Diabetes Information

Are Diabetic Men At Risk of Fertility Problems?

2012-01-15T06:07:00.001-07:00

Although diabetes is known to be associated with many complications, infertility amongst men is not traditionally thought of as being one of them. Similarly, when a couple presents to a fertility clinic, diabetes in the man is not typically on the list of conditions to rule out. As it turns out, diabetes in men can have an impact on fertility from several perspectives, right down to the DNA of the sperm themselves.

As reviewed by Sandro De Vignera and colleagues, the prevalence of subfertility or infertility amongst men with diabetes has been reported to be as high as 35-50% in some series, and is significantly higher than sub/infertility amongst men without diabetes. Smoking and obesity appear to be the strongest risk factors for infertility amongst diabetic men.

There are several mechanisms by which diabetes can be associated with fertility problems. It is well known that diabetes can be associated with erectile dysfunction, lower testosterone levels (particularly in cases of severe insulin resistance or obesity), and retrograde ejaculation (ejaculation ‘backwards’, into the bladder).

More recently, it has been discovered that diabetes can also be associated with damage to the DNA of sperm. Studies suggest that diabetic men have a higher percentage of sperm with DNA damage compared to non diabetic men, and it has been postulated that this may be due to increased concentrations of ‘advanced glycation end products’ throughout the reproductive tract (proteins with sugar stuck to them, which is a consequence of elevated blood sugar over time), leading to more ‘stressed’ metabolic processes (known as ‘oxidative damage’) and thereby DNA damage.

While several of the above mentioned elements can occur in both type 1 and type 2 diabetes, there are some differences as well. While type 2 diabetics are more likely to suffer from the insulin resistant mechanisms of infertility (obesity, low testosterone), men with type 1 diabetes have an increased risk of concomitant autoimmunity against the developing sperm or related structures.

While this topic can be discussed in far more detail than I have presented here, the key take home message today is that diabetes may play an important role in male factor infertility. Fertility concerns or desires should be addressed in the evaluation of the diabetic male patient, and the possibility of diabetes should be considered in a man presenting with fertility concerns.

drsuetalks@gmail.com

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The Global Impact of Diabetes

2011-12-17T08:04:00.002-07:00

Though the prevalence of diabetes is alarming in every country, the Middle East has come on the radar more recently, and is in fact home to six of the top 10 countries for diabetes rates worldwide. It is thus very fitting that this year's World Diabetes Congress, hosted by the International Diabetes Federation, was held last week in Dubai, United Arab Emirates. I had the pleasure of hearing diverse speakers from around the globe at the conference, and what I would like to share with you this week are some hard numbers and facts about the impact of diabetes around the planet (with reference to the excellent speakers, as well as the International Diabetes Federation's Diabetes Atlas, 5th edition).

Did you know that:

1. There are currently 366 million people in the world with diabetes (including about 8.3% of the world's adult population). By 2030, this number will be 552 million.

2. There is little gender difference in diabetes rates, with 185 million men and 181 million women affected worldwide.

3. All nations are suffering the impact of the diabetes endemic; there is no country in the world where diabetes rates are not increasing.

4. Fifty percent of people who have diabetes - don't know it. In Africa, 78% of people with diabetes are undiagnosed.

5. There are more people with diabetes living in urban areas compared to rural areas. (The reasons why are probably several: urbanites tend to have more access to fast/Western unhealthy food choices, and tend to be less active, to name two.)

6. The greatest number of people with diabetes are in the 40-59 age group.

7. In addition to the people who already have diabetes, an additional 6.4% of the world's adults are estimated to have impaired glucose tolerance (a form of prediabetes). That's a total of nearly 15% of the world's adults who currently have prediabetes or diabetes.

8. Rates of gestational diabetes (diabetes in pregnancy) are on the rise worldwide as well; further, women who have had gestational diabetes are at very high risk of developing type 2 diabetes.

9. 80% of people with diabetes live in low and middle income countries, who often have little or no access to medications needed for control of blood sugars.

10. The country with the highest diabetes prevalence is the Pacific island nation Kiribati, at a staggering 25.7%.

Food for thought. (pun intended)

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The Vote is In, but the Jury is Out - Is Bariatric Surgery an Appropriate Treatment Option for Type 2 Diabetes?

2011-12-08T01:36:00.002-07:00

At this week's World Diabetes Congress in Dubai, hosted by the International Diabetes Federation, I had the opportunity to listen to a fantastic debate as to whether bariatric (weight loss) surgery is an appropriate treatment option for Type 2 Diabetes.

The argument in favor of bariatric surgery was presented by Dr Francesco Rubino, a bariatric surgeon and leading authority on the issue from Cornell University, in New York. He highlighted key points of evidence regarding the benefits of bariatric surgery in terms of improving diabetes, noting that bariatric surgery provides a powerful potential opportunity to reverse the course of an otherwise progressive disease. While the current criteria for bariatric surgery in diabetics include a Body Mass Index (BMI) ≥35, he presented for us the International Diabetes Federation position statement on the role of bariatric surgery, which suggests that surgery should also be considered in people with BMI 30 to 35 when diabetes cannot be adequately controlled by medical therapy, especially in the presence of other cardiovascular risk factors. (BMI can be calculated here)

Dr Rubino noted that bariatric surgery stands apart from some other medical treatments of diabetes, in that many medications cause weight gain, whereas bariatric surgery can result in substantial weight loss. He noted that patients who are most likely to have the greatest improvement (or complete remission) of diabetes include those with a shorter duration of diabetes, and lower preoperative medication requirements; in other words, earlier intervention appears to produce the best results. He noted that not only does bariatric surgery improve diabetes, but can also be very effective to prevent new cases of diabetes. Other benefits include some improvement in cholesterol profile and blood pressure, which are also risk factors for cardiovascular disease. Gastric bypass is superior to gastric banding in achieving these effects. (Sleeve gastrectomy was not discussed in particular - I enter my own editorial comment here, that sleeves are proving to be quite effective to treat type 2 diabetes as well, somewhere between gastric bypass and banding in terms of efficacy, but so far appearing to be closer in efficacy to gastric bypass).

