

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

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