Endocrine Society Recommends Against Testosterone Treatment in Women

There is a lot of conflicting information out there for women who seek answers about testosterone.  To answer many important questions around this issue, the Endocrine Society has recently released an updated Clinical Practice Guideline about testosterone treatment in women.


Key points in these guidelines:

1. They recommend against diagnosing 'testosterone deficiency' in women. 

Reason: The data out there is unclear as to whether low testosterone levels correlate with symptoms or not.  Also, it is normal for testosterone levels to decrease with reproductive aging.

2.  They recommend against treatment of women with testosterone.   The only exception to this is postmenopausal women who have been formally diagnosed with Hypoactive Sexual Desire Disorder (HSDD).   They specifically recommend against treating with testosterone for reason of: infertility; cognitive, cardiovascular, metabolic, or bone health; sexual dysfunction (other than HSDD); or general well being.

Reason:  It has not been proven that testosterone treatment is of clear benefit for uses other than in HSDD; government approved and monitored preparations of testosterone for women are not readily available; and, there is not evidence to prove long term safety of testosterone treatment.  Further, there is a concern that testosterone treatment could stimulate hormone responsive cancers to grow.

3.  They recommend against treatment of women with DHEA.

Reason: It has not been proven that DHEA treatment is of clear benefit; and, there is not evidence to prove long term safety.  This holds true for women with and without adrenal insufficiency.

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Are All Milks Created Equal?

Alternatives to cow’s milk are growing ever popular, due to aggressive marketing campaigns suggesting that these other milks may be healthier.  Many options are available, from goat to almond to soy to coconut, hemp, flax or oat.  Not only are a growing number of adults drinking these milks, but parents may choose to provide these milks to their kids because of a perceived health benefit. 

Because these alternative milks are not required to be vitamin D fortified (whereas it is mandatory that all cow’s milk in Canada is fortified with vitamin D), the concern has been raised as to whether Canadian kids who drink non-cow’s milk are getting enough vitamin D.     

A recent Canadian study looked at this question in children age 1-6, using the TARGet Kids research network in Toronto.   They found that kids who drank non-cow’s milk were almost three times more likely to have insufficient levels of vitamin D, compared to kids who drank cow’s milk.   (Remember that most Canadians do not get enough vitamin D naturally, because we live too far from the equator to get enough sun exposure to make vitamin D.  There are a few natural dietary sources of vitamin D, including salmon, trout, tuna, and egg yolks.)

In addition, research has suggested that we may not absorb dietary calcium as well from non-natural calcium sources, compared to calcium occurring naturally in food such as cow’s or goat's milk, other dairy products, and green leafy veggies like spinach and kale.  Alternative milks are often (but not always) fortified with calcium – in other words, calcium is not naturally occurring in these alternative milk products.  (Recommended intake of calcium from Health Canada can be found here, and more on my thoughts re dietary vs supplemental calcium here).

Another plus of cow’s milk (and goat’s milk) is that it contains about 9 grams of protein per cup, whereas many alternative milks contain only 1-3 grams of protein per cup.

So, it seems that the health benefits of protein and naturally occurring calcium put cow’s milk (or goat’s milk) on top as the healthier milk. 

We will likely see a growing number of alternative milk products containing vitamin D as the manufacturers catch on that this is important, and perhaps legislation will someday mandate fortification of alternative milks in addition to cow’s milk.  Until then, it’s important that Canadian kids who drink non-cow’s milk are getting adequate vitamin D through supplementation (read more about vitamin D needs at all ages from Health Canada here, and my summary from the 2010 Osteoporosis Canada guidelines regarding adults here).   

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Could Coffee Protect Your Liver?

Despite being one of the most commonly consumed beverages worldwide, the effects of coffee on our metabolism is surprisingly poorly understood.  (You can read about the controversial effects of coffee on blood sugars on my previous blog post here.)

Recently, there has been interest in understanding the effects of coffee on the liver.  Several studies have shown that liver enzyme tests are lower (which is good) with increasing coffee consumption ('inversely associated' in statistical terminology).  Some studies have suggested that coffee consumers have a decreased risk of having a fatty liver, liver cirrhosis (scarring), and even liver cancer.  An article from the American NHANES study has even suggested that people who drink 2 or more cups of coffee per day have half the risk of developing chronic liver disease, compared to those who drink less than 1 cup per day.

If coffee really is protective to the liver, an important question arises: is it caffeine that is protective, or something else in coffee?  This question was addressed in a recent study published in Hepatology, again utilizing the NHANES database.  They found that higher intake of coffee, regardless of whether it was caffeinated or decaffeinated, was associated with lower liver enzyme levels.  Components of coffee such as polyphenols, cafestol, and kahweol may be the protective elements, but no one really knows for sure.