In discussion of the very limited accessibility to bariatric surgery, Dr Rubino provocatively noted:

"If there were a pill or a shot that can control blood sugars, improve body weight, cholesterol and blood pressure, and improve survival, would it be acceptable that >99% of people do not have access to the treatment? "

He concluded with the comment that we should not be using BMI as the most important criteria or cutoff in choosing the right patient for bariatric surgery; rather, we should be considering the metabolic disease (in particular, diabetes) that each patient carries, and stratify our decision re surgical candidates based on cardiovascular risk profile, as the BMI does not tell the whole story.

The negatives for bariatric surgery in the treatment of type 2 diabetes was presented by Dr John Pinkney, professor of diabetic medicine from Plymouth, UK.

Dr Pinkney opened with a discussion of the treatment goals for type 2 diabetes, including increasing life expectancy, reducing cardiovascular disease, reducing small vessel complications of diabetes (eye, kidney, and peripheral nerve complications), and improving quality of life, using treatment modalities where the benefits exceed the risks. Many of these health goals are achieved by optimizing control of vascular risk factors (diabetes control, blood pressure, and cholesterol).

In terms of treatment targets for diabetes, Dr Pinkney notes that several recent diabetes trials have suggested that tight glucose control may not actually prevent cardiovascular events, compared to slightly less tight glycemic control. He wondered, then, whether getting diabetes into excellent control with bariatric surgery would really be of that much benefit (and worth the risk?) in patients who had reasonable control of their diabetes in the first place.

He noted that while the improvements in blood pressure and cholesterol with bariatric surgery are statistically significant, that the absolute improvements are not that big. From the prevention of small vessel diabetes complications perspective, he noted that there is not yet much study in this area, and the question as to whether bariatric surgery prevents these diabetes complications in the long term remains unanswered.

While improvements or remission of diabetes is certainly impressive, the long term durability of diabetes remission was discussed, in that the most recent literature is now suggesting that a substantial proportion of diabetes that initially goes into remission, recurs years down the road.

The downsides of bariatric surgery require very serious consideration, and the risks vs benefits must be weighed carefully. The risk of death due to the surgery itself was discussed, though Dr Rubino noted that this risk is approximately that of a gall bladder removal surgery (ie, fairly low as far as surgeries are concerned). Although the need for diabetes medications may decrease with surgery, these treatments are 'traded in' for the need for a new array of lifelong nutritional supplements (the exact array of supplements needed depends on the type of surgery). Not taking these supplements or not having them monitored carefully can result in life threatening complications. The removal of the freedom to 'eat as I wish' and the potential impact on quality of life was also noted.

Dr Pinkney noted that type 2 diabetes is a complex disease that is very common, and suggested that it may not be feasible or productive in general to consider a treatment (surgery) that is very expensive, requires lifelong follow up, and is therefore not accessible for any but a small sliver of the people with diabetes worldwide.

Both presenters were grateful for the opportunity to present this important topic, noting that the topic of bariatric surgery has only been taken seriously as a potential therapy for diabetes in the last few years.

At the conclusion of the presentations, a show of hands of the audience was requested as to how many people were in favor vs against the use of bariatric surgery to treat type 2 diabetes (this was an auditorium containing several hundred diabetes health care professionals from around the world) - to my eye, the vote was roughly evenly split.

My feeling on this issue is reflected in an underlying theme to both of these presentations: the decision for bariatric surgery is a highly patient specific decision. Each patient must be considered on a case by case basis, with the benefits and risks carefully weighed and discussed in exquisite detail. For the right diabetic patient, bariatric surgery can provide an appropriate treatment option.

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Does Your Genetic Background Result In Your Diabetes or Weight Struggles being Unmodifiable?

2011-11-11T10:20:00.000-07:00

In my post last week, I discussed the large and important contribution of genetic background towards the tendency to develop type 2 diabetes or obesity. Since that time, I've had a couple of people ask me whether there is any point to undertaking lifestyle intervention (ie changes in eating patters and/or activity) if their genetics have already dictated that they are going to have a lifelong struggle with these conditions.

As I noted last week:

While it is true that eating well and exercising are the cornerstones of the management of type 2 diabetes, and can certainly improve diabetes control, it is not possible for most people with diabetes to make it go away with these lifestyle changes.

This week I would like to bring the focus to the first part of this statement - ie, that lifestyle changes can certainly improve diabetes control, and improve obesity as well. Just about everyone with type 2 diabetes or weight struggles can see some improvement with permanent lifestyle change. How much improvement that is seen is going to depend on several factors, including:

For those who struggle with their weight or eating patters: Have the root causes of that struggle been addressed? (emotional eating, depression, medications causing weight gain, untreated sleep apnea.... the list of possibile contributors is long)
What is the degree of motivation to change?
What permanent lifestyle interventions have been undertaken, and are they in line with the genetically determined tendencies and ethnic/cultural considerations of the patient?

On the last two points - yes, it's true - our genetic makeup plays a part in determining which lifestyle changes will work best for us, and may even play a role in our levels of motivation to do so. For example, studies have shown genetic differences in the natural tendency to exercise than others, so for some, exercise will play a greater part in the success of their permanent lifestyle changes than for others. As another example, each of us has our own unique balance point of hunger and satiety hormones, such that some of us need more food or a higher body weight to feel full than others. For those people, medications that are directed towards modifying these hormone balances may be a great leap forward in helping them lose weight (such medications are available to treat type 2 diabetes, but not to treat obesity per se).

