tag:blogger.com,1999:blog-14998009082163496632024-02-19T18:50:33.813-07:00ResearchDr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comBlogger183125tag:blogger.com,1999:blog-1499800908216349663.post-80443174869937306422018-09-01T05:58:00.002-06:002018-09-01T06:06:37.823-06:00Obesity Medication Lorcaserin Neutral For Cardiovascular Events<div dir="ltr" style="text-align: left;" trbidi="on">
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Lorcaserin (trade name Belviq) is an obesity medication that is not available in Canada, but is used in USA and other countries as a treatment of obesity. A recent study evaluated the cardiovascular safety of lorcaserin in people with obesity or overweight, with either established cardiovascular (CV) disease, or multiple cardiovascular risk factors but without established CV disease. (skip to <u style="font-weight: bold;">BOTTOM LINE</u> below as to why this study is important)<br />
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In the study, <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1808721" target="_blank">published</a> in the <i>New England Journal of Medicine</i>, 12,000 people were randomized to receive either lorcaserin or placebo for a median of 3.3 years. Seventy-five percent of participants had established cardiovascular disease. At one year, people on lorcaserin lost -4.2kg, compared to -1.4kg in the placebo group. At 3.3 years, there was no difference in the rate of cardiovascular events (a composite of cardiovascular death + nonfatal heart attack + nonfatal stroke) between groups, at 2.0% per year on lorcaserin vs 2.1% per year on placebo.<br />
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In people who had diabetes at the start of the study (57% of the total population), diabetes control was improved slightly at 1 year (-0.3% greater reduction in A1C than placebo). Amongst those with prediabetes at the start, the proportion of people on lorcaserin who went on to develop type 2 diabetes was slightly lower (3.1% per year) than those on placebo (3.8% per year).<br />
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The rate of discontinuation of study medication was similar between the two groups, at 12.0% per year in the lorcaserin group vs 12.7% in the placebo group. In the lorcaserin group, the most common side effects leading to stopping treatment were known potential side effects of dizziness, fatigue, headache, diarrhea, and nausea.<br />
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Echocardiogram (heart ultrasound) was performed in a subset of 3270 study participants, because an related obesity medication previously available (fentermine-phenfluramine or Fen-Phen) was found to have an adverse effect on heart valves. After a year of treatment, they found no statistically significant difference in heart valve problems between the two groups, with 23 cases of new onset, mild aortic valve insufficiency on lorcaserin vs 15 on placebo, and 13 cases of pulmonary hypertension on lorcaserin vs 8 on placebo.<br />
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So what's the <b><u>BOTTOM LINE</u></b>? This is the first time that the cardiovascular safety of an obesity medication has been rigorously tested and proven to be safe. Some previously available obesity medications have been pulled from most markets due to safety concerns (eg <a href="https://www.nejm.org/doi/pdf/10.1056/NEJMoa1003114" target="_blank">sibutramine</a> due to increased cardiovascular events in people with CV disease, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60935-X/abstract" target="_blank">rimonabant</a> due to psychiatric side effects).<br />
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Regarding the three currently available obesity medications in Canada:<br />
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<li>Orlistat (Xenical) has not been tested in this fashion </li>
<li>Liraglutide as a diabetes treatment (Victoza 1.8mg) <a href="http://drsuetalks.blogspot.com/2016/06/diabetes-medication-liraglutide-saves.html" target="_blank">has been shown to reduce cardiovascular events and death in people with type 2 diabetes</a>. Though liraglutide as an obesity treatment (Saxenda 3.0mg) has not been specifically studied for CV safety, these data are accepted by regulatory agencies as reassurance for CV safety in the lower risk population of people with obesity without diabetes</li>
<li><a href="http://drsuetalks.blogspot.com/2018/02/new-obesity-medication-approved-in.html" target="_blank">Naltrexone/bupropion (Contrave)</a> had a study started but stopped part way through because of a release of interim results that was felt to compromise the integrity of the study. A new trial is now in the planning stages. </li>
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Looking very forward to more safety outcome data in this area.<br />
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<i>Disclaimer: </i><i style="background-color: white; caret-color: rgb(50, 82, 122); color: #32527a; font-family: Verdana, sans-serif; line-height: 19.7119998931885px; margin: 0px; padding: 0px;">I receive honoraria as a continuing medical education speaker and consultant from the makers of liraglutide (Novo Nordisk) and naltrexone/bupropion (Valeant).</i><br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-35667655784357165922018-08-19T05:59:00.001-06:002018-08-19T08:49:44.490-06:00Unprecedented Weight Loss With Semaglutide<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="http://drsuetalks.blogspot.com/2018/01/semaglutide-new-diabetes-medication.html" target="_blank">Semaglutide</a> is a medication that is used to treat type 2 diabetes (trade name Ozempic). Not only does it <a href="https://diabetes.medicinematters.com/semaglutide/type-2-diabetes/a-quick-guide-to-the-sustain-trials/12206922" target="_blank">improve blood sugars more than any other medication that it has been compared to (so far) in the diabetes world</a>, but it is also very effective to help with weight loss. Thus, semaglutide is currently under study as a medication to treat obesity in people without diabetes.<br />
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We have now completed the first study of semaglutide as an obesity treatment. The study, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31773-2/fulltext" target="_blank">published</a> in <i>The Lancet, </i>in which I was an investigator and also an author of this paper, randomized 957 people to receive various doses of once daily semaglutide, with liraglutide 3mg and placebo as controls. (Liraglutide 3mg is also called <a href="http://drsuetalks.blogspot.com/2015/03/health-canada-approves-new-obesity.html" target="_blank">Saxenda</a>, which is a medication already in use for treatment of obesity.)<br />
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At 1 year, 93% of patients were retained in the trial, which is much better than most studies of weight loss medication, which tend to have much less follow up data. Overall, 81% of patients completed the full year of treatment. A higher percent of the placebo group (24%) stopped treatment than did those on semaglutide (18%).<br />
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The weight loss after one year on semaglutide was impressive, ranging from -6.0% weight loss on the lowest tested dose of semaglutide (0.05mg per day) to an impressive -13.8% weight loss on the highest dose tested (0.4mg per day), compared to -2.3% weight loss on placebo and -7.8% on liraglutide 3mg per day.<br />
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The weight loss had not plateaued by one year on the highest doses of semaglutide, suggesting that if the study had been longer than a year, even more weight loss may have been seen.<br />
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In terms of side effects, gastrointestinal were most common (e.g. nausea), in keeping with what we already know about this class of medication; these side effects increased with higher doses of semaglutide, and were a little higher on the highest semaglutide dose than on liraglutide 3mg. There was also a higher risk of gallbladder side effects (e.g. gallstones), which was a little more common on the highest dose of semaglutide compared to placebo.<br />
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The weight loss seen in this study is more than has been seen with any other existing weight loss medication. The next phase of studies of semaglutide for weight loss is underway.<br />
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<i style="background-color: white; color: #32527a; font-family: verdana, sans-serif; line-height: 19.7119998931885px; margin: 0px; padding: 0px;">Disclaimer: I was a principal investigator in this research trial and an author of the paper discussed. I am/have been involved in other trials of semaglutide and liraglutide as an obesity treatment. I receive honoraria as a continuing medical education speaker and consultant from the makers of semaglutide and liraglutide (Novo Nordisk). </i><br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-52861315518246808392018-08-01T06:10:00.001-06:002018-08-01T06:10:37.091-06:00Could Intermittent Fasting Benefit Our Metabolism?<div dir="ltr" style="text-align: left;" trbidi="on">
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(this figure is from the study discussed below)</div>
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Intermittent fasting (IF) is a popular dietary strategy these days amongst people who are looking to shed pounds. While I<a href="http://drsuetalks.blogspot.ca/2017/05/does-intermittent-fasting-work.html" target="_blank">F has not been shown to be any better than daily calorie restriction for weight loss,</a> many have speculated that IF may improve cardiometabolic health, with conflicting data as to whether this is actually the case. <br />
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A new study suggests that IF at the right <i>time</i> of day may actually improve metabolic health.<br />
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<a href="https://www.ncbi.nlm.nih.gov/pubmed/29754952" target="_blank">The study</a> was small but elegant - 8 men with pre diabetes, who were assigned to intermittently fast using a new technique called 'time restricted feeding' by eating during only 6 hours per day (with dinner before 3pm), or to eat over a more typical 12 hour period each day. They followed this eating pattern for 5 weeks, and later crossed over to the opposite eating assignment for another 5 weeks.<br />
All meals were supervised, and were geared towards keeping body weight the same (i.e. this was not a weight loss study).<br />
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They found that eating only 6 hours per day resulted in improved insulin sensitivity, blood pressure, appetite, and markers of oxidative stress.<br />
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How does this work? Well, there is a hypothesis that after 12 hours or more without food, our bodies flip a 'metabolic switch' of sorts, turning to fat as a fuel source once liver glycogen (sugar) stores have run out (there is an interesting <a href="https://www.ncbi.nlm.nih.gov/pubmed/29086496" target="_blank">review from the journal <i>Obesity</i></a> on this).<br />
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Interestingly, the time of day when food is eaten seems to be important - while this study showed a metabolic benefit to restricting food intake to 6 hours earlier in the day, other studies restricting food intake to the late afternoon or evening have shown either no benefit or <i>worsening</i> of metabolic parameters (these studies are referenced in <a href="https://www.ncbi.nlm.nih.gov/pubmed/29754952" target="_blank">the article</a>). This may be because eating earlier in the day fits better with our circadian rhythm of hormones, as our insulin sensitivity, and also the calories we burn while digesting food are higher in the morning.<br />