While the findings of this study were consistent regardless of body weight or presence of diabetes, I would be interested to know what the non-coffee drinkers were drinking instead.  For example, if non coffee drinkers were consumers of Coca-Cola instead, could the soda be having a negative impact on the liver, rather than coffee having a positive impact?    More research is needed on many fronts before we will have a good understanding of exactly what is happening here.

Enjoying my java..... :)

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Myths and Misconceptions About Obesity

Some of the biggest barriers to successful management of obesity in our society are the myths and, frankly, garbage, that pervade popular culture, media, and even medical publications. Recently, Dr Chaput and colleagues reviewed both popular media and scientific journals to bring to light the Top 7 Misconceptions about obesity: 

1.  Obesity is primarily caused by a lack of physical activity or by unhealthy dietary habits. 

Clear scientific evidence has shown us repeatedly that the picture is FAR more complex than this.  Factors such as insufficient sleep, stress, environmental chemicals, and exposures during fetal life have evidence that is as compelling, if not more compelling, than the traditional concepts of eating the wrong foods and not exercising enough. 

2.  Obese individuals are less active than their normal weight counterparts. 

This is a particularly harmful myth, as it paints the picture that people with obesity are lazy, and creates a harsh platform for weight discrimination and bias.  Recent data from the Canadian Health Measures Survey, which used accelerometers to document physical activity, shows that youth with obesity have similar levels of physical activity as youth without obesity.  Canadians in general do not exercise enough, and we as a society would benefit from increased physical activity, regardless of body size. (read about Canada's physical activity guidelines here)

3.  Diets work in the long term. 

Studies have shown that almost all people who lose weight on a diet will regain it within the next 5 years, with the majority regaining it within the first year.  The harmful follow up myth from there is that people who regain weight do so because they lack willpower.  NOT. TRUE.  The truth of the matter is that our genetics have been developed evolutionarily to very powerfully defend body weight, as a survival strategy built over thousands of years of regular famine.  The problem is that now, in our society, there is only feast. 

4.  Weight loss does not have significant adverse effects. 

While weight loss certainly has a long list of health benefits, there are potential downsides as well.  Weight loss that is too fast increases the risk of gall stones.  Weight loss reduces energy expenditure, meaning that less calories are burned by basic metabolic functions in a day, thereby defending body weight and promoting weight regain.  Weight loss in some people can increase psychological stress and depressive symptoms.  Failed weight loss attempts or weight regain can also lead to issues with self esteem as well as body image issues.  

The message is still that weight loss in people with obesity is still most definitely a good thing for health, but these weight loss efforts need to be gradual, sustainable, and partnered with the support that each individual needs to make these efforts a long term success!


5.  Exercising is better than dieting to lose weight. 

Exercise alone has generally not been found to result in significant weight loss.  Think about it this way: if you exercised as hard as you could for 1 minute, you might burn 15 calories.  If you ate as fast as you could for 1 minute (picture a big milkshake), you can down 2,000 calories or more.  The reality is that because it takes so little food intake to make up for a long period of exercise, exercise alone doesn't usually work.  As I say to my patients: focus 90% on the food side of the equation, and 10% on the exercise. 

6.  Everyone can lose weight with enough willpower. 

Untrue.  Remember that each of is built differently, with very different genetics either working with us, or in most cases against us, to maintain a healthy body weight.  There are also many medical issues and medications that can make it exceptionally difficult to lose weight. 


7.  A successful obesity management program is measured by the amount of weight lost. 

Rather than focusing on the numbers on the scale, a successful obesity treatment program should be focused on the improvement in health.  With a permanent lifestyle change, did that person's quality of life improve?  Did their diabetes get better? Do their joints hurt less? Did their sleep apnea improve?  Does the individual just feel better? These are the bars by which a successful treatment program should be judged.  

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Is Eating Organic Really Better?

Aggressive marketing campaigns have many of us convinced that eating organic is healthier than conventional fare – to the point where sales of organic food in USA increased by over 7-fold between 1997 and 2010.  With organic food costing around twice as much as conventional food, we must ask – is there truly a health benefit to eating organic? 

First of all, let’s talk about what is meant by ‘organic’.  Organic certification requirements vary worldwide (a potential limitation in itself), but in general, organic foods are produced without synthetic pesticides or fertilizers, without irradiation or chemical food additives, and without the routine use of growth hormones or antibiotics.  Organic animals are fed organically produced food and are raised in an outdoor environment where they are free to move around. Also, genetically modified organisms (GMOs) are not used in organic food production. 

The question as to whether eating organic is healthier was addressed in a systematic review published in the Annals of Internal Medicine.  From 240 identified studies, the following key findings were noted:

1.  The differences in terms of nutrients in organic compared to standard fare are minimal. 

There is a slightly higher level of phosphorous in organic food, but this is not thought to make a difference in overall health, as phosphorous deficiency is only seen in states of near-total starvation.  There are also higher levels of beneficial fatty acids in organic milk and chicken, and a couple of other small nutrient differences of questionable significance.