Again on the line of genetics, it is important that practical goals are set, with regards to controlling type 2 diabetes or managing obesity with lifestyle changes. For diabetics, there may be only a certain amount of glucose control that can be obtained by making lifestyle change - the pancreas gets tired over time (genetics and stress on the pancreas caused by overweight both play a role here), and for many, medications need to be started despite the very best efforts on the part of the patient.

From a weight stance, the goals must be practical as well. Remember that even a 5% body weight reduction (in those who are overweight or obese) decreases the risk of a whole host of complications associated with excess body weight.

The key in maximizing lifestyle success is in finding the form, or forms, of permanent lifestyle change that work for you - the bulk of this blog is dedicated to just that, in an attempt to help provide you lots of different lifestyle options to try on your journey towards permanent lifestyle change. And don't be afraid to ask your healthcare providers for help - remember, there is no shame.

Dr Sue Pedersen www.drsue.ca © 2011 drsuetalks@gmail.com

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There Should Be No Shame in Having Diabetes

2011-11-04T12:02:00.002-06:00

I came across this excellent article online yesterday on msnbc.com, which discusses the stigma often associated with having diabetes. The personal stories made me sad, then made me mad, and then I decided to take matters into my own hands and discuss this very important topic as this week's blog.

Mary's story is one that I hear from my patients on a regular basis - there is often a feeling of shame associated with having type 2 diabetes. Because type 2 diabetes is often seen in association with overweight, there is a stigma upheld by many members of the general public that people who have diabetes are lazy, eat too much, don't exercise, and are not interested in their health.

What people need to realize, is that it is not the fault of the individual that they have diabetes. There is a very strong genetic basis for developing diabetes (as blogged previously), and a very strong genetic basis for obesity as well (read more here), which we are learning more about every day as new genes involved are continuously being discovered. Furthermore, there are many people out there with type 2 diabetes who are not overweight or obese - this speaks to the very strong genetic tendency towards developing diabetes in these individuals. While it is true that eating well and exercising are the cornerstones of the management of type 2 diabetes, and can certainly improve diabetes control, it is not possible for most people with diabetes to make it go away with these lifestyle changes.

When I am discussing optimization of diabetes control with my patients, they often tell me that they feel embarrassed to check their blood sugars in public, or to administer medications or insulin in front of other people. As a result, they may choose to forgo checking sugars or administering medications at times like lunch, when they are often out in public. It breaks my heart each time I hear this - how can our society be so cruel and judgemental?

It's high time that our society gets a grip on what it actually means to have type 2 diabetes. This disease has a strong genetic predisposition; our extremely toxic, fast food, sedentary enviroment is conducive to bringing it out in many people who are genetically prone.

People with diabetes who are seen checking blood sugars or administering insulin in public are showing committment and motivation to watch their numbers, and to do everything they can to optimize their glycemic control and their health - they deserve a HIGH FIVE! from all of us!

And a High Five to msnbc.com for writing this fabulous article - I hope their far reach will do well to get this message out to many. Feel free to pass on this article as well, to everyone you know!

Dr Sue Pedersen www.drsue.ca © 2011 drsuetalks@gmail.com

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Smoking and Diabetes Risk: A Deadly Combination

2011-01-30T10:53:00.001-07:00

It comes as no surprise to anyone reading this blog that smoking is bad for your health. Interestingly, the risk goes far beyond cancer risk and heart disease - smoking has an important impact on diabetes as well.

As reviewed by Patasi and Hall, several studies have demonstrated that smoking increases the risk of developing type 2 diabetes 2- to 3- fold. The likely reason behind this fact is that smoking decreases the body's ability to use insulin. In fact, smoking 1 cigarette reduces the body's ability to use insulin by 15% for an entire day! We also see that amongst patients with type 2 diabetes, smokers have higher blood sugars than nonsmokers.

Vascular disease is a complication of both smoking and diabetes, so it should come as no surprise that having both risk factors compounds the risk. Smoking diabetes are more than 10 times more likely to develop peripheral vascular disease than nonsmoking diabetics, and also have a higher risk of small vessel diabetic complications such as nerve, eye, and kidney damage. Smoking can also lead to impotence amongst diabetic men. And that's not all - the list goes on.

Given that we know that smoking increases the risk of several cancers as well as the risk of vascular disease, and that 80% of diabetics will die as a result of heart disease or stroke, smoking and diabetes are truly a deadly combination.

Dr Sue Pedersen www.drsue.ca © 2011 drsuetalks@gmail.com

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Are Genetics Important in Diabetes?

2011-01-22T17:05:00.000-07:00

In a world where the epidemic of diabetes threatens to spiral out of control, our understanding of the influences that put people at risk of developing the disease is crucial. As a second part to my recent blog about the important genetic influence on the development of obesity, it is also very important to consider the genetic contribution towards diabetes.

In North America, approximately 80% of diabetes is caused by Type 2 Diabetes, which is a condition of elevated blood sugars caused by resistance of the body's organs and tissues to the effects of insulin, to the point where the pancreas is not able to produce sufficient insulin to overcome this state of insulin resistance. Insulin resistance and Type 2 Diabetes worsen with weight gain and improve with weight loss; however, there are a subset of people with Type 2 Diabetes who are normal weight. About 10% of diabetes is Type 1 diabetes, where the immune system attacks the pancreas and causes it to fail to produce insulin. The final 10% of diabetes is causes by various rare genetic disorders.