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We often recommend: "Eat breakfast like a king, lunch like a prince, and dinner like a pauper." While this principle was founded on the idea of avoiding overeating in the evening due to not eating enough during the day, it seems that there may be a physiologic basis for eating earlier in the day to promote metabolic health.<br />
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Perhaps our new slogan should be: Eat breakfast like a king, lunch like a prince... and have your dinner early.<br />
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Stay tuned to www.drsue.ca for discussion of a brand new study on intermittent fasting in people with type 2 diabetes, coming soon!<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-73585102426342266732018-07-14T05:41:00.003-06:002018-07-14T05:41:21.155-06:00Should Fertility Clinics Deny Treatment To Women With Obesity?<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="http://drsuetalks.blogspot.com/2018/07/fertility-care-for-women-with-obesity.html" target="_blank">As blogged previously</a>, due to concerns about poor clinical outcomes and maternal/fetal risks, many fertility clinics in Canada impose an upper body mass index (BMI) cutoff of about 35-40 kg/m2, above which they will not offer fertility treatments. Is this the right thing to do?<br />
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The new <a href="https://www.jogc.com/article/S1701-2163(18)30369-4/abstract" target="_blank">Canadian Clinical Practice Guideline for the delivery of fertility care to women with obesity</a> reviews the evidence on this very controversial topic.<br />
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Based on survey studies of fertility clinics, whether a BMI cutoff is used, and what BMI cutoff is used if so, is highly variable and not based on any specific or clear evidence. Most clinics that have an upper BMI cutoff beyond which they will not offer fertility treatments cite anesthesia risk as the main reason for the cutoff.<br />
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Not only are BMI cutoffs arbitrary and without consensus, getting below the BMI cutoff goals may be very difficult for many women with obesity to achieve. Furthermore, one study suggested that over half of the fertility clinics with a BMI cutoff did not offer any weight loss instructions or guidance to their patients - sounds to me like telling a person to row a boat but not showing them how to use the oars.<br />
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Denying fertility care to women with obesity is highly stigmatizing and discriminatory, and can worsen feelings of low self esteem, social isolation, anxiety, and depression. Denying older women fertility care until they have lost weight may cost them valuable time and any chance of pregnancy.<br />
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There is no doubt that there are risks of obesity to both the mother and the unborn child, and weight loss should be encouraged and supported. However, as the guidelines point out, the risk of obstetrical obesity-related complications does not clearly exceed the risk of complications with other pre-existing medical conditions like hypertension, diabetes, or epilepsy. In addition, <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/27242175/?i=2&from=sharma-a%20fertility%20obesity" target="_blank">obesity related health status is a better predictor of pregnancy with fertility treatment than BMI,</a> and also a better predictor of overall health outcomes in general, so why is there so much focus on the numbers on the scale in the first place?<br />
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As the Guideline states:<br />
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<i>In the absence of simple, safe, and effective strategies that reliably help patients with obesity lose weight in a timely fashion, it is difficult to advocate for a universal BMI cut-off in place of careful counselling, screening for metabolic abnormalities and informed consent. </i><br />
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<i>Programs that impose BMI cut-offs should offer resources for patients to help them lose weight, and should inform patients about both the risks and benefits of delaying fertility treatment.</i><br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-39336589733679273102018-07-07T12:40:00.000-06:002018-07-07T12:40:01.887-06:00Fertility Care For Women With Obesity<div dir="ltr" style="text-align: left;" trbidi="on">
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Obesity has a profound impact on reproductive health from many perspectives. We now have a brand new Canadian Clinical Practice Guideline which provides us evidence based recommendations for fertility care for women with obesity.<br />
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<a href="https://www.jogc.com/article/S1701-2163(18)30369-4/abstract" target="_blank">The Guideline, published</a> in the <i>Journal of Obstetrics and Gynecology of Canada</i>, provides 21 key recommendations that answer the following questions (highlights discussed here - please see the full article for details):<br />
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<b><u>What is the impact of obesity on female fertility?</u></b><br />
<b><u><br /></u></b>Women with obesity have a risk of infertility due to a lack of ovulation that is more than twice that of women without obesity. Even if ovulating, the physiologic ability to reproduce is still reduced.<br />
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<b><u>What is the impact of obesity on MALE fertility?</u></b><br />
<b><u><br /></u></b>While men with obesity have lower testosterone levels, it is unclear whether obesity has an impact on sperm quality and semen parameters. Men with obesity do have a higher risk of erectile dysfunction, which may be improved with weight loss.<br />
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<b><u>What is the impact of female obesity on fertility treatments?</u></b><br />
<b><u><br /></u></b>There is a lower oocyte (egg) yield with IVF. Implantation, pregnancy and live birth rates decline with increasing severity of obesity. Live birth rates decline by 0.3-0.4% for every 1 increase in BMI over 25 kg/m2.<br />
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<b><u>What is the impact of obesity on mum's health risk in pregnancy?</u></b><br />
<b><u><br /></u></b>There is an increased risk of gestational diabetes, high blood pressure, prolonged labor, need for instrument assistance for delivery, shoulder dystocia, and C-section. These risk increase with higher BMI.<br />
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<b><u>What is the impact of obesity on baby's risk during pregnancy?</u></b><br />
<b><u><br /></u></b>The risk of having a large baby or a baby with a congenital abnormality is increased.<br />
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<b><u>What screening tests are appropriate for women with obesity seeking fertility care?</u></b><br />
<b><u><br /></u></b>Screening should include testing for diabetes, cholesterol levels, high blood pressure, cardiovascular disease, breast cancer, and endometrial cancer. These screenings should be done before starting fertility treatment.<br />
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<b><u>What are the most effective treatments to help infertile women with obesity lose weight?</u></b><br />
<b><u><br /></u></b>Modest weight reductions (5-10%) improve metabolic risk. Help should be offered for lifestyle modifications. Medications to treat obesity, or bariatric surgery, should be considered for those who do not have success with lifestyle changes.<br />
<i><br /></i>Women in their late reproductive years who have had bariatric surgery should be advised that the possible benefits of waiting for 1-2 years after surgery to conceive should be balanced against the decline in fertility related to advancing age.<i> </i><br />
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Bariatric surgery lowers the risk for large babies, gestational diabetes and hypertension, but increases risk for small babies.<br />
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<b><u>Is there data demonstrating a difference in fertility outcomes for women who lose weight before pregnancy, compared to women who proceed directly to fertility treatment?</u></b><br />
<b><u><br /></u></b>Yes - weight loss improves spontaneous fertility rates.<br />
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<b><u>Should there be a national BMI cutoff for access to fertility care?</u></b><br />
<b><u><br /></u></b>In Canada and around the world, concerns about poor clinical outcomes and maternal/fetal risks have resulted in many fertility clinic medical directors imposing an upper BMI cutoff to their program, above which they will not offer fertility treatments. Stay tuned on this one - I am going to dedicate a whole blog post to discuss this very important and hotly debated topic.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-80892764292284253942018-03-24T08:08:00.001-06:002018-03-25T07:53:29.450-06:00How Weight Loss Affects Different Body Tissues, Fat Genes, And Inflammation<div dir="ltr" style="text-align: left;" trbidi="on">
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(this is fat tissue under a microscope)</div>
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We know that a 5-10% weight loss improves many health conditions associated with obesity. However, it is very interesting to note that some health issues like blood sugar starts to improve with as little as 2-3% weight loss, whereas other health issues like sleep apnea require closer to 10% weight loss before we start to see improvements. Why is this?<br />
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An eloquent <a href="https://www.ncbi.nlm.nih.gov/pubmed/26916363">study</a> helps us to understand how different tissues in our body respond to weight loss. This was a randomized controlled clinical trial, assigning 40 patients to a target 0%, 5%, 10%, or 15% weight loss, and then conducted an array of testing to understand the metabolic changes that occur at each of these degrees of weight loss. Testing was extensive and included assessment of body composition, 24h blood pressure monitors, blood testing for metabolic parameters and inflammatory markers, tests of organ-specific insulin sensitivity, and even biopsies of fat tissue. Participants were weight stable for at least 3 weeks before testing was conducted.<br />
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Key findings were truly fascinating.<br />
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After a 5% percent weight loss:<br />
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<li>There was a decrease blood sugar, insulin levels, triglycerides, ALT (liver test)</li>
<li>systolic blood pressure decreased (the top number), but not diastolic (bottom number)</li>
<li>NO effect on good cholesterol (HDL), bad cholesterol (LDL), glucose tolerance test (OGTT)</li>
<li>improvement in insulin sensitivity in fat, liver, skeletal muscle </li>
<li>improvement in beta cell function (the cells in the pancreas that make insulin)</li>
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After 11% weight loss: (the 10% group ended up losing 11%)</div>
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<li>continued reduction in insulin and triglycerides </li>
<li>altered gene expression in subcutaneous fat tissue - including genes involved in fat synthesis, cholesterol flux, and inflammation</li>