2. There was no difference in allergic symptoms or outcomes (eczema, wheezing, etc). 

3. There was a 30% higher risk for pesticide contamination in conventional produce compared to organic, but the differences in risk for exceeding maximum allowed limits were small.  Two studies showed lower urine pesticide levels in children who ate organically. 

4. Overall, E coli contamination risk was no different in organic produce, but the results of individual studies was conflicting and the authors noted that more research needs to be done in this area.

5. In chicken and pork, the risk of exposure to antibiotic-resistant bacteria was higher in conventional meat compared to organic meat.  However, it’s not clear if this is of importance to human health, because it is inappropriate use of antibiotics in humans (not in the meat we eat) that is the major cause of antibiotic-resistant infections in humans. 

6. There are no long term studies on the effect of eating organically on human health. 

The authors conclude that eating organically does not seem to have a great health benefit… But who really knows?   Long term studies on human health would need to be done to know this answer for sure.  I agree that there is not convincing evidence at this time to say that eating organically has big health benefits – but this possibility has not been ruled out.  The definition of ‘organic’ is variable worldwide, and the first step to understanding the benefits of organic food would be to at least standardize how we define it. 

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Does Weight Loss Improve Fertility Treatment Outcomes?

Obesity is a known, and common, risk factor for infertility. Most studies have shown that women with obesity have markedly reduced success with fertility treatments (also called assisted reproductive technology, with examples include artificial insemination and in vitro fertilization).  The next natural question, then, is: does weight loss in these women before assisted reproduction improve pregnancy rates?

This question was addressed in a review article recently published in Obesity Reviews.  Overall, they found that the quality of the available data is weak, with few patients studied and few studies done.  They did find that the majority of the studies, which looked at a variety of means to achieve weight loss before assisted fertility techniques were undertaken, showed improved pregnancy and/or live birth rates.

It is sometimes asked whether a more drastic means of weight loss, such as the very low calorie diet (VLCD) or bariatric surgery is appropriate to improve fertility.   With regards to the VLCD, they found conflicting data the two studies that looked at it, with one study showing improved pregnancy rates, and the other showing particularly poor fertility outcomes.  This may be related to the fact that the successful study had a follow up (less stringent) diet after the VLCD was complete, whereas the other study gave no guidance after the very low calorie phase was complete. (my editorial comment – VLCDs are not recommended in any case – read more here).

They located two studies of women having bariatric surgery before assisted reproduction (note: only 6 patients total), with excellent results for improving pregnancy rates.  (Note that after bariatric surgery, it is important to wait 1-2 years before conceiving for safety reasons.)

Perhaps the most important findings that came from this review is that of six studies that evaluated whether anyone became spontaneously pregnant, five of the studies reported that pregnancies did occur without needing any reproductive treatments, in women who had previously been unable to conceive at a higher body weight.

So, based on current knowledge, it seems that weight loss is of benefit in women who struggle with excess body weight, both for improving spontaneous conception, and also for conception by assisted reproduction.

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Intestinal 'Condom' For Weight Loss?

Another interesting approach to less invasive obesity/metabolic surgery that is currently being studied is the duodenal-jejunal bypass liner.  This is a temporary 60-cm liner that is delivered into the upper part of the small intestine endoscopically (ie, by putting a camera and insertion equipment down through the mouth).  It is left in place for a number of months, and then removed.  It's sometimes referred to as the 'duodenal condom' in that... well, you can see the resemblance... but both ends are open to allow food to pass through.

The idea behind this is to mimic (in a shorter version) the intestinal component of the Roux-en-Y gastric bypass surgery, where the intestines are surgically rerouted to bypass about the first 150cm of small intestine.  We think (based on studies) that one of the major reasons why type 2 diabetes often improves dramatically after gastric bypass surgery is the hormone changes that happen when the intestine is rerouted in this fashion; therefore, there is a lot of interest in seeing whether the liner would have an effect not only on weight loss, but also on type 2 diabetes.

                                Gastric Bypass Surgery


A clinical trial was recently done on the liner, where 77 patients with type 2 diabetes and obesity were randomized to receive either the liner, or dietary counselling (control group).  After 6 months, patients who had the liner had greater weight loss, better diabetes control, and required less diabetes medication than the control group.

Patients then had the liners removed, and both groups were followed up for an additional 6 months after liner removal, with 66 patients completing the full study. There was some weight regain in the group who had previously had the liner, though at 1 year they still had greater weight loss than the control group.  At 1 year, there was no longer a difference in diabetes control between the groups.

In the short term, it appears that the liner is quite effective to help people lose weight and improve their type 2 diabetes control.  However, removal of the liner has to happen at some point, because the longer the liner is left in, the higher the risk that it can lose its hold and migrate further down the intestine, or cause bleeding or perforation (a hole in the intestinal wall), which are all serious complications.  So far, the liner has been shown to have a low risk of these complications after 6 months, and a few studies have now been published suggesting the risk is also low after 1 year.