The evidence for a strong genetic tendency towards developing Type 2 Diabetes is strong. For example:

some ethnic groups residing in North America (such as Hispanic, South Asian, and Aboriginal) are at 2-6 fold higher risk of developing Type 2 Diabetes compared to North American Caucasians
a twin of a person with Type 2 Diabetes is at 90% risk of developing the disease (as compared to Type 1 diabetes, where the risk is lower at 50%)
nearly 40% of patients with Type 2 Diabetes have at least one affected parent (whereas in Type 1 Diabetes, the risk of the child of a Type 1 Diabetic parent getting the disease is only 6%)
the lifetime risk of a person getting Type 2 Diabetes is 5-10 times higher if they have a first degree relative with the disease, compared to not having a relative with the disease

As reviewed by Dr McCarthy, the search for genes connected to Type 2 Diabetes has really taken off with the ability to search the entire human genetic makeup (called the 'genome') in recent years. In fact, there are at least 40 genetic spots (called 'loci') in the human genome that have been found to be associated with a susceptibility to developing Type 2 Diabetes. These genetic variants are associated with a variety of disturbances that affect the risk of developing Type 2, including alterations in the development of the pancreas, insulin synthesis, and insulin secretion. The genes that contribute to development of obesity (as blogged previously) likely contribute to the risk of type 2 diabetes as well, as the insulin resistance that characterizes type 2 diabetes worsens with weight gain.

In terms of the influence of these genetic variants on the risk of Type 2 Diabetes, it appears that in some cases, having two abnormal copies of these genes may as much as double the risk of getting diabetes, compared to having two normal copies of these genes.

For some individuals, the eventual development of Type 2 Diabetes may be unavoidable, due to their genetic makeup. However, many cases of Type 2 Diabetes are preventable, as many people develop sufficient insulin resistance to generate full blown diabetes only when they reach a state of overweight or obesity. While obesity in itself has some genetic predisposition as well, both obesity and type 2 diabetes can be improved with dedicate attention towards a healthy lifestyle.

As for obesity genetics, our understanding of the genetic basis for Type 2 Diabetes is essential, as it will help us in better understanding the disease, finding new targets for treatment, and hopefully allowing us to improve individual strategies towards treatment and prevention.

Dr Sue Pedersen www.drsue.ca © 2011 drsuetalks@gmail.com

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After Gestational Diabetes: What's Next?

2011-01-09T20:54:00.000-07:00

Gestational diabetes, or diabetes diagnosed for the first time during pregnancy, is a common condition, affecting approximately one in 25 pregnant women in Canada. After the baby is born, women who had gestational diabetes may be eager to leave their blood sugar concerns behind, but beware: women who have had gestational diabetes are at high risk of developing type 2 diabetes.

In pregnancy, there are several factors that contribute to the development of gestational diabetes, including increased food intake, weight gain, decreased exercise, and the production of several hormones by the placenta that make the mother more resistant to the effects of insulin. As the development of gestational diabetes identifies women whose pancreas is not able to keep up in the face of the stress of pregnancy, it also identifies women who are at future risk of developing full blown type 2 diabetes (outside of pregnancy). In fact, having had gestational diabetes increased the risk of developing type 2 diabetes later in life by up to 12 fold. Further, some cases of gestational diabetes were likely type 2 diabetics before the pregnancy started, but they did not come to medical attention until the pregnancy began.

Because the impact of undiagnosed type 2 diabetes postpartum is of serious consequence to the mother's health, and also has implications for future childbearing, it is essential that these women undergo screening for type 2 diabetes postpartum. Blood sugars will be checked following delivery in the hospital, but this alone is not enough, as diabetes can return after discharge home when normal life and eating patterns resume.

All women who have had gestational diabetes must undergo a glucose tolerance test within 6 weeks to 6 months postpartum. This involves drinking a glucose containing drink, with measurement of blood sugar before and 2 hours after the drink is taken. Checking fasting blood sugars is not enough, as this will miss 40% of type 2 diabetes in the postpartum population.

Additionally, women with previous gestational diabetes must be screened for type 2 diabetes:

* before any future pregnancies
* every 3 years, or more often, depending on other risk factors

Unfortunately, as few as 25% of women who have had gestational diabetes complete this important postpartum testing. Having undiagnosed type 2 diabetes can cause injury to blood vessels supplying vital organs including the heart, kidneys, and eyes. Having undiagnosed type 2 diabetes at the time of the next pregnancy can have devastating consequences to the fetus, including congenital malformations and miscarriage.

If you have or have had gestational diabetes, speak to your doctor to be sure that you have undergone, and continue to undergo, the appropriate screening.

Dr Sue Pedersen www.drsue.ca © 2010 drsuetalks@gmail.com

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Dental Disease and Diabetes: What's the Connection?

2010-11-20T10:09:00.000-07:00

It is well known that diabetics are at an increased risk of vascular complications, and that control of blood sugar, cholesterol, and blood pressure are important to prevent these complications from developing. One often overlooked risk factor in diabetics is periodontal disease, a chronic bacterial infection affecting the gums and bone that support the teeth.

Periodontal disease is known as gingivitis in its mildest form, presenting as tenderness, redness, and swelling of the gumline. If untreated with proper oral hygiene (adequate brushing and flossing), this can evolve to a chronic condition with gum recession, plaque accumulation and bone loss, called periodontitis.

The relationship between periodontal disease and Type 2 Diabetes is something of a vicious cycle. First of all, it is known that diabetics are at higher risk of developing periodontal disease, and that it is more severe than in non diabetics. The elevated blood sugars increase the susceptibility to infection - bacteria thrive on the excess sugar that is available.

On the other side of the coin, having periodontal disease is associated with an increased risk of developing diabetes, and is also associated with poor blood sugar control in patients with diabetes.

A key factor responsible for the relationship between periodontal disease and diabetes appears to be inflammation. As discussed by Dr Tenenbaum and colleagues in a recent publication by the Canadian Diabetes Association, periodontal disease produces a low grade inflammatory state, with increased levels of inflammatory chemicals in the blood stream. These inflammatory mediators are known to be associated with increased risk of vascular disease, and true to that, an increased prevalence and incidence of cardiovascular disease has been observed in patients with periodontal disease. We also know that Type 2 Diabetes and the complications that develop are partially mediated by inflammatory changes in the blood vessel wall, so this may be part of the link between the two conditions.