<li>no additional benefit to insulin sensitivity in fat tissue or liver</li>
<li>additional improvement in insulin sensitivity in skeletal muscle</li>
<li>additional improvement in beta cell function</li>
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After 16% weight loss: (the 15% group ended up losing 16%)</div>
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<li>reduction in inflammatory markers (plasma free fatty acids, CRP)</li>
<li>more marked altered gene expression in subcutaneous fat tissue - including genes involved in fat synthesis, cholesterol flux, and inflammation</li>
<li>continued reduction in insulin and triglycerides</li>
<li>no additional benefit to insulin sensitivity in fat tissue or liver</li>
<li>additional improvement in insulin sensitivity in skeletal muscle</li>
<li>additional improvement in beta cell function</li>
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So what is the BOTTOM LINE from this (rather complicated) study? </div>
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1. A 5% weight loss has important benefits to our health, primarily related to a decrease in our body's resistance to insulin. </div>
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2. Further weight loss continues to improve our body's insulin resistance (particularly in muscle), with additional improvements in our metabolic health. </div>
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3. At 11% weight loss, we start to see changes in how our fat tissue expresses genes, in favour of better health.<br />
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4. At 16% weight loss, there is a decrease in inflammation in our bodies, and a more marked change in fat tissue gene expression.<br />
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While a smaller degree of weight loss (even just 2-3% based on other studies) has a very important impact on our metabolic health, the changes in inflammation and fat gene expression seen at over 10% weight loss may well be what it takes to see benefits in other medical conditions associated with obesity, such as obstructive sleep apnea and arthritis.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-41375992963094358992018-03-18T06:53:00.002-06:002018-03-18T06:56:01.614-06:00How Your Diet Influences Where You Lose Fat<div dir="ltr" style="text-align: left;" trbidi="on">
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In weight management, our goal is to improve overall health. In a perfect world, it would be preferable if we could melt away the fat around and inside the internal organs (called 'visceral fat') rather than the fat under the skin, as it is this visceral fat that contributes most to health complications of obesity such as diabetes, high blood pressure, and metabolic syndrome. <br />
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A recent study suggests that what we eat actually can help us to target this visceral fat.<br />
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The CENTRAL study, <a href="http://circ.ahajournals.org/content/137/11/1143" target="_blank">published</a> in the journal <i>Circulation, </i>randomized 278 sedentary adults with either abdominal obesity or high cholesterol to follow either the Mediterranean diet versus a low fat diet for 18 months. Six months into the trial, participants were also randomized to follow an exercise program or not. They used MRI scans to evaluate fat under the skin, fat around the organs, fat in the liver, pancreas, and even around the heart.<br />
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At the end of the 18 month study, weight loss was the same between all four groups (Mediterranean vs low fat diets, with or without exercise) at -3.2%. However, <i>where </i>fat was lost from, and how this influenced health, was different between groups:<br />
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<li>People on the Mediterranean diet lost more fat from the liver, pancreas, and around the heart. </li>
<li>Exercise with either diet had a greater effect on reducing visceral fat. </li>
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Whether or not total body weight was lost: </div>
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<li>Losing visceral fat and/or liver fat improved cholesterol.</li>
<li>Losing fat deep under the skin improved insulin sensitivity.</li>
<li>Losing fat just under the skin had no effect on health and reduced levels of leptin (a hormone that tells our brains that we feel full). </li>
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The findings that the Mediterranean diet preferentially reduces the more dangerous visceral fat may explain why it is the only diet that has been convincingly found to <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1200303" target="_blank">prevent cardiovascular events</a>. </div>
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These results also show us that it's not about numbers on the scale, as this does not reflect the important changes going on with fat deposit patterns inside. </div>
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-19701605036109500912018-03-11T06:32:00.000-06:002018-03-11T06:32:26.584-06:00Why Short Term Weight Gain Can Be Easier to Lose Than Long Term Weight<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="mso-ansi-language: EN-US;">No weight gained is easy to lose, but - have you ever wonder how Hollywood's actors can gain weight for a movie role, and the next thing you know, they are back at their usual weight for their next photo shoot? </span>While one may think that it’s simply the superstar access to personal chefs and trainers that gets actors back in shape, there is actually a physiologic basis that can make it less difficult to shed a quick/temporary/intentional weight gain than excess weight that has been present for the long term.</div>
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<span style="mso-ansi-language: EN-US;">As discussed in a recent <a href="https://academic.oup.com/edrv/article/38/4/267/3892397" target="_blank">Scientific Statement on Obesity Pathogenesis</a> by the Endocrine Society, obesity is associated with inflammation in various tissues, including muscle, fat tissue, vascular system, and liver, and this inflammation appears to be a consequence of chronic obesity. </span>There is also inflammation in the hunger/fullness centre of the brain, called the hypothalamus.<br />
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For a person who has been struggling with weight long term, inflammation in these tissues causes maladaptive changes in those tissues that make them more resistant to weight loss. It takes time for this inflammation to develop, so for a person who has had a fairly acute weight gain, it may be easier to drop pounds because they don't have this inflammation working against them.<br />
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So then you may wonder - why do some people seem to lose quickly gained weight more easily than others? (e.g. after pregnancy)?<br />
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Well, the story of the hunger/fullness centre in the brain is a little more complex. It turns out that this inflammation may not only be a consequence of long term obesity, but may actually be present in some people <i>before</i> obesity develops.<span style="mso-spacerun: yes;"> </span><span style="mso-ansi-language: EN-US;"> </span>Some animal studies suggest that eating a high fat diet triggers these inflammatory changes, damaging the neurons in the hypothalamus, which may then result in a disruption of sensations of hunger/fullness, lead to weight gain, plus make it harder to lose it again.<br />
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In other words, people who struggle to lose weight after a fairly quick/new weight gain may have inflammation in their hunger/fullness centre that was there before the weight gain, thus making them not only more prone to weight gain, but also making it harder to lose weight than the person without the inflammation. </div>
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-50504813710377808902018-02-25T06:26:00.002-07:002018-02-25T06:26:30.322-07:00How Do Our Gut Bacteria Contribute To Obesity... And Can We Treat Them? <div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="http://drsuetalks.blogspot.ca/2015/04/gut-bugs-and-obesity.html" target="_blank">As blogged previously,</a> we are learning that the bacteria we carry in our intestines (called the gut microbiota) have a role in obesity. While we still seem to have more questions than answers on this topic, a fascinating review was just <a href="https://www.ncbi.nlm.nih.gov/pubmed/29363272" target="_blank">published,</a> discussing some very interesting perspectives on this topic. Here are some key points:<br />
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<b><u>1. We know there is an association between certain types of gut bacteria and obesity. </u></b> However, which is the 'chicken' and which is the 'egg', so to speak, is not clear, and the answer may be both. In other words, there is evidence that certain types of gut bacteria contribute to the development of obesity, while others are protective. There is also evidence that developing obesity can change the gut bacteria in favour of those that further contribute to obesity.<br />
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<b><u><br /></u></b><b><u>2. Several ways that gut bacteria can contribute to obesity</u></b> are identified:<br />
<ul style="text-align: left;">
<li>some gut bugs are better at helping us extract calories from food by fermenting otherwise indigestible fibers</li>
<li>gut bacteria can influence permeability (leakiness) of the gut lining, allowing bacterial products into the bloodstream that can trigger an obesity-promoting low grade inflammatory response </li>
<li>short chain fatty acids produced by gut bugs may have an effect on the gut's barrier function, as well as inflammation and appetite</li>
<li>(particularly fascinating in my opinion:) gut bacteria can have an impact on the genes we express in the hunger/fullness center in the hypothalamus in our brains through effects on inflammation and nerve signalling. </li>
</ul>
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<b><u>3. Can we treat obesity by changing our gut bacteria?</u></b><br />
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Knowing that some types of gut bacteria contribute to the development of obesity, the next natural question then is whether we can treat obesity by changing gut bacteria.<br />
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There is preliminary evidence that some strains of bacteria, provided as probiotic supplements, may be of benefit in weight management, but there is still much to learn in this area. There is also a lack of regulation in the supplement industry and a huge variation in what different probiotic supplements provide, so it can be hard to know what you're getting. Some studies suggest that some fibres with prebiotic like effects may be beneficial as well.<br />
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Interestingly, metformin, which is an antidiabetic medication, has been shown to alter gut bugs in rodent studies in favour of a gut bacteria that is associated with less adiposity. (While metformin is considered to be weight neutral, some people do lose weight with it.) Also, metformin loses efficacy in animals when pretreated with antibiotics - could this be because of an alteration in gut bacteria? </div>
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We also know that bariatric surgery changes the gut bug composition, and may play a role in the weight loss effect of surgery, by altering gut bugs in favour of those that are not so good at helping us harvest calories from food. </div>
