Hormone Treatments for Weight Loss?

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

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

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

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

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A Different Kind of STAMPEDE

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

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

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

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

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

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

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Landmark Study Shows Physical Activity Decreases Heart Attack Risk

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

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

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

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

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

Follow me on twitter: @drsuepedersen

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The Low Down on Electronic Cigarettes

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


1.  What are e-cigarettes?

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


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

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

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

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


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

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

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Could Cinnamon Be....Dangerous?

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

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

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

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

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

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

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

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

The study found that:

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

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

"Physicians may want to caution patients that, to

support cardiovascular health, it is safest to consume less than

15% of their daily calories as added sugar."

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

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Mythbusting Garcinia cambogia

There are a kajillion substances, herbs, and naturopathic remedies that are all over the internet, purporting their magical abilities to cause weight loss, but which do not have evidence to support that they actually work.  You can add Garcinia canbogia to this list.

Garcinia cambogia extract comes from a type of tamarind tree native to Asia.  In addition to being available as an extract, it is also an ingredient in Hydroxycut, which has been associated with cases of liver toxicity.  Now that Dr Oz has been throwing his weight behind Garcinia, it's getting more attention than ever before.  (More on my thoughts re Dr Oz here.)

We can put to rest the controversy behind Garcinia simply by looking at the science.  A randomized controlled trial was conducted long ago, back in 1998, showing that Garcinia cambogia failed to produce significant weight loss compared to placebo.

Friends, today's blog is short and not so sweet: Garcinia cambogia has been proven NOT to work, and it may be harmful.

Follow me on twitter: @drsuepedersen

www.drsue.ca © 2013

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