To minimize your risk of periodontal disease, follow these important tips from the Canadian Dental Association:

Brush your teeth and tongue twice a day with toothpaste and floss once a day to remove plaque between teeth. When choosing oral health care products, check for the Canadian Dental Association (CDA) Seal of Recognition.
Products bearing this Seal have been reviewed by CDA and have demonstrated specific oral health benefits.
Check your gums regularly. Look for the warning signs of gingivitis and report them to your dentist right away.
See your dentist for regular check ups, and schedule a professional cleaning to remove stains and built-up tartar.
Eat healthy foods for your oral health as well as your overall health. Eating excess sugar is one of the primary causes of dental problems. With the proper nutrients that come from healthy eating and proper oral hygiene, you can fight cavities and gingivitis.
Don't smoke. Smoking is a major contributor to dental problems and may cause oral cancer.

Dr Sue Pedersen www.drsue.ca © 2010 drsuetalks@gmail.com

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Video Blog: Test Tubes Illustrate High vs Normal Blood Sugars

2010-11-18T20:04:00.000-07:00

In this video blog, Dr Sue shows you two mock test tubes, illustrating what normal blood looks like and how it flows, compared to blood when blood sugar is high. It is important to control blood sugars (keeping levels as close to normal as possible) to prevent or delay the complications of diabetes over time, including damage to the eyes, heart, kidneys, nerves in the feet, and blood vessels throughout the body.

Dr Sue Pedersen www.drsue.ca © 2010 drsuetalks@gmail.com

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Benefits to Barley and Buckwheat? The Low Glycemic Index Diet

2010-10-16T12:23:00.002-06:00

Amongst the plethora of weight loss strategies that abound out there, the Low Glycemic Index Diet is touted as yet another way to 'guarantee' substantial weight loss. Let's debulk the mystery - is this fact or fiction?

The Glycemic Index of a particular food refers to the rapiditiy with which the sugars (carbohydrates) in that food are absorbed into our bloodstream. Technically speaking, it is defined by the incremental rise in blood sugar after ingestion of 50 grams of a particular carbohydrate, compared to 50 g of a reference food, which is usually white bread. White bread has arbitrarily been set to have a glycemic index (GI) of 100. A low GI food has a GI of less than 55, while a high GI food has a GI of more than 70.

There has been much controversy as to whether a low GI diet actually results in weight loss. Overall, studies show that a low GI diet is NOT particularly effective, resulting in a 2 lb weight loss over the course of 6-12 months, with a 10-15 GI difference between diets. As low GI diets are usually also high fiber diets, it may actually be the higher fiber content of the low GI diet that is responsible for any weight loss that is seen, as fiber helps to keep us feeling fuller longer, therefore resulting in a lower caloric intake overall.

For diabetics, however, glycemic index is a very important consideration, as a lower GI diet helps to control the rise in blood sugar that is often seen after eating. Having said that, however, the glycemic index has its limitations, as it tells us nothing about the quantity of carbohydrate, only about the quality of carbohydrate.

Therefore, it is not only the glycemic index, but also the Glycemic Load that is important. The Glycemic Load is defined as the GI of a food, multiplied by the number of grams of carbohydrate in a serving of that food, thereby capturing both the quality AND quantity of carbohydrate intake. In other words, if you consume a low GI food (eg brown rice, GI=50) but a large quantity of it (resulting in a high Glycemic Load), the quantity of carbohydrates can contribute not only to a post meal glucose rise, but also to significant weight gain. Thus, it is important to exercise portion control in order to limit the Glycemic Load of a meal.

To improve diabetes control, and to assist in weight maintenance, a few important tips are as follows:

1. Switch up your high Glycemic Index foods for lower GI foods. Examples are to exchange white bread, pasta, or rice, for brown. Try incorporating some interesting carbohydrate alternatives such as pearl barley (pictured above, GI=25-33), lentils (GI 21-30), or buckwheat (GI=50-54).

2. Exercise portion control to limit your Glycemic Load!

3. Balance your meal: including protein, a small amount of fat, or a more acidic content to your meal decreases the Glycemic Index of your meal overall, and can decrease post meal blood sugars by as much as 20%!

Dr Sue Pedersen www.drsue.ca © 2010 drsuetalks@gmail.com

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Protecting You and Your Baby: Diagnosing Diabetes Before, During, and After Pregnancy

2010-06-26T05:03:00.004-06:00

In parallel with the explosion of type 2 diabetes in recent years, so too are we seeing a marked increase in gestational diabetes, or diabetes which is diagnosed in pregnancy. Because of the critical importance of diagnosing and appropriately treating these women, consideration is currently being undertaken for changing the way we approach the diagnosis. These changes would result in a much broader group of pregnant women being identified as diabetic.

The impetus for considering a change in the diagnosis of gestational diabetes (GDM) is that an important study demonstrated that increasing maternal blood sugars were associated with increased birth weight and high insulin levels in the newborn baby, at levels below current Canadian diagnostic blood sugar thresholds for GDM. The International Association of Diabetes and Pregnancy Study Groups has therefore proposed a new set of blood sugar criteria for the diagnosis of GDM which are lower than our current thresholds.

The implications are enormous: as many as 18% of pregnant women would be considered to have gestational diabetes, compared to only 8% with current criteria.

Another important change being proposed is that certain blood sugar criteria would result in the diagnosis of Type 2 Diabetes while pregnant. Currently, when a woman is found to have high blood sugars in pregnancy, we make a diagnosis of Gestational Diabetes, which by definition is a state of elevated blood sugars that would be anticipated to resolve postpartum. However, it is increasingly recognized that many of these women were likely undiagnosed Type 2 Diabetics prior to pregnancy, and in these women, their blood sugar elevation will persist after delivery.

Though there is much ongoing debate as to whether these new criteria should be adopted, the opportunity to underline the importance of diagnosing and treating elevated blood sugars before, during, and after pregnancy must not be missed. The following steps are of crucial importance:

1. Blood sugars should be checked before pregnancy, such that diabetes before pregnancy can be detected and treated to control before conception. This is critically important, as high blood sugars in the first trimester is associated with increased risks including congenital malformations (birth defects), miscarriage, and high blood pressure in the mother.