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Fecal transplant (yes, you read that correctly!) is also being considered as a possible treatment strategy for obesity.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-26902085978600283552018-01-25T09:26:00.001-07:002018-01-25T09:31:41.767-07:00Could Your Cholesterol Medication Cause Diabetes? <div dir="ltr" style="text-align: left;" trbidi="on">
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With any medication, there are benefits and risks that need to be considered. Medications are generally recommended to a patient when the potential benefit of the medication is felt to be greater than the potential risks.<br />
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While it is extremely important for both doctors and patients to be well informed of potential side effects of medications, the media unfortunately loves to hype up side effects, often making it seem like the risks of taking a medication must outweigh any potential benefits.<br />
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Statins, a group of cholesterol medications, have taken a particular beating in the media over the years. A colleague of mine approached me not too long ago saying that he was worried about his patients being afraid of taking their statin cholesterol medications because of fear of developing diabetes as a side effects, and asked me if I would publish a post on this topic.<br />
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An excellent review was <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)31357-5.pdf">published</a> in <i>The Lancet, </i>which does a great job of addressing the question of benefit vs risk of statin therapy.<br />
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If 10,000 people are treated with statin therapy for 5 years: (with the example given of 40mg of atorvastatin (Lipitor) daily)<br />
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Benefits:<br />
<ul style="text-align: left;">
<li>if these 10,000 people had a past history of 'blocked arteries' (occlusive vascular disease) - eg prior heart attack or stroke: 1,000 would be saved from another heart attack or stroke</li>
<li>if these 10,000 people had no history of vascular disease: 5,000 would be saved from a heart attack or stroke</li>
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Risks: </div>
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<li>50-100 will develop diabetes because of their statin</li>
<li>5-10 will have a bleeding type (hemorrhagic) stroke</li>
<li>5 will develop serious muscle complications</li>
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The risk of developing diabetes due to statin medications is higher with the more powerful statins (atorvastatin (Lipitor) and rosuvastatin (Crestor)), and with higher doses. However, it is precisely these particular statins at the higher doses that have the biggest benefit to prevent heart attacks and strokes in people who have a past history of vascular disease.<br />
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People with risk factors for developing diabetes (eg, prediabetes, obesity) are at higher risk of statins tipping them up into diabetes range blood sugars. However, e<i>ven if</i> a person develops diabetes due to their statin, the health benefit in preventing heart attacks and strokes is much greater than the adverse effect of diabetes on their health, provided the diabetes is well managed.<br />
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<a href="http://guidelines.diabetes.ca/browse/chapter24#bib47">For people who already have diabetes</a>, statins also have a powerful benefit in preventing heart attacks and strokes, which is felt to far outweigh any small increase in blood sugars that may occur (and can be managed with adjustment to diabetes medication).<br />
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As to how statins increase the risk of developing diabetes, <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61183-1/fulltext">another study in <i>The Lancet</i></a> suggests that it may be related to the mechanism of statins to inhibit an enzyme called HMG CoA reductase, and may be genetically mediated.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-35827254330576782312018-01-18T12:46:00.001-07:002018-01-22T08:15:18.432-07:00Is Your Doctor NOT Talking Nutrition?<div dir="ltr" style="text-align: left;" trbidi="on">
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Everyone out there: I would like you to raise your hand if your doctor has NOT recently talked to you about good nutrition. If you have your hand up, you are not alone - only about 12% of office visits include counselling about diet, despite there almost always being a good reason to talk about nutrition (eg diabetes, obesity, high blood pressure, and so forth).<br />
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Doctors out there - do you feel like you don't do a great job in counselling your patients on good nutrition? If so, you are definitely not alone.<br />
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A recent Viewpoint paper <a href="http://jamanetwork.com/journals/jama/fullarticle/2653762?amp;utm_source=JAMAPublishAheadofPrint&utm_campaign=07-09-2017">published</a> in the <i>Journal of the American Medical Association </i>uncovers some important issues that limit good nutritional counselling in the doctor's office.<br />
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Issues cited that limit doctors in providing nutritional counselling:<br />
<ul style="text-align: left;">
<li>Doctors receive very little nutritional training in medical school. </li>
<li>Limitations of time in an appointment. </li>
<li>Limitations in reimbursement (pay) for doctors to provide nutrition counselling.</li>
<li>Frustration in trying to counsel on healthy food choices when our environment is so full of unhealthy choices.</li>
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Here are some easy steps that clinicians can take to improve nutritional counselling: </div>
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1. Start the conversation - check out this easy to use <a href="http://jamanetwork.com/data/Journals/JAMA/0/jvp170116t1.png">tool</a>, which contains eight quick and easy questions you can ask, with suggestions for reasonable changes that you could recommend. </div>
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2. Use the <a href="http://www.obesitynetwork.ca/5As">5As of Obesity</a> to help start a conversation when you note that your patient carries excess weight. </div>
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3. Focus on small steps - use the <a href="http://jamanetwork.com/data/Journals/JAMA/0/jvp170116t1.png">tool</a> for suggestions. </div>
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4. Don't do it alone (if possible) - nutrition counselling and weight management require multidisciplinary support! Engage any support you have to help provide your patient the help they need from various avenues: dietitian, nutritionist, psychologist, health/weight management classes - anything you can find to provide your patient with lots of health care provider time to guide them through their journey. </div>
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-70901959572583700802018-01-06T05:58:00.001-07:002018-01-06T05:58:08.475-07:00Are Less People With Overweight Or Obesity Trying To Lose Weight?<div dir="ltr" style="text-align: left;" trbidi="on">
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As we look forward into a new year, it is also worthwhile to cast a glance backwards in time to understand how perceptions and attitudes towards weight loss may be changing, in the face of a landscape where obesity is on the rise.<br />
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One of the most read 2017 studies in the <i><a href="https://jamanetwork.com/journals/jama/fullarticle/2608211?utm_source=silverchair&utm_campaign=altmetric&utm_content=2017_year-end&cmp=1&utm_medium=email">Journal of the American Medical Association</a></i> used the American National Health And Nutritional Examination Survey (NHANES) data to assess whether there has been any change in the percentage of people with overweight or obesity (defined as BMI of 25 or greater) trying to lose weight during the time frames of 1988-1994, 1999-2004, and 2009-2014.<br />
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Upon analysis of the data from 27,350 people aged 20-59, they found that the percentage of people with overweight or obesity increased over time, from 52.7% in 1988-1994, to 65.6% in 2009-2014.<br />
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The percentage of people trying to lose weight <i>decreased</i> during the same period, from 55.7% in 1988-1994, to 49.2% in 2009-2014.<br />
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So why would the proportion of people trying to lose weight be decreasing, while obesity is actually on the rise? <br />
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Well, we know that there has been a <a href="https://www.ncbi.nlm.nih.gov/pubmed/19875997">generational shift in perceptions of body weight norms</a> - in other words, people with overweight are less likely to classify themselves as such as they did in years past, because overweight may be perceived more like the 'new normal'. So if people who carry excess weight perceive themselves to be of a healthy weight, they would be less inclined to try to lose weight.<br />
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The authors of this study suggest that the length of time that people struggle with obesity may be a factor - the longer people live with obesity, the more frustrated they may be come with unsuccessful weight loss attempts and thus less likely to try to manage their weight.</div>
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I think the issues go even deeper - and likely have much to do with barriers to effective obesity care that we know exist. The <a href="http://drsuetalks.blogspot.ca/2017/11/time-to-take-action-barriers-to.html">ACTION study</a> in USA highlighted some of these important barriers that needed to be addressed. Data collection for the <a href="https://clinicaltrials.gov/ct2/show/NCT03235102">ACTION study in Canada</a> (for which I am an author and member of the Steering Committee) is now complete; we are currently working hard to put together and publish our results, to better understand barriers that exist, and how we as a country can overcome these barriers to better help Canadians with weight management. </div>
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-58097120247130432202017-12-15T03:59:00.001-07:002017-12-15T03:59:13.037-07:00Is My Daughter At Risk Of Getting Her First Period Early?<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="color: black; font-family: "times";"><br />Over the last several decades, we have seen the average age of first period (called menarche) decrease by 1-2 years. The prevalence of girls in USA having early menarche (before age 11) has also increased from 2.6-4.6% to 6.6-12.2% over the last 60 years. <span style="mso-spacerun: yes;"> </span>Understanding why periods are starting earlier is important as it can be distressing for these young girls, and is also associated with a higher long term risk of breast cancer, depression, and metabolic risk factors including type 2 diabetes and obesity.<o:p></o:p></span></div>