The liner's current temporary nature is reminiscent of many of the 'diets' out there - they do nothing to help make permanent lifestyle changes, so after the diet (or the liner) is gone, the likelihood is that weight will be regained, along with its metabolic complications.  It would be interesting if the liner could be left in safely for a longer period of time - I'll be watching this area with interest, as the duration of study is growing.  In the meantime, while the liner's results look good in the short term, I'm not overly enthusiastic about an intervention if it is only temporary.

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Vagal Nerve Blockade for Weight Loss?

As severe obesity has proven so difficult to treat, much study is underway to try to find innovative treatment options.

The vagus nerve is thought to play an important role in the feeling of fullness (called 'satiety') and metabolism, so the question has arisen as to whether blocking this nerve could help to treat obesity.
An interesting study recently reported in the Journal of the American Medical Association (JAMA) was published, evaluating whether intermittent blockade of the vagus nerve would be effective to induce weight loss.

This study was a randomized, controlled trial of 239 patients with a Body Mass Index (BMI) between 35-45, where an electrical device was implanted to intermittently block the vagal nerve in half of the patients, and the other half had a 'sham' surgery (meaning they went through the implantation procedure, but the device was not hooked up to the vagus nerve).  All patients received lifestyle counseling.

They found that at 1 year, the vagal blockade patients lost a little more weight (3.2%) than the control group, but the vagal blockade group also had a higher risk of serious adverse events (8.6% vs none in the control group). Interestingly, the control group, with lifestyle counseling only, lost 6% of their body weight (compared to 9.2% in the vagal blockade group), showing that lifestyle counseling alone (plus a possible placebo effect of the sham surgery) can result in substantial weight loss.

So, based on this study, intermittent vagal nerve blockade doesn't seem like a promising option - weight loss benefits are minimal, and the rate of serious adverse events is concerning.

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Bariatric Surgery - More Long Term, High Quality Data Needed

Based on the available evidence, bariatric (obesity) surgery is effective to improve upon complications medical conditions related to obesity (such as type 2 diabetes and sleep apnea) and helpful for weight loss.  However, most of this data is based on shorter term results, and there is a concern regarding gaps in high-quality knowledge as to the benefits and risks of bariatric surgery over the long term.

In a recent literature review by Puzziferri and colleagues in Journal of the American Medical Association,  the current status of long term high quality data in bariatric surgery research was assessed.  They examined the literature to see just how much high quality longer term data is out there (defined as studies of 2 years or more, with follow up data on at least 80% of patients by the 2 year mark).

They found that only 29 studies total (less than 3% of studies identified) had 80% or more of patients followed up past the 2 year mark (7,971 patients total).  On analysis of available data in these studies, they found that the average excess weight loss was 66% for gastric bypass surgery, vs 45% for gastric band.  Type 2 diabetes remission rates (based on 6 studies) were 67% for gastric bypass, vs 29% for gastric band.  Remission of hypertension (high blood pressure, based on 3 studies) was 38% for gastric bypass and 17% for gastric banding. There wasn't enough data to analyze these parameters for sleeve gastrectomy.  No study had data past 5 years.  Concerningly, only half of the studies reported on complications at least 2 years after surgery.

So, while the existing high quality long term data is encouraging, we are still lacking in quantity of good quality data (clinical trials with low long term dropout rates) to have a thorough understanding of long term effects of bariatric surgery.  While we do have encouraging observational studies to guide us on longer term benefits vs risks of bariatric surgery (encouraging particularly for gastric bypass surgery and sleeve gastrectomy), randomized controlled clinical trials ideally need to be done and patients followed long term (with less dropouts) to have a more comprehensive understanding of long term effects.

The above being said - as discussed in a recent study by Courcoulas and colleagues, and as I can certainly attest to from my own research experiences - this is a tall order to fill.

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Do iWant the iWatch?

Big news in the technology world - the Apple Watch was unveiled for the first time, and it's expected to arrive on shelves in 2015.  Of the multitude of fascinating features, one aspect that is getting a lot of attention is the iWatch's ability to track physical activity and provide integrated fitness/activity apps to help guide your progress.   You may find yourself asking - is this something that iWant? that iNeed? Will iBenefit?? Can iTrust it??

While there are many fitness apps out there, here's what catches my attention: the iWatch can measure your heart rate, and your total body movements (via an accelerometer).  It also uses the GPS and wifi in your iPhone to track how far you've moved.  There's a little circular icon that fills up each day as you move - even letting you know how many minutes you have stood during the day.

Pretty nifty that you can now track your activity, heart rate, and personal info all together in one internet-linked system.  I also really like the encouraging nature of the movement icons filling up, with Apple's stated goal to be 'Sit less, move more, and get some exercise by completing each ring each day.'