2. Aggressive screening for diabetes in pregnancy, starting as early as at the time of diagnosis of pregnancy. The screening strategy is more aggressive in women with risk factors for diabetes, which include overweight, family history of diabetes, previously giving birth to a large infant, presence of metabolic syndrome, and certain ethnic backgrounds (such as Aboriginal Indian, South Asian, African ancestry). Remember that a woman who does not have diabetes before pregnancy can develop diabetes even in the very beginning of pregnancy, as several hormonal changes occur in pregnancy that can predispose towards development of diabetes.

3. Diabetes must be carefully checked for after delivery, so as to identify women who have diabetes that persists beyond pregnancy. Checking blood sugars after delivery is not enough; a glucose challenge test (performed under the care of your doctor) must be undertaken.

4. Breast is best: in addition to numerous benefits to the baby, breastfeeding also helps to control blood sugars postpartum in the woman who is persistently diabetic. Breastfeeding is also a great method to help shed pounds after pregnancy, as about 300 calories are expended in breast milk each day (including 50 g of carbohydrates)!

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Nine Percent of Canadians to be Newly Diagnosed with Diabetes over Ten Years

2010-06-19T20:15:00.001-06:00

It is not new news that a diabetes epidemic is upon us. Currently, nearly 6% of Canadian adults (about 2 million people overall) are diagnosed with diabetes. Most of these cases are Type 2 diabetes, which is caused by a state of insulin resistance, and often brought on by overweight or obesity.

Predicted rates of diabetes in the near future in Canada are even more starggering.

An investigative report was undertaken by Canada's Institute for Clinical Evaluative Sciences, to try to predict how many new cases of diabetes we are going to see in Canada over the next few years.

The study found that 1.9 million Canadians are predicted to develop diabetes in the ten year period between 2007-2017. This will nearly double the number of currently diagnosed cases. Although the risk of developing diabetes is higher with a higher weight or higher Body Mass Index (with 'obesity' being defined as a Body Mass Index >30), most of the new cases of diabetes will be in the 'overweight' category (with BMI 25-30), because there are more overweight than obese people in the country. Another concerning trend that is being seen is that younger Canadians are becoming affected by Type 2 Diabetes, due to higher rates of childhood obesity. The youngest Canadian with Type 2 Diabetes currently on record is only six years old. Risk factors for developing type 2 diabetes in Canada were identified, and include:

higher Body Mass Index (you can calculate your own BMI here, in the right hand column)
increasing age
being male (vs female)
people who have immigrated to Canada (compared to people born in Canada)
being a lower-income woman, or a higher-income man
ethnic background
having lower levels of education

In this report, a Diabetes Population Risk Tool has been constructed, with which the risk of a particular individual developing diabetes can be generated, taking into account various risk factors and demographic data (BMI, age, gender, and other factors). They provide two profiles for comparison:

Profile 1: Female, 33 years old, BMI=22 kg/m2, no hypertension, white, not immigrant, post-secondary education.

Ten-year risk of being diagnosed with diabetes: 1.2%.

Profile 2: Male, 55 years old, BMI=38 kg/m2, hypertensive, white, does not have heart disease, smoker, less then secondary school education.

Ten-year risk of being diagnosed with diabetes: 44%.

The report has some good news too - and that is related to the predicted benefits in prevention of diabetes that could be achieved with simple lifestyle intervention. Based on Ontario population data, for example, it is estimated that by providing individuals at highest risk for diabetes with lifestyle therapy (and provided they adhere), only eleven people would need to be treated to save one person from developing diabetes.

The bottom line: Prevention is Key!!

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Diabetes Treatment: Is Weight Loss Surgery the Answer?

2010-05-08T08:57:00.001-06:00

Canada, like the rest of the world, is caught in a diabetes epidemic. Over 2 million Canadians are diagnosed with the disease, and by the year 2020, those numbers are expected to rise to 3.7 million. This epidemic is paralleled by the high prevalence of obesity, which currently affects 25% of Canadian adults and 10% of Canadian children. One of the treatment options that is being increasingly considered to treat type 2 diabetes in the setting of severe obesity is weight loss surgery.

I attended the First Canadian Diabetes Surgery Summit in Montreal this week, hosted by McGill University, to discuss this very issue. Over two very intense and productive days, a collection of international leaders in the area presented their research and clinical experience to a diverse group including Canadian surgeons, family physicians, endocrinologists, health care professionals, and policy makers. A wealth of learning, sharing, and ideas were generated from this summit, of which I am going to discuss over the course of several articles in the coming weeks. Here are the highlights.

In short, bariatric surgery is a very effective treatment for type 2 diabetes. The results depend on the type of surgery done, but remission rates of diabetes of over 80% have been documented, and sustained for at least 2 years. Much of this success is related to the impressive weight loss that is seen with bariatric surgery, but gut hormone changes with certain types of surgery (such as gastric bypass surgery) play an important role as well.

It must be emphasized that bariatric surgery is only appropriate for a very select group of people. The current guidelines recommend bariatric surgery as a potential option for patients with a BMI >40, or a BMI >35 with at least one serious medical complication (such as diabetes), who have failed intensive attempts at weight loss with conventional treatments (lifestyle alteration, medications, etc). Bariatric surgery has a long list of potential side effects and complications that must be seriously considered, and which vary depending on the type of surgery performed. On balance, however, bariatric surgery has been shown to decrease mortality by 28-40% in this population, and as such, may be the most appropriate option for some people.