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<span style="color: black; font-family: "times";">While some of the trend towards earlier periods over the last several decades is due to better health and living conditions, it is also increasingly recognized that environmental factors including weight gain in pregnancy and energy availability during fetal life and early childhood may play an important role.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="color: black; font-family: "times";">A recent review <a href="https://www.ncbi.nlm.nih.gov/pubmed/28872224">published</a> in Obesity Reviews summarizes the currently available data on this topic. </span><span style="font-family: "times";">While it reveals that the literature on this topic is complex, challenging to interpret, and even contradictory at times, the overarching conclusions were that there may be a higher risk of a girl having an early first period when her birth weight is lower, and with higher body weight and weight gain in in infancy and childhood.<span style="mso-spacerun: yes;"> </span><span style="color: black;"><o:p></o:p></span></span></div>
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<span style="font-family: "times"; mso-ansi-language: EN-US;">So why would energy availability/energy stores have an influence on age of first period? Here are some possible links:<o:p></o:p></span></div>
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<span style="font-family: "times"; mso-ansi-language: EN-US;"><b><u>1. Leptin</u></b>, which is a signal of energy availability produced by fat tissue, is elevated in obesity, and also in children with low birth weight experiencing catch up growth. Leptin is thought to be necessary for the onset of puberty, so higher leptin may stimulate earlier puberty.<o:p></o:p></span></div>
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<span style="font-family: "times"; mso-ansi-language: EN-US;"><b><u>2. Fat tissue converts testosterone to estrogen</u></b> (and vice versa). Rapid weight gain and childhood obesity is associated with greater production of testosterone derivatives from the adrenal glands, so there may be more of this testosterone available to convert to estrogen in fat tissue, contributing to an earlier first period.<o:p></o:p></span></div>
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<span style="font-family: "times"; mso-ansi-language: EN-US;"><b><u>3. Increased insulin levels</u></b> (as seen in obesity) may advance sexual maturation; in fact, there is some evidence that metformin, a diabetes medication that lowers insulin resistance, may delay onset of periods in low-birth-weight girls with early onset of puberty.<o:p></o:p></span></div>
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<span style="font-family: "times"; mso-ansi-language: EN-US;"><b><u>4. Genes</u></b> have been discovered to be associated with both obesity and age of first period, suggesting there may be some common genetic threads here too.<o:p></o:p></span></div>
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<span style="font-family: "times";">Also interesting: </span></div>
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<span style="font-family: "times"; mso-ansi-language: EN-US;"><b><u>5. Nutritional factors.</u></b> </span>Breast feeding, and higher intake of plant proteins and fibre may be protective of excessive weight gain and thus protect against earlier periods. F<span style="font-family: "times"; font-size: 12pt;">ormula feeding and high intake of cow’s milk and animal protein is associated with an earlier first period (possibly by stimulation of IGF-1 secretion, thus triggering earlier growth). </span><span style="font-family: "times"; font-size: 12pt;">Higher sugary beverage consumption is also associated with earlier periods, independent of body mass index (BMI).</span></div>
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<span style="font-family: "times"; mso-ansi-language: EN-US;">6. C<b><u>hemicals</u></b> in our environment that mess with our hormone systems (called endocrine disruptors) may modify age of first period directly (by modulating hormone responsiveness, epigenetic effects, or stimulating maturation directly), or indirectly by increasing the risk of childhood obesity.<o:p></o:p></span></div>
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<span style="font-family: "times"; mso-ansi-language: EN-US;">So, it seems that prenatal life, infancy and childhood may present opportunities to improve overall health, and thereby possibly prevent early onset of menstrual periods.<span style="mso-spacerun: yes;"> </span>This includes:<o:p></o:p></span></div>
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<li>Ensuring appropriate nutritional status of mom while pregnant</li>
<li>Watching for suboptimal fetal growth (and managing appropriately depending on cause)</li>
<li>Watching for, and managing, excessive weight gain in childhood</li>
<li>Watching for signs of early pubertal development and intervening where appropriate with lifestyle/weight management strategies.<span style="font-family: "times"; font-size: 12pt;"> </span><span style="font-family: "times"; font-size: 12pt;">I would be very curious to hear from my pediatric colleagues whether they are using metformin in this scenario – please contribute your comments at the end of this blog post!</span></li>
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-48726566384285925142017-12-09T06:37:00.001-07:002017-12-09T06:37:26.451-07:00What Does It Take To Keep Weight Off 6 Years Later? <div dir="ltr" style="text-align: left;" trbidi="on">
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Understatement: <i style="mso-bidi-font-style: normal;">The Biggest Loser</i> is <a href="http://drsuetalks.blogspot.ca/2016/05/what-biggest-loser-teaches-us-about.html">not my favorite show</a>. <o:p></o:p></div>
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<span style="mso-ansi-language: EN-US;">However, the National Institute of Health took this opportunity to learn some things about metabolism after weight loss, and to determine whether changes in food intake or physical activity are associated with keeping the weight off vs regaining weight over the long term.<o:p></o:p></span></div>
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In a <a href="http://drsuetalks.blogspot.ca/2016/05/what-biggest-loser-teaches-us-about.html">previous blog</a>, we talked about the finding from <i>The Biggest Loser </i>contestants that 6 years after losing weight on the show, there was about a 500 calorie lower daily calorie burn than what would be expected at their weight 6 years later, which helps to explain why it is so hard to keep weight off after weight loss.<o:p></o:p></div>
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In the <a href="http://onlinelibrary.wiley.com/doi/10.1002/oby.21986/full">most recent publication</a>, we learn that people who were able to keep weight off 6 years after being on <i style="mso-bidi-font-style: normal;">The Biggest Loser</i> had higher daily physical activity levels than those who experienced weight regain.<span style="mso-spacerun: yes;"> Specifically, those who maintained a weight loss of 25% had increased their physical activity by 160% compared to the start of the study, whereas those who weighed more than they did at the start of the study had increased their physical activity by 'only' 34% (not enough to offset the decrease in metabolism that happens after weight loss). </span><br />
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<span style="mso-spacerun: yes;">Energy intake at 6 years after the show was estimated to be similar between those who maintained weight loss (8.7% less than before the study) vs those who regained weight (still 7.4% less than before the study!). (Scientists: daily energy intake was assumed to be equal to total daily energy expenditure, as weight was reported as stable both at the start of the show, and at the 6 year mark.)</span></div>
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Previous studies such as the LOOK AHEAD study and the <a href="http://drsuetalks.blogspot.ca/2015/10/secrets-to-success-keeping-weight-off.html">National Weight Control Registry</a> have also suggested that people who are able to keep weight off are those who do more physical activity after weight loss, but in these studies, physical activity was self reported (and we know from other studies that physical activity is over reported).<span style="mso-spacerun: yes;"> </span><a href="http://onlinelibrary.wiley.com/doi/10.1002/oby.21986/full">The current study</a> is the first to use the gold standard of doubly labeled water to measure changes in physical activity several years after weight loss.</div>
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<span style="mso-ansi-language: EN-US;">Bottom Line: While we know that physical activity is not as important for achieving weight loss, the evidence points to physical activity being very important for maintaining weight lost over the long term.<o:p></o:p></span></div>
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-35609864392631338622017-11-26T07:15:00.002-07:002017-11-26T11:12:12.811-07:00Do Low Fat Diets Prolong Life? <div dir="ltr" style="text-align: left;" trbidi="on">
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There is hot debate these days as to whether low fat diets are good or bad for us, and whether we have gone overboard in promoting low fat as the way to go in guidelines over the last several decades.<br />
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A recent study, <a href="http://www.bmj.com/content/359/bmj.j4849">published</a> in the <i>British Medical Journal</i>, conducted a systematic review and meta analysis, with their goal actually being to determine whether dietary lifestyle interventions targeting weight loss reduces mortality, cardiovascular disease, and cancer in people with obesity. They hadn't intended to study low fat diets in particular, but out of the 54 randomized clinical trials that they identified for analysis, all but one of these trials described a low fat diet being included as at least one of their interventions (and all but three trials included some form of exercise advice). The diets were also usually low in saturated fat.<br />
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In this analysis of over 30,000 clinical trial participants in studies of at least 1 year duration, they found that weight loss interventions decreased mortality by 18%, corresponding to 6 fewer deaths per 1000 participants in the studies. Weight loss after 1 year was 3.4kg (7.5lb), and about 2.5kg (5.5lb) after 2-3 years.<br />
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That this study found that dietary interventions reduce mortality in people with obesity is noteworthy, as the amount of weight lost was fairly low, and also because singular diet studies have not shown a reduction in mortality. In fact, the only obesity studies that have really shown a reduction in mortality are those of bariatric surgery. It is encouraging that perhaps a mortality benefit from lifestyle intervention emerges when we look at enough people together (as in the current study).<br />
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But does this mean that low fat diets are the way to go? Not necessarily.<br />
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It is true that we cannot know if the benefits seen in this study were because of the weight lost, because of the low fat nature of the diets, or a combination of both.<br />
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However, a problem with the low fat diet approach in real life (ie outside of a clinical trial) is that it most often results in overconsumption of carbohydrates, which has likely contributed to the increase in obesity that we have seen in the last several decades. <a href="http://drsuetalks.blogspot.ca/2017/01/mediterranean-diet-may-slow-brain.html">The Mediterranean diet</a>, which is not a low fat diet (fat intake is 35-47% of total calories, with a focus on the healthier unsaturated fats), has been shown to be associated with a reduction in mortality (in systematic reviews and meta analyses of cohort and case control studies). <br />