There are rumblings as well that the iWatch will someday be able to check blood sugar without poking the skin.   (Currently, the closest a diabetic can get to this is with a continuous glucose monitor, which still requires that a sensor is worn under the skin, and it has to be calibrated against the standard finger-poke twice a day.  There is also a brand new technology just approved in Europe early this month, whereby a small round sensor is placed on the skin with a small filament that is inserted just under the skin; a reader is scanned over the sensor to get a glucose result. More on this on drsue.ca soon - stay tuned.)      As testing blood sugars can be painful and frustrating for my diabetic patients, this news not only got me sitting up, but also spiked my own heart rate to well over 100.

With real time, painless monitoring of these parameters, I get carried away into a dream land where patients could be monitored in second-to-second real time with internet data transmission to their family members, caregivers, or health care professionals anywhere in the world... do I dare to dream?? (editorial note: there are a number of established glucose monitor companies working on this for blood glucose monitoring, in various stages of development)

Before we get carried away, though, we need a lot of questions answered.  How have they validated their technology?  How accurate is their accelerometer? How accurate is the heart rate monitor?  Can the heart rate monitor pick up irregularities and notify the patient or caregiver?  If they are going to incorporate a blood glucose monitor, how will this be tested and validated for precision and accuracy?  I suspect these details and information will become available as the iWatch unfolds into the marketplace, but if we as people, patients, and health care professionals are going to trust the data, we need to know that the studies have been done to prove that it is worthy of our trust.

Definitely exciting, though - my eyes will be focussed on these interesting developments in health technology.

Thanks to Glenn for the heads' up, and to Anita Dobson for her input.

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Low Salt Intake - Good Or Bad For Your Heart Risk?

High blood pressure, called hypertension, is a major risk factor for cardiovascular disease.  Because we know that high salt intake is associated with a higher risk of having high blood pressure (especially in those who are genetically prone to hypertension, and those who carry other medical conditions that increase risk for hypertension such as obesity), huge efforts have been made around the world to try to get the general population to eat less salt.  Interestingly, recent studies have raised the question as to whether too little salt may be associated with higher heart risk as well.

This issue was addressed in a recent issue of the New England Journal of Medicine, with two studies (3 articles) and an accompanying editorial.

The first study, called the PURE study, looked at urine samples from over 100,000 adults in 18 countries, and found that 96% of people studied exceed the current US guidelines for sodium intake. They found that the relationship between blood pressure and salt intake was strongest in those with high salt intake.  They also found that people with both high and low sodium excretion had a higher risk of cardiovascular disease.

Interestingly, high salt intake was more strongly associated with high blood pressure in people with lower potassium intake, and there was a lower risk of cardiovascular events and death in people who had higher potassium intake.  These findings suggest that higher potassium diets might achieve better blood pressure reduction and cardiovascular protection than sodium reduction alone.

The second study, called the NUTRICODE study, looked at global salt intake based on surveys from 66 countries, analyzed data from 107 published clinical trials, and found a strong relationship between sodium intake and cardiovascular events.  They estimated that a whopping 1.65 million cardiovascular deaths in 2010 were attributable to excess sodium consumption.

So where does this leave us?   One major take home message is that 96% of people studied are eating more salt than what is recommended.  We know that excess salt intake is linked to increased risk of high blood pressure and heart disease, so for the vast majority of us, cutting back on our excess salt intake is needed.  There is much added salt in our food supply, especially in processed foods, so cutting back on manufactured food is one of many steps in the right direction!

Second, it appears that eating more potassium may be beneficial - BUT - there are many people in whom it could be dangerous to up potassium intake, such as patients with kidney problems.  There are also many medications (especially some blood pressure meds) that can increase potassium levels.  Too much potassium in the blood can be dangerous, so it is VERY important to discuss with your doctor before making any changes to your potassium intake.

As to whether low salt intake could increase the risk of heart disease - the question has definitely been raised by the above data.  The American Institute of Medicine has evaluated the data, and concluded that current data is not sufficient to make conclusions on this.  Now, we need a high quality clinical trial to give us a definitive answer to this provocative question.

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Diabetic Alert Dogs - Fact or Fiction?

Some dog-owning diabetics have reported that their dogs alert them to the fact that they are having a low blood sugar.  As such, there are a number of organizations out there that train dogs specifically to alert their owners to a hypoglycemic (low blood sugar) event.  So, does having a hypoglycemia alert dog actually work?

A recent study evaluated seventeen diabetics (age 5-66) who acquired trained hypo alert dogs.  Though the accuracy of the dog alerting the individual of a low blood sugar was variable, all 17 people reported reduced paramedic calls, decreased unconscious episodes, and an increase in independence compared to before they had the dog.  Pretty impressive!

People who have diabetes and require insulin, or are taking a type of diabetes medication called sulfonylureas, are at risk of low blood sugars.  Having a low blood sugar can be a very unpleasant feeling, and can be downright dangerous, as both the heart and the brain depend on sugar to function.  Older people with diabetes, people who have had diabetes for a decade or more, and people who have frequent low blood sugars, may not feel their low blood sugars.  Not feeling a low makes it even more dangerous, as people who not aware that they are low don't recognize the need to take steps to bring their sugars back up.  It is for these people that a hypo alert dog may be of particular benefit.