In Canada, we struggle with very limited accessibility to bariatric surgery. As Dr. Nicolas Christou, one of Canada's leaders in bariatric surgery, pointed out:

Based on very conservative estimates that 5% of the 1 million Canadians who fit criteria for bariatric surgery would actually be appropriate candidates for surgery, 50,000 Canadians would currently be candidates for the procedure.
Approximately 3,000 bariatric procedures will be done in Canada this year.
According to these numbers, then, Canada currently has in excess of a 15 year back log of patients who could benefit from these procedures.

What can we do about this? The problem of course, is funding. Funding for bariatric surgery is extremely limited in Canada, though accessibility does vary greatly by province. Cost analyses suggest that for patients with diabetes, the costs of bariatric surgery to the government are recouped by 26-30 months post operatively, and after that, there are only savings to be had by the health care system due to the decreased rate of diabetes related complications, hospitalizations, and medication requirements of these patients.

On balance, increased accessibility to bariatric surgery in Canada, provided in the appropriate clinical setting by a multidisciplinary, experienced health care team, should be discussed amongst Canadian health care professionals, patients, and the general public.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Western Bad Habits contribute to Diabetes Epidemic in China

2010-03-28T09:34:00.001-06:00

Modern day China provides an unfortunate example of the toxic effects of adopting more western-style habits of unhealthy eating and sedentary lifestyle: according to a new study, there are now nearly over 200 MILLION people affected by either diabetes or prediabetes.

The China National Diabetes and Metabolic Disorders Study Group published an article in this week's New England Journal of Medicine that spells out the details of this metabolic disaster. They conducted an impressively large study of over 46,000 adults from across China, and tested their blood sugars. They found that based on this sample, approximately 92.4 million Chinese adults have diabetes (more than half of these being undiagnosed), and 148.2 million Chinese adults have prediabetes.

When you consider that these numbers total over six times the entire population of Canada, the implications are simply staggering to try to comprehend.

The underlying contributors to this explosion of diabetes in China are several, but one of the dominant themes is the urbanization and 'westernization' of Chinese society. With the advent of fast food to this nation, obesity has exploded in this society in a likewise fashion. Similarly, Chinese urban centres are coming more and more to resemble our own: motorized transport, increased use of the internet, less focussed exercise.... all of these elements have sunk the activity levels to an all time, Western-style, low. So, it seems that the bad habits of the western world have had a seriously negative impact on the metabolic health of our Chinese friends.

To add to the difficulty of the situation, people of Chinese ethnicity have a higher risk of developing diabetes, due to a higher genetic disposition to develop insulin resistance at a lower BMI. Diabetes onset often occurs at a lower BMI compared to people of caucasian ethnicity (though this certainly varies from person to person).

The way in which people of Chinese background manifest high sugars also presents a challenge. According to this recent study and studies before it, Chinese people have a disposition towards having high sugars after a meal even if they have normal blood sugars in the fasting state. As the first step in screening for diabetes is with a fasting blood sugar, it is possible that some of these diabetes diagnoses could be missed if sugars are not tested after a carbohydrate challenge as well.

The situation in China raises yet another red flag: the global tendency towards a progressively more unhealthy lifestyle is having a serious toll on our health, and raises potentially grim prospects for our futures unless we turn things around.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Getting Help in Losing Weight!

2010-01-23T21:39:00.000-07:00

There is no question that each and every one of us is different, and our approach to weight loss is no exception. Success with one weight loss program will be variable from one person to the next, depending on how well it is geared towards that person's strengths, weaknesses, and the areas where that person needs the most support. Some people need help in gaining a better understanding of what healthy food choices are; many need a re-education on portion control (as our toxic society oversizes portions everywhere we look, making it harder to know what an actual portion size should be). Some individuals prefer to design their own weight loss diet, whereas others will excel with a diet plan that is handed to them, and which they simply have to follow without thinking further about it!

In my mission to help my overweight patients achieve a healthy weight, I've come across two fabulous resources that you might consider if you are battling the bulge:

1. Reality Bites (www.mymealplan.ca)

This is a fabulous healthy eating program designed by Canadian dieticians. There is a special emphasis on helping people with diabetes, but the diet plans can be used by anyone who wants to lose weight or simply eat healthy! When you join, you need to select the small (1200-1500 cal), medium (1500-1800 cal), or large (1800-2100 cal) diet plan. To figure out which plan you need in order to lose weight (or maintain weight if you already at appropriate weight), use the BMR calculator on my main page in the right hand column (www.drsue.ca), or talk to you health care provider. This program will then provide you with a fabulous meal plan and a grocery list that makes it very easy to adhere to!

The meal plans are carb and calorie controlled, as well as fulfilling recommendations for intake of fiber, sodium, cholesterol, fat, and saturated fat. There are a plethora of excellent recipes and diabetes information on the site as well. Membership costs $20.95 per month.

2. TOPS (www.tops.org)

TOPS (Take Off Pounds Sensibly) is a nonprofit, noncommercial, weight loss support organization based in the US, with chapters located worldwide. It operates primarily by offering group support, and by accountability with weekly weigh-ins at chapter meetings.

New members should consult with their physician to obtain a goal weight, and then report it to their chapter Weight Recorder. A private weigh in occurs at each chapter meeting, followed by a program on a wide variety of topics pertaining to the weight loss journey and healthy lifestyle. Meetings provide members with positive reinforcement and motivation in adhering to their food and exercise plans.

Cost is $30 CDN per month, plus a few dollars per month in chapter operating costs. There are lots of chapters - I counted 36 within a 25 mile radius of my own postal code! You can locate a chapter here.

These are just a couple of suggestions - there are lots of great weight loss organizations out there. Find the one that's right for you!

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

Prevent Diabetes with Lifestyle: Study

2009-12-03T02:42:00.004-07:00

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

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

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

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

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

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

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

The bottom lines:

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

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

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

The SLEEP AHEAD Study: Weight Loss Improves Obstructive Sleep Apnea

2009-10-03T06:35:00.003-06:00

Obstructive sleep apnea (OSA) is a huge problem. Did you know that 25% of adults are at risk of having OSA? Amongst obese type 2 diabetics, a whopping 86% suffer this disorder. Even worse - many don't know that they have it.