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We must also remember that all systematic reviews and meta analyses of studies are subject to limitations in interpretation as they are compiling data from a variety of different studies, so they must all be taken with a grain of salt.<br />
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BOTTOM LINE: This study suggests that weight reducing diets (which happened to be mostly low fat diets) may reduce mortality. I would now like to see more studies of diets with moderate carbohydrate restriction and more generous unsaturated fat intake to understand if these diets may have the same benefit.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-55953923016011772952017-11-19T13:50:00.002-07:002017-11-19T13:50:20.578-07:00Does Earlier Menopause Mean A Higher Risk Of Diabetes?<div dir="ltr" style="text-align: left;" trbidi="on">
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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.<br />
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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.<br />
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The <a href="https://link.springer.com/content/pdf/10.1007%2Fs00125-017-4346-8.pdf">study</a>, published in the journal <i>Diabetologia</i>, 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.<br />
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They found that the risk for developing type 2 diabetes, compared to women with late menopause (at more than 55 years old), is:<br />
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<ul style="text-align: left;">
<li>3.7 times higher for women with premature menopause (at less than 40 years old)</li>
<li>2.4 times higher for women with early menopause (at 40-44 years old)</li>
<li>1.6 times higher for women with normal age of menopause (at 45-55 years old)</li>
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They found that for every year later that menopause occurred, the risk of developing diabetes decreased by 4%.</div>
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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 <a href="http://drsuetalks.blogspot.ca/2010/10/sleep-deprivation-is-strongly-linked-to.html">known risk factor for obesity</a> 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.</div>
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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, <i>independent</i> of these hormone levels, and also independent of body mass index at baseline or shared genetic factors.<br />
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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. </div>
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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!<br />
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After menopause, we can combat cardiovascular and diabetes risk by:<br />
<ul style="text-align: left;">
<li>Keeping active - engage those muscles! This helps to combat the decrease in muscle mass. </li>
<li>Making healthy permanent lifestyle changes </li>
<li>Having good sleep hygiene</li>
<li>Getting help from your doctor if you are struggling with menopausal symptoms.</li>
</ul>
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-58131792913937906822017-11-10T05:17:00.001-07:002017-11-10T05:17:39.213-07:00Time To Take ACTION! Barriers To Effective Obesity Care <div dir="ltr" style="text-align: left;" trbidi="on">
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Despite the fact that obesity is one of the most prominent medical conditions in existence, it is sadly one of the most poorly treated. There exists very little education about obesity for health care providers, and the stigma against obesity is even stronger in the medical community than it is in the general population. Although this is slowly changing, only a small minority of people with obesity actually have this medical condition addressed and treated with the help of their health care provider.<br />
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<a href="http://onlinelibrary.wiley.com/doi/10.1002/oby.22054/full">The ACTION study</a> was thus designed to better understand the barriers to effective obesity care. This study was a survey conducted in USA, completed by three groups of people:<br />
<ul style="text-align: left;">
<li>3,008 people with obesity</li>
<li>606 health care providers (primary care/family medicine, internal medicine, and obesity specialists)</li>
<li>153 employers who provide health insurance or wellness programs to their employees</li>
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Here are some of the key findings: </div>
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1. While over 80% of health care providers viewed obesity as a chronic disease, only 55% of people with obesity reported receiving an actual diagnosis of obesity. (How can a health care provider move towards treatment of this medical condition if they are not making the diagnosis?)</div>
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2. Top 5 reasons that health care providers reported as to why they may not initiate a conversation about weight loss: </div>
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<li>not enough time</li>
<li>more important issues to discuss</li>
<li>they did not believe their patient was motivated to lose weight </li>
<li>they did not believe their patient was interested in losing weight (au contraire - data supports that the vast majority of people with obesity are interested in losing weight)</li>
<li>concern over patient's emotional state or psychological issues</li>
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3. Top 5 barriers to initiating a weight loss effort (agreed to be the same top 5 by people with obesity, health care providers, and employers):<br />
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<li>lack of exercise (note: exercise is less important for weight loss and more important for weight maintenance)</li>
<li>lack of motivation (could this be because of a lack of understanding of the causes and contributors to each individual's weight struggle?)</li>
<li>preference for unhealthy food (could this be because food is being used to medicate untreated depression or pain by releasing 'happy hormones' in our brains?)</li>
<li>controlling hunger</li>
<li>cost of healthy food</li>
</ul>
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4. Only 24% of people who had a discussion about obesity with their doctor had a follow up appointment scheduled. (Obesity requires long term management - one appointment isn't enough!)<br />
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5. Only 17% of people with obesity felt that their employers' wellness offerings were helpful in weight management.<br />
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The ACTION study is truly a treasure trove of information that should help all components of society better identify, understand, and gradually overcome the barriers to successful weight management.<br />
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You may be wondering if the results of the ACTION study applies to Canada or other countries, as attitudes and approaches can be very different in different parts of the world. I'm thrilled to share that the <a href="https://clinicaltrials.gov/ct2/show/NCT03235102">ACTION study is currently underway in Canada</a> (I am on the steering committee for this study) - stay tuned for our results next year. ACTION will be conducted in several countries around the world as well, with deployment planned to begin in 2018.</div>
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<i style="background-color: white; color: #32527a; font-family: verdana, sans-serif; font-size: 12.32px; margin: 0px; padding: 0px;">Disclaimer: The ACTION study is funded by Novo Nordisk, the maker of weight management medication Saxenda (liraglutide 3.0mg).</i><br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-87182579561468978702017-10-22T16:43:00.000-06:002017-10-22T16:43:06.214-06:00Anemia, Mortality, and Type 2 Diabetes<div dir="ltr" style="text-align: left;" trbidi="on">
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Health care providers out there may have noticed that anemia is a not-infrequent finding amongst patients with type 2 diabetes.<br />
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It turns out that there are multiple reasons for anemia in type 2 diabetes - and the health consequences may be severe.<br />
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<a href="https://www.ncbi.nlm.nih.gov/pubmed/28433448">A study</a> 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.<br />
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They found multiple risk factors independently associated with a higher risk of anemia, including:<br />
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<ul style="text-align: left;">
<li>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</li>
<li>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</li>
<li>metformin use: likely related to vitamin B12 deficiency, but other mechanisms such as low magnesium are considered</li>
<li>thiazolidinedione use [pioglitazone (Actos) or rosiglitazone (Avandia)]: likely related to fluid retention</li>
<li>peripheral arterial disease: possibly related to higher oxidative stress, inflammation, atherosclerosis</li>
</ul>
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Other risk factors were identified as well, such as low iron, and low testosterone in men.</div>
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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.</div>
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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.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-8131763800824019122017-10-15T07:03:00.001-06:002017-10-15T07:03:01.408-06:00Does Gastric Bypass Surgery Save Lives Only In People With Diabetes?<div dir="ltr" style="text-align: left;" trbidi="on">
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While we know that weight loss of just 5-10% is associated with an improvement in many parameters of health, the only treatment for obesity that has been suggested to reduce mortality is bariatric surgery. A new study suggests that if gastric bypass surgery reduces mortality, it may be people with diabetes in particular who enjoy this benefit.<br />
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The study, <a href="http://care.diabetesjournals.org/content/early/2017/07/26/dc17-0519">published</a> in <i>Diabetes Care</i>, matched 2,428 people in their database who had gastric bypass surgery by age, BMI, gender, and diabetes status to a control group in the database who had not had surgery.<br />
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They found that for the 625 people who had diabetes before gastric bypass surgery, their risk of death from any cause was reduced by 56% at 5.8 years after surgery, compared to people who had diabetes but hadn't had surgery. In particulary, death from cardiovascular disease, lung disease, and diabetes were lower in the group who had surgery. The reduction in mortality was the greatest for people whose diabetes went into remission after surgery.<br />
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For the 1,803 people who didn't have diabetes before gastric bypass surgery, the risk of death at 6.7 years after surgery was not significantly different than those who didn't have diabetes and didn't have surgery. When they boiled it down, the risk of death from cancer and lung diseases was lower in the people who had had gastric bypass surgery, but the risk of death from external causes (including injuries, overdose, and suicide) was higher, especially for younger people.<br />