How could a dog know that a person is having a low blood sugar?  When a person is having a low blood sugar and doesn't know it, they may show symptoms of decreased blood sugar to the brain - for example, confusion, or a change in behavior.  The dog may be noticing and responding to this.  It has been suggested that there may be a scent released by the person with the low blood sugar that the dog may pick up, but this has not been proven.

Interestingly, even untrained dogs have been shown often to attract their owners' attention when the owner is having a low - to my knowledge, there is no research to study directly how a trained dog performs compared to an untrained dog.

Perhaps another reason to call a dog a wo/man's best friend!

PS thanks to Erin for the inspiration for this blog. :)

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Portion Distortion - Does Bowl Size Affect How Much Your Kids Eat?

We know that downsizing dinnerware can be helpful for weight loss in adults (see my randomized controlled clinical trial results here).  Do kids response to dishware cues in the same way adults do?

An interesting new pair of studies by Dr Wansink and colleagues, published in the Journal of Pediatrics, looks to answer that question.  In the first study, 69 preschoolers were enrolled in a trial where they were randomized to receive either a small (8oz) or large (16oz) cereal bowl, and asked how much cereal they wanted for a morning snack.  The kids given the larger bowl requested almost twice as much cereal than those presented with the smaller bowl (in parallel with the difference in the size between the two bowls).

In the second similar study, 18 school aged kids were given the 8oz bowl for breakfast on one day and the 16 oz bowl on another day, and asked how much cereal and milk they wanted for breakfast.  The kids consumed 52% more, and wasted 26% more (what they couldn’t eat), when served in the larger bowl.

These studies teach us that just like for adults, tableware size is important for helping to guide kids in terms of how much is appropriate to eat.  This doesn’t come as a surprise, given that portion sizes have increased by 300-400% compared to what they were three decades ago.  The increase in plate sizes is thought to be one contributor to this portion distortion - what used to be a dinnerplate is the millenium’s lunchplate, with a supersized dinner set present in many restaurants and homes.

We are looking at The Diet Plate ™’s Kids’ Plate right now in a clinical trial through the Alberta Children’s Hospital to see if these plates and bowls are helpful for kids who struggle with their weight – stay tuned for the results! 

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Exactly How Important is Obesity in Heart Attack and Stroke Risk?

It is well known that the risk of developing diabetes, high blood pressure, and high cholesterol is increased with overweight or obesity.  However, it's been long debated as to whether obesity itself increases the risk of heart attack and stroke (and if so, how important is this effect), or whether the risk conferred by excess body weight is strictly mediated by these risk factors.

A new study in the Lancet puts some numbers on these answers for us.  The study pooled data from 1.8 million people from almost 100 different studies globally, and they looked at what percentage of heart attack and stroke risk was attributable to blood sugar, blood pressure, cholesterol, vs overweight and obesity themselves.

They found that for every 5 kg/m2 increase in body mass index (you can calculate your own BMI here in the right hand column), the risk of heart disease went up by 27%, and the risk of stroke increased by 18%.  They found that only about half of the excess risk of heart disease with higher BMI was mediated by blood sugar, blood pressure and cholesterol, and about three quarters for the risk of stroke.

In other words, about half of the risk of heart disease, and about a quarter of the risk of stroke, appears to be mediated by excess body weight itself (and/or possibly unknown risk factors), independent of these other risk factors.

The take home messages here, as I see it, is that it is not enough to treat the blood sugar/pressure/cholesterol abnormalities in a person who carries excess body weight, nor is it enough to target weight management alone - all too often, we see these risk factors go untreated for years as individuals continue to try the lifestyle approach, unfortunately most often without success. These risk factors need to be proactively treated, in addition to a sound approach to permanent lifestyle changes that will facilitate weight management and improvement in these risk factors.

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Obesity and Hearing Loss in Women

Excuse me?  Didn't quite catch that.  Yes - it's correct that obesity and hearing loss are together in the title of this post, as it seems that obesity is an emerging risk factor for hearing impairment.

A recent study looked at over 68,000 women enrolled in the Nurses' Health Study between 1989 and 2009, and found that just over 11,000 cases of hearing impairment were reported.  They found that for women with a Body Mass Index of 40 or higher, there was a 25% increased risk of developing hearing impairment, compared to women with a BMI under 25.  A larger waist was also associated with a higher risk of hearing loss.

Interestingly, higher physical activity was associated with a lower risk of hearing impairment.