In obstructive sleep apnea, breathing is abnormal during sleep because of narrowing or closure of the throat; this results in air movement being periodically diminished or stopped. It is a serious condition that can affect a person's ability to safely perform normal daily activities and can affect long term health.

It is a well known fact that obesity increases the risk of developing obstructive sleep apnea, and as such, it would make sense that weight loss would improve OSA; however, this had not been definitively proven - until this week.

In the Archives of Internal Medicine, Gary Foster and colleagues published results from their SLEEP AHEAD study. They enrolled 264 overweight or obese patients with type 2 diabetes, and randomized them to receive either a portion controlled diet plus a moderate exercise program, versus three group diabetes education sessions without a specific weight loss plan, for a 1-year period. People in the diet group lost 24 lbs, compared with just over 1 lb in controls. Overall, there was a marked improvement in OSA in the diet group, while OSA worsened in the control group, despite not gaining weight. In addition, more than three times as many participants in the diet group had total remission of their OSA compared to the control group.

Take home messages here are:

1. If you have a risk factor for OSA, or symptoms of OSA, speak with your family doctor about it, as OSA is often underdiagnosed. Risk factors include overweight, male gender, increasing age, and use of sedative medications. Symptoms can include restless sleep, morning headaches, awakening with a choking sensation, awakening feeling unrested, and having difficulty concentrating.

2. We now have clear evidence that in overweight individuals, weight loss improves OSA. Though this study was conducted in diabetics, it is likely that this weight loss benefit would extend to non diabetics as well.

3. A big weight loss and significant improvement in OSA was seen using simple measures: portion control and moderate exercise! Portion control in this study was in the form of liquid meal replacements, snack bars, and portion controlled meals (such as Healthy Choice and Lean Cuisine), which are great options; a portion control plate is a good choice as well!

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

Does Insulin Glargine Cause Cancer?

2009-07-26T06:54:00.004-06:00

Both Health Canada and the FDA are undertaking a safety review of insulin glargine (trade name is Lantus ©), in response to four studies that were published in this month's Diabetologia journal. Three of these four European observational studies suggested that there may be higher rates of cancer amongst patients who use Lantus insulin.

Lantus is one of two long acting synthetic insulins (the other is insulin detemir, trade name Levemir ©). Levemir © was not studied in the above mentioned studies, because it is a newer insulin that was not available at that time. These insulins have been altered from long acting human insulin (known as N or NPH insulin), resulting in different actions of these insulins, with benefits including a longer duration of action and lower risk of low blood sugars (hypoglycemia) compared to human insulin.

Some studies have suggested an increased risk of cancer in all patients with diabetes (on any kind of treatment), though the common denominator here may be obesity (obesity is a well known risk factor for several types of cancers). People with type 2 diabetes (particularly in the earlier years) and people who are overweight or obese often have high insulin levels, also known as insulin resistance. Insulin is an important growth factor, for example for cells that line the colon; in fact, insulin has been shown to stimulate colonic tumor cells. So, insulin in general, whether produced internally, or given as a treatment of diabetes, may be associated with an increased risk of cancer.

So how does Lantus © play into all of this? Lantus © is known to interact with insulin growth factor receptors to a higher degree than other insulins, which could theoretically be associated with increased cancer risk. However, it has to be taken into consideration that these recent studies were observational only, and therefore not high quality data (in other words, not something we can hang our hat on).

The bottom line is, that we do not know at this time whether Lantus © increases cancer risk. Health Canada and the FDA are doing the right thing by looking into this issue. In the meantime, it is important not to take extreme reaction to information that is highly debatable. If you are taking Lantus ©, it is important that you do not simply stop taking it, as not treating your diabetes can lead to dangerously high blood sugars. If you are concerned, please speak to your doctor about the issue, and make a decision about your diabetes treatment that is best for you.

What's YOUR risk of getting Type 2 Diabetes?

2009-06-24T10:32:00.002-06:00

Alongside the obesity epidemic in our society and across the globe, type 2 diabetes has also become - pun intended - a large and growing problem. Nearly 2 million Canadians have diabetes, and even more alarming, as much as 3% of the adult population are walking our streets with diabetes, but don't know that they have it.

One of those people could be you.

Also worrisome is the fact that by the time most people with type 2 diabetes are diagnosed, they have had it for 5-7 years, but did not know it. This is because in many cases, type 2 diabetes can be more or less without symptoms for a number of years, so if an individual does not see their doctor for regular checkups, the diabetes is not detected. Unfortunately, even though there can be little in the way of symptoms, the diabetes is still very active behind the scenes, causing damage to the heart, kidneys, eyes, and nervous system.

The British Medical Journal has recently published a tool called the QDScore, that you can use to calculate your approximate risk of developing Type 2 Diabetes over the next 10 years. This diabetes risk calculator is based on British data from over 2.5 million people, and is valid for use for people between the ages of 25-79. Although it is based on British data, it should still give a very reasonable estimate for Canadians.

To use the calculator, you need to know your weight in kg, and your height in cm.

Weight in kg = Weight in lbs/2.2

Height in cm = height in inches x 2.54(there are 12 inches to a foot, so someone who is 5 feet 4 inches = 64 inches = 163 cm)

So, you've calculated your risk. Now what? See your doctor to talk about it. Your MD will likely elect to test you for diabetes with blood tests, and if negative, you can build a strategy of diabetes prevention together. Should you happen to be one of those 3% with previously undiagnosed diabetes - then you and your doctor can tackle the issue head on, and get started on a treatment plan without delay.

While this risk calculator is a useful tool, it does not replace a visit to your doctor. It is important to see your doctor for regular check ups - but it doesn't hurt to come prepared with this extra information. Knowledge is Power