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This study is the first to suggest that a reduction in all-cause mortality after gastric bypass surgery may be limited to people who have diabetes before surgery. However, even if people without diabetes don't enjoy enhanced life expectancy overall, remember that there are still many health benefits to be enjoyed from bariatric surgery. It's also important to emphasize that this study is retrospective, meaning that researchers looked back in time and analyzed pre existing data. This type of data can be muddied by other factors that can't be controlled for (called 'confounding factors'), so we have to take them with a grain of salt.<br />
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The increased death risk from injuries, overdose, and suicide for people without diabetes who had surgery needs attention. It is known that there is a <a href="http://drsuetalks.blogspot.ca/2017/09/how-successful-is-gastric-bypass.html">higher risk of self harm after surgery</a>, pointing towards the need for psychological counselling and support both pre and post surgery. There is still very little known about how bariatric surgery changes the absorption of medications and other substances, increasing the risk of potential overdose; further studies are desperately needed in this area.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-49935187080203423072017-09-29T08:15:00.001-06:002017-10-02T08:24:57.232-06:00Are Obesity Genetics Written In Stone? <div dir="ltr" style="text-align: left;" trbidi="on">
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In my practice, I often talk about the genetic predisposition to obesity.<br />
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Modern science has now identified over 100 genes that are associated with obesity, with each of these genes contributing a pound or two to the overall weight struggle. So if a person has a high number of these 'bad' genes, they will have a bigger struggle with obesity, and a higher 'set point' of body weight, than someone who has only a few of these genes. This can seem like a huge bummer - you can't change your genes (side bar: well actually you can but not in a good way - that's a story for another day) - so does this mean that the efforts to lose weight are hopeless?<br />
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The answer is, no. Even for people who have more of the obesity-engendering genes, it is possible to lose weight, though a realistic weight goal will likely be higher than someone who has less obesity engendering genes. In addition, a new study sheds light on gene-environment interactions in obesity, teaching us that certain behaviours can modify the effect of our genes on our body weight.<br />
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The study, <a href="http://journals.plos.org/plosgenetics/article?id=10.1371/journal.pgen.1006977">published</a> in PLOS Genetics, looked at gene-environment interactions for body mass index, using a large database of over 350,000 Caucasian people from the UK Biobank. They found 15 lifestyle factors that influence our genes' effects on body weight, including:<br />
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<li>alcohol intake frequency</li>
<li>usual walking pace</li>
<li>socioeconomic status</li>
<li>number of days per week of physical activity lasting at least 10 minutes</li>
<li>time spent watching TV</li>
<li>frequency of climbing stairs</li>
<li>smoking </li>
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So, the good news here is that we CAN influence our genes' effect on body weight to some extent with the lifestyles we lead. While some of the ability to use these factors may be affected by e.g. physical limitations, I think it's encouraging to know that the effect of our genetics are not set in stone.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-9504785242489553102017-09-23T07:07:00.001-06:002017-09-23T07:07:46.736-06:00How Successful is Gastric Bypass Surgery 12 Years Later? <div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Times, Times New Roman, serif; font-size: small;">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.</span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: small;">The study, <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1700459">published</a> by Adams and colleagues in the <i>New England Journal of Medicine, </i>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.<o:p></o:p></span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: small;">Here are some of the key findings: (skip to <u style="font-weight: bold;">take home messages</u> below for the short version)<o:p></o:p></span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: small;"><b><u>1. Weight loss:</u></b><o:p></o:p></span></div>
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<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">Two years after gastric bypass surgery, the mean weight loss was 45 kg. </span></li>
<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">At 6 years postop, the mean weight loss was 36.3kg (so there was about 20% weight regain, which is very consistent across studies).</span></li>
<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">At 12 years postop, the mean weight loss was 35kg – so weight was overall stable from 6 years to 12 years after surgery.</span></li>
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<span style="font-family: Times, Times New Roman, serif; font-size: small;"><o:p> [</o:p>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).]</span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: small;"><b><u>2. Type 2 diabetes:</u></b><o:p></o:p></span></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: small;">Among patients in the surgery group who had type 2 diabetes before surgery:<o:p></o:p></span></div>
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<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">At 2 years postop, 75% of diabetes had gone into remission.</span></li>
<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">At 6 years postop, 62% of diabetes cases were in remission</span></li>
<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">At 12 years postop, 51% of diabetes cases were in remission.</span></li>
<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">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.</span></li>
<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">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%). </span></li>
<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">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.</span></li>
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<b><u><span style="font-family: Times, Times New Roman, serif; font-size: small;">3. Mortality rates:</span></u></b></div>
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<span style="font-family: Times, Times New Roman, serif; font-size: small;">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 <a href="http://drsuetalks.blogspot.ca/2017/09/mental-health-and-bariatric-surgery.html">here</a> and <a href="http://drsuetalks.blogspot.ca/2011/04/what-we-dont-know-about-absorption-of.html">here</a> and <a href="http://drsuetalks.blogspot.ca/2010/07/psychology-of-weight-loss-surgery.html">here</a> for discussion of suicide risk after bariatric surgery ) <o:p></o:p></span></div>
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<b><u><span style="font-family: Times, Times New Roman, serif; font-size: small;">Take home messages from this study:</span></u></b></div>
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<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">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.</span></li>
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<li><span style="font-family: Times, Times New Roman, serif; font-size: small;">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.</span></li>
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-51122310555171610892017-09-15T09:01:00.002-06:002017-09-15T09:01:14.640-06:00Mental Health and Bariatric Surgery - Canadian Data<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="mso-ansi-language: EN-US;">We know that there is a relationship between mental health and obesity, with mental health issues such as depression being associated with an increased risk of obesity, and with the risk of mental health issues developing increasing as weight increases. In people with more pronounced obesity who are considering bariatric surgery as a treatment option, it is important to consider how mental illness may impact the efficacy and safety of surgical treatment for obesity.<o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;">These issues were beautifully summarized in a recent <a href="https://www.ncbi.nlm.nih.gov/pubmed/28623081">review</a> by Val Taylor and colleagues, published in the <i style="mso-bidi-font-style: normal;">Canadian Journal of Diabetes</i>, with a focus on Canadian data.<o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;">Here are a few of the highlights:<o:p></o:p></span></div>
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<b><u>1. How common are mental health issues in Canadian bariatric surgery patients? </u></b><br />
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Over half of patients presenting in Ontario for bariatric surgery had a history of mental illness (most commonly depression). Neither a history of depression nor bipolar disorder seem to be associated with success of weight loss with bariatric surgery, but stability and control of mental health issues preoperatively is important to optimize success.<span style="mso-spacerun: yes;"> </span>The prevalence and severity of depression in the bariatric population are consistently decreased after surgery – but there is a risk of development of depression for some people as well, which may be related to some of the <a href="http://drsuetalks.blogspot.ca/2017/04/after-bariatric-surgery-patients.html">psychological challenges </a>that can present after surgery.<span style="mso-spacerun: yes;"> </span>Many people with mental health issues are taking medications to treat these conditions, and absorption of these meds may be affected after surgery, so close monitoring to ensure good control of the mental health issue after surgery is important.</div>
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<span style="mso-ansi-language: EN-US;"><b><u>2. Eating disorders:</u></b><o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;">Binge eating disorder (BED) has a prevalence of up to 30% in people presenting for bariatric surgery, with the data conflicting on whether BED reduces the success of weight loss with bariatric surgery. Management of the feeling of loss of control and regulation of emotions in these individuals are important factors to help reducing binge eating in this group.<o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;">Active bulimia is a contraindication to bariatric surgery.<o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;"><b><u>3. Suicide risk:</u></b><o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;">While depression usually improves after surgery, the risk of suicide is increased after bariatric surgery, with a multitude of possible reasons/contributors behind this fact.<span style="mso-spacerun: yes;"> </span>The risk of self harm seems to be increased at least 3 years after surgery, so long term psychological follow up and support of bariatric patients is essential.<o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;"><b><u>4. What if there is a past history of sexual abuse?</u></b><o:p></o:p></span><br />