How can this be?  It is possible that in states of obesity or poorer metabolic health, some of the 'bad' or 'inflammatory' chemicals that are produced by the unhealthy metabolic fat that collects around our organs may damage the nerve cells in the ear.  In medical terms, this includes oxidative stress and the formation of reactive species.  Hardening of the arteries probably also plays a role - just like atherosclerosis manifests as narrowing of the arteries in the heart and brain, the small arterioles become hardened as well and can compromise blood supply to our hearing apparatus.

One more health concern to add to the list of possible concerns associated with carrying excess body weight.

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Hormone Treatments for Weight Loss?

In our toolbox of obesity treatments, there is very little available as far as medications go.  We know that there are many hormones involved in the the sensation of feeling full (called 'satiety'), so current research is now exploring these hormones, to see if they can ultimately be developed into obesity treatments.

My colleagues and I at the University of Copenhagen have just published one such study in the American Journal of Physiology.  We studied two hormones, GLP-1 and PYY3-36, both of which are hormones that are released when we eat, working to slow down our stomachs and tell our brains that we feel full.  We looked at intravenous infusions of these hormones, to try to understand how they may work together, and how they may affect a person's desire to eat when given in combination.

We found that when GLP-1 and PYY3-36 were given together, the inhibitory effect on food intake was synergistic - ie, more than then sum of each hormone individually.  We found that these hormones together elicited a decrease in a hunger hormone called ghrelin, as well as a slight increase in nausea (due to the stomach slowing effect), but in further analyses, we found that neither of these factors was responsible for the lower amount of food that participants elected to eat after the infusions were complete.

So, this study shows us that these two hormones in combination work together in some way to give us a sense of satiety or fullness, but exactly how they work together is not clear.  One small step forward in the big picture of understanding the complex web of hunger and fullness!

Follow me on twitter: @drsuepedersen

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A Different Kind of STAMPEDE

Obesity (bariatric) surgery has become accepted as an option for the treatment of type 2 diabetes by most diabetes guidelines around the world. The data on which these recommendations are based are from shorter studies, from weeks to months to up to 2 years. 

Now, in a landmark randomized controlled trial published in the New England Journal of Medicine, 3 year data shows us that the benefit of bariatric surgery to diabetes control is sustained out to at least 3 years.

The study, called the STAMPEDE study, randomized 150 people with type 2 diabetes, to receive either intensive medical treatment of diabetes alone (with a goal A1C of 6.0%), vs medical treatment plus gastric bypass surgery, vs medical treatment plus sleeve gastrectomy.

The study clearly shows that gastric bypass surgery and sleeve gastrectomy are superior to intensive medical therapy alone, to have control of type 2 diabetes at 3 years. Thirty-eight percent of patients who had gastric bypass surgery had tight control at 3 years, compared to 24% after sleeve gastrectomy, compared to only 5% receiving medical treatment alone. (The difference between the gastric bypass and sleeve groups was not statistically significant.)

With the above being said, I do take issue to how this study was structured, in that the goals for control of diabetes were too tight. We no longer recommend an A1C of 6.0% as a goal, as another landmark study (the ACCORD study) showed that control this tight was associated with an increased risk of death. It would be interesting to know how the numbers would have panned out if the commonly accepted A1C target of 7.0% was used instead.

However, the point of the article remains that gastric bypass and sleeve gastrectomy results in control of type 2 diabetes in significantly more patients than medical treatment alone. There is no doubt that Bariatric surgery is an important tool in our toolbox of diabetes therapy in the 21st century.

Follow me on twitter: @drsuepedersen

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Landmark Study Shows Physical Activity Decreases Heart Attack Risk

We have all heard before that physical activity is important for overall health.  Believe it or not, it is now for the first time that we have solid evidence to prove that being more active in daily life decreases the risk of cardiovascular events (eg heart attacks) in particular.

The study, recently published in Lancet, assessed pedometer data (recording # steps per day) in over 9,000 people with prediabetes from 40 countries around the world.  They examined how many steps per day each person took at the beginning of the study and again at 1 year, and then followed them up for an additional 6 years.  They found that:

• people who were more active at baseline (start of the study) had a lower risk of cardiovascular events
• people who became more active over the course of a year had a lower risk of cardiovascular events at 6 years
• for every 2,000 steps/day increase in activity over a year (about one mile or 1.6 km), there was an 8% decrease in cardiovascular events!

Prior to this study, the studies suggesting that being more active decreases the risk of cardiovascular events have been based on less rigorous data and study design.  Also, previous studies have generally been based on self reported data (ie the person in the study gauges how active they are), whereas this study objectively measured number of steps per day with pedometers.  For these reasons, this study is considered a landmark trial in that it has shown us, very objectively and in a high quality study design, that being active really does decrease heart risk in a group of high risk individuals.

See if you can find ways to take more steps in your day!

