ENDO 2015: Diabetes and Bones

And....we're off!!! ENDO 2015 is off to a fabulous start.  I'm excited to share with you our learnings about diabetes and bone disease from a symposium held this morning.  You'll need a few extra minutes to read this post - it's a little longer than my usual blogs - so much to cover and share!  Grab a cuppa and get comfy. :)


We were first provided an overview of the impact of type 1 diabetes (T1DM) and type 2 diabetes (T2DM) on the skeleton, by Dr Ann Schwartz.  We learned that diabetics are at an increased risk of fracture (broken bones) than people without diabetes. In T1DM, bone density is lower than in non diabetics, suggesting a moderately increased risk of hip fracture.  However, studies have shown that a type 1 diabetic is actually at over a 6 times higher risk of a hip fracture compared to a non diabetic (much higher than differences in bone density would suggest), suggesting that there is much more to the story than a lower bone density.

In type 2 diabetics, the situation is different.  As 90% of T2DM patients struggle with overweight or obesity, bone densities are higher, a result of the higher body weight that the skeleton supports. Despite this, T2DM patients are at 40% higher risk of hip fracture; after adjusting for body mass index (BMI), there is a 70% increased risk of hip fracture compared to non diabetics.  

While diabetics are at a higher risk of falls (see below for more thoughts on this), studies that controlled for falls still show a higher fracture risk – again suggesting that there is something going on in the bones themselves that increase fracture risk.

So why are diabetics at a higher risk of fracture for a given bone density?  Many possibilities have been suggested in terms of differences in bone structure at the microarchitectural level, but as Dr Mary Larsen Bouxsein pointed out, there is little that is currently understood about exactly what is happen at the microscopic level in terms of the damage that high blood sugars could be doing to bone.  Dr Josh Farr showed us data suggesting that cortical bone microarchitecture in women appears to be compromised in T2DM due to decreased bone formation and turnover, but these studies are limited by size and data are not available in men.

As diabetics have a higher fracture risk for a given bone density, our traditional means of evaluating fracture risk may not be appropriate.  It has been shown that bone density testing (using the T score) does predict risk of hip fracture in diabetics, but at a particular T score, the fracture risk is higher than a non diabetic with the same T score.  The FRAX score, which we often use to predict risk of fracture in our patients, underestimates the risk of fracture in T2DM.

Medications that treat type 2 diabetes may have variable effects on bone as well, as reviewed by Dr Christian Meier.  Metformin, our first line treatment for type 2 diabetes, seems to be protective of the bones.  We know that the group of medications called thiazolidinediones increase the risk of fracture in postmenopausal women and older men, and with longer duration of treatment. There is some evidence to suggest that the group of type 2 diabetes medications called incretin therapies may be protective of bone, but much further study needs to be done.  A newer class of medications called the SGLT2 inhibitors may slightly increase fracture risk, but again, much more study is needed in this area.

A few important points that I would like to highlight (from this session, as well as my own thoughts):  

• It is crucially important to avoid low blood sugars in patients with diabetes.  A low blood sugar can cause a fall that can result in a fracture.  
• Prevention of diabetic nerve damage is also crucial, as fall risk increases in those who have loss of sensation to their feet.  
• Being fit and strong is also important to prevent falls. 
• Finally, checking vitamin B12 in patients on metformin is important as well, as low vitamin B12 can cause nerve damage, and metformin can rarely cause vitamin B12 levels to be low.

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Dr Oz Fails The True Test Of Research

There are a lot of conflicting opinions about Dr Oz out there.  Some people feel that he is the guru of modern medicine, whereas others, including many health care professionals, are very critical of his claims.  I'm thrilled to report that researchers at the University of Alberta have put this debate to the true test of research.

In the study, which was published in the British Medical Journal, researchers analyzed 40 episodes each of The Dr Oz Show and The Doctors, and objectively analyzed medical claims made in each show.

They found that only one out of three Dr Oz recommendations had believable evidence behind it, and one out of two for The Doctors. They found that overall, insufficient information was provided for medical claims made, and therefore it was not possible for viewers to make informed decisions about what they were hearing.  Their conclusion was that recommendations taken by patients watching these shows ends up being based on trust of the TV host rather than on the actual information provided.

As quoted by one of the authors of the study on the University of Alberta website: “Our bottom-line conclusion is to be skeptical of what you hear on these shows.”  Amen!

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Endocrine Society Recommends Against Testosterone Treatment in Women

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


Key points in these guidelines:

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

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

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

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

3.  They recommend against treatment of women with DHEA.

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

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Are All Milks Created Equal?

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

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

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

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

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

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

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

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Could Coffee Protect Your Liver?

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

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

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

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

Enjoying my java..... :)

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Myths and Misconceptions About Obesity

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

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

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

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

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

3.  Diets work in the long term. 

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

4.  Weight loss does not have significant adverse effects. 

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

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


5.  Exercising is better than dieting to lose weight. 

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

6.  Everyone can lose weight with enough willpower. 

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


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

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

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Is Eating Organic Really Better?

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

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

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

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

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

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

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

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

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

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

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

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