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<span style="mso-ansi-language: EN-US;">A history of sexual abuse is present in 21.5% of people in the Ontario Bariatric Surgery Registry.<span style="mso-spacerun: yes;"> </span>While this does not appear to influence the success of surgery, these individuals are at a higher risk of mental health issues such as depression, speaking to the need for proper assessment and follow up.<o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;"><b><u>5. Substance use/abuse:</u></b><o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;">A history of substance use (alcohol, tobacco, or recreational/illicit drugs) seems to be correlated with a risk of substance use after surgery, particularly if the substance use history is near to the time of surgery.<span style="mso-spacerun: yes;"> </span>Alcohol abuse is a particular risk, as <a href="http://drsuefaq.blogspot.ca/2017/08/obesity-addiction-alcohol-and-bariatric.html">alcohol hits harder and fasterafter surgery</a>.<span style="mso-spacerun: yes;"> </span>A ‘transfer’ of addictions from one thing to another (eg, from food to gambling) after surgery has been described, and should be discussed and managed ahead of time.<o:p></o:p></span></div>
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<span style="mso-ansi-language: EN-US;">Most often, mental health issues can generally be well managed to optimize success of the individual undergoing bariatric surgery.<span style="mso-spacerun: yes;"> </span>Identifying and managing these issues before surgery is essential, and long term support after surgery is key as well.<o:p></o:p></span></div>
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-54781243178625808342017-09-09T13:14:00.001-06:002017-09-09T13:14:51.249-06:00Blood Sugar and Insulin Levels As A Biomarker For Weight Loss Success? <div dir="ltr" style="text-align: left;" trbidi="on">
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To date, no particular diet composition has been shown to be superior to another for weight loss success in the general population. However, we haven't yet ruled out that some types of diets may work better for certain specific groups of people. For the first time, a new study suggests that people with prediabetes or diabetes, and people with higher fasting insulin levels, may have better weight loss success with either a lower glycemic load diet, or a diet containing a large amount of fiber and whole grains.<br />
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The study, <a href="https://www.ncbi.nlm.nih.gov/pubmed/28679551">published</a> in the <i>American Journal of Clinical Nutrition, </i>evaluated data from three studies and stratified weight loss results by fasting blood sugar and insulin levels.<br />
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The first trial, called the DioGENES study (as <a href="http://drsuetalks.blogspot.ca/2010/11/higher-protein-lower-glycemic-index.html">blogged previously</a>), looked at the ability to maintain weight loss using a high vs low glycemic index and high vs lower protein diet. The results of this study overall showed that a low GI, higher protein diet was superior to a high GI, lower protein diet to maintain lifestyle-induced weight loss. In the current analysis, they found that people with prediabetes regained 5.83kg more on a high GI diet than a low GI diet, whereas people with normal blood sugar regained only 1.44kg more on a high GI diet than a low GI diet.<br />
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The second study, called the SHOPUS study, was designed to test the <a href="http://foodoflife.ku.dk/opus/english/about/nnd/">New Nordic Diet</a>, which is high in fiber and whole grains. People with prediabetes lost a mean of 6 kg on this diet, whereas people with normal blood sugars lost only 2.2kg.<br />
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Finally, in the NUGENOB study, which was designed to test nutrient-gene interactions in obesity, people with diabetes lost a mean of 2kg more on the high fat/low carb diet than on the low fat/high carb diet, whereas people with normal sugars lost only 0.43kg more on the above comparison.<br />
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When the authors incorporated fasting insulin levels into these analysis, the associations above were strengthened further. Some interesting phenotypes were also revealed:<br />
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<li>people with lower fasting blood sugar and high fasting insulin levels responded equally on all 3 pairs of diets </li>
<li>people with high fasting sugars and low fasting insulin levels did better on diets with a lower glycemic load and more fiber and whole grains</li>
<li>people with lower blood sugar and lower fasting insulin did better on a low fat/high carb diet. </li>
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We often talk about <i>precision medicine</i> - customization of health care decisions based on each individual's genetics, lab results, hormone levels, and so on; yet in obesity medicine, we have very little routinely measured information that can help us determine what type of management program may be best for our patient. Finally we have some data, using easily measurable blood tests, that may help to guide us.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-41755436896199306392017-09-02T06:32:00.001-06:002017-09-02T06:32:47.900-06:00Obesity, Addiction, Alcohol and Bariatric Surgery Part II<div dir="ltr" style="text-align: left;" trbidi="on">
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We know that the factors behind each individual's struggle with obesity are unique, with a long list of physiologic, psychological, and environmental factors as potential contributors. We are also learning increasingly that there are many areas of neurophysiologic (brain), psychological and behavioral overlap in the realms of obesity and addiction.<br />
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In <a href="http://drsuetalks.blogspot.ca/2017/08/obesity-addiction-alcohol-and-bariatric.html">part I</a> of this two-part blog post, we discussed some of the changes that happen after bariatric surgery, as discussed in a recent <a href="https://www.ncbi.nlm.nih.gov/pubmed/28429582">review</a>.<br />
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Now, some threads that weave a connection for some people between obesity and addiction: </div>
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<b><u>1. For some people, food is an addictive substance.</u></b> People who have high scores on food addiction questionnaires have similar patterns of brain activation as in people with other addictions. Also, overconsumption of certain nutrients (eg sugar) elicits chemical responses in our brains, similar to those that result from consumption of drugs or alcohol.<br />
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Some people think that combatting a food addiction is no different than trying to quit smoking. But remember, a person who quits smoking can (and ideally will) lead their life without ever touching another cigarette. But the person battling a food addiction can't stop eating - they have to continue to eat for the rest of their lives, while controlling the addictive component that leads to overeating: a very, very difficult thing to do. </div>
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<b><u>2. Some people with obesity have more 'turbo-charged' food reward circuits </u></b>in their brains, which results in a powerful drive to seek high calorie food. Obesity can also be accompanied by a reduced brain-driven ability to resist temptation and control impulses to eat, with data suggesting that there is a genetic component to these differences. After gastric bypass surgery, research has identified some changes in this brain activity, and these changes may be associated with the amount of weight lost after surgery.<br />
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Know that feeling of: <i>I am so hungry I don't care what it is it just has to happen RIGHT NOW...?</i><br />
For some people, this feeling may come only if meals are skipped for many hours, or after a fierce workout. For others, they may feel like this until their body is at a higher body weight 'set point'. The level of energy reserves, or time from last meal that contributes to the threshold for this feeling to set in, is very different from person to person.<br />
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So for people who have a food addiction, as well as for people who have a more powerful reward circuitry, weight management will be difficult, but not impossible - having a psychologist with professional training in obesity management is an important part of the team to help manage their weight struggles.<br />
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Dr. Sue Pedersenhttp://www.blogger.com/profile/07864506443463982355noreply@blogger.comtag:blogger.com,1999:blog-1499800908216349663.post-61425234803977146892017-08-26T14:38:00.001-06:002017-08-26T14:38:50.075-06:00Obesity, Addiction, Alcohol and Bariatric Surgery Part I<div dir="ltr" style="text-align: left;" trbidi="on">
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We know that the factors behind each individual's struggle with obesity are unique, with a long list of physiologic, psychological, and environmental factors as potential contributors. We are also learning increasingly that there are many areas of neurophysiologic, psychological and behavioural overlap in the realms of obesity and addiction. A recent <a href="https://www.ncbi.nlm.nih.gov/pubmed/28429582">review</a> draws on our knowledge of alcohol use after bariatric surgery to help us understand these connections.<br />
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After gastric bypass surgery:<br />
<ul style="text-align: left;">
<li>9.4% of patients who have had gastric bypass surgery report a period of excessive alcohol intake at some point after surgery</li>
<li>7% of patients with no preoperative history of excessive alcohol intake develop a problem after surgery</li>
<li>middle aged females seem to be at higher risk</li>
<li>post bariatric surgery addiction problems seem to be fairly specific to alcohol (though addictions to other substances, or activities such as gambling are also seen - see 'addiction transference' below)</li>
<li>when a person who has had gastric bypass surgery drinks alcohol, there is a faster rise, higher peak, and longer duration of blood alcohol levels </li>
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Interestingly, some people who were frequent alcohol consumers before surgery actually have a decreased enjoyment of alcohol after surgery, which may be mediated by an increase in the gut hormone GLP-1, and a decrease in the hunger hormone ghrelin.</div>
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Psychological and social factors can also have a big influence on alcohol consumption after surgery. <a href="http://drsuetalks.blogspot.ca/2011/08/alcohol-abuse-risk-after-gastric-bypass.html">As blogged previously</a>, food addiction seeking a new outlet (called 'addiction transference') may be a factor for some people. A need for a coping mechanism as a person watches their body change after surgery may be involved. Some may reach for alcohol as a way to manage the <a href="http://drsuefaq.blogspot.ca/2017/03/after-bariatric-surgery-pateints.html">complex psychological issues</a> that can arise after surgery. </div>
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Stay tuned for the next blog post, where I'll discuss some of the parallels between obesity and addiction discussed in this review. </div>
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