Follow me on twitter: @drsuepedersen

www.drsue.ca © 2014

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The Low Down on Electronic Cigarettes

For many Canadians (and Canadian doctors), e-cigarettes are an enigma wrapped in a mystery.  Though they are not regulated or approved for sale in Canada, they seem to be finding their way across the border in increasing quantities.  The Canadian Medical Association Journal published a couple of great articles about them in a recent issue to teach Canadian doctors what e-cigarettes are all about.   Here are some key points:


1.  What are e-cigarettes?

They are canisters shaped like cigarettes, which release vapor containing flavoring agents, other chemicals, and sometimes nicotine.  They are intended to simulate smoking without exposure to as many chemicals as tobacco.


2.  Are e-cigarettes safer than smoking regular cigarettes?

Hard to say.  Some studies show that e-cigarettes contain some impurities and carcinogens; also, the ones that contain nicotine still promote the nicotine dependence that keeps people addicted to smoking.  Even worse, smoking e-cigarettes could induce an addiction in someone who was previously a nonsmoker.

3.  Are e-cigarettes useful to help someone stop smoking?

Again, hard to say, as they have not been well studied. One randomized controlled clinical trial was not able to show superiority compared to nicotine patches. Contrast this with several other medication and behavioral approaches to smoking cessation which have been proven effective in clinical trials (the list is available here).  Also, I would add to this discussion that stopping the physical behavior of smoking is an important component of stopping smoking as a habit - in other words, the action of e-smoking may be too close to actual smoking to actually help a person to break the behavior.


A concern in the US is that e-cigarette companies are free to tempt American youth with fruit flavored e-cigarettes and celebrity endorsements, effectively resurrecting marketing campaigns that the tobacco industry used to use.  Thus, there is a fear that the e-cigarette industry could lure young people (or anyone for that matter) into nicotine addiction and possibly subsequent tobacco use.

So, while e-cigarettes may seem like a good idea on the surface, they have a dark side: those that contain nicotine propagate the addiction and may not effectively help people quit smoking; and even worse, they may lure non smokers into the dangerous world of smoking addiction.

Follow me on twitter: @drsuepedersen

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Could Cinnamon Be....Dangerous?

Cinnamon first came to my attention over a decade ago, when a randomized clinical trial was published suggesting that cinnamon improved blood sugars and cholesterol levels in people with type 2 diabetes.  Another randomized controlled trial confirmed the improvement in blood glucose as well.  However, the quantities used were quite large, up to 6 grams per day - imagine dumping that amount of powder on your cereal in the morning?!  Ick.

It turns out that taking in generous quantities of cinnamon may in fact be harmful - depending on what kind of cinnamon you consume.  The most common type of cinnamon sold is cassia cinnamon, which contains a natural but toxic component called coumarin, which has been associated with possible liver toxicity. This is contrasted with ceylon cinnamon, which is thought to contain little coumarin.

It actually doesn't take that much cinnamon to exceed the daily tolerable intake of coumarin - as little as a teaspoon (which is just under 3 grams) of cassia cinnamon per day may be too much.

This has lead to an outrage and heartbreak in Denmark, where the cinnamon bun or kanelsnegle (a staple Danish bakery product) has come under attack following the EU's recent moves to limit cinnamon consumption due to the risks noted above.

So, cinnamon is not a great treatment for patients with diabetes - cassia cinnamon must not be taken in the quantities needed to have an impact on blood sugars due to possible toxicity, and eating that amount of ceylon cinnamon every day just isn't practical.

Follow me on twitter: @drsuepedersen

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Should Sugar Be Removed From The FDA's 'Safe' List?

Sounds ridiculous, doesn't it - the notion that sugar, which was originally revolutionary in sustaining humankind, should now be considered unsafe (in excess).  There is in fact a longstanding strong outcry from public health advocates to the FDA to pull sugar from its 'generally regarded as safe' list, and a recent study adds to the data to tell us why.

The study, published by Yang and colleagues in JAMA Internal Medicine, examined data from the NHANES database to understand the relationship between added sugar consumption and risk of death from cardiovascular disease.

The study found that:

• The risk of death from cardiovascular disease (CVD) starts to rise when intake of added sugar makes up over 15% of total daily calorie intake. (15% of daily calories in a 2,000 calorie diet is equivalent to a 600mL bottle of pop)
• People who consume 1/3 or more of their daily calories as added sugar are at a 4 times increased risk of death from CVD. (According to the study, about 10% of Americans were consuming this amount)
• Drinking one 355 mL can of soda per day increases the risk of CVD death by almost one third, independent of total calories consumed and other cofactors.
• These findings were largely consistent, regardless of body weight, age, or physical activity levels.

As the excellent accompanying editorial by Laura Schmidt, PhD, notes:

"Physicians may want to caution patients that, to

support cardiovascular health, it is safest to consume less than

15% of their daily calories as added sugar."

The authors are picking on soda and other sugar sweetened beverages in particular for good reason - these beverage constitute 37% of the total added sugar intake in the American diet.  So, without a doubt, beverage consumption is the first place to look for an easy place to cut back on unneeded extra sugar.

Follow me on twitter: @drsuepedersen

www.drsue.ca © 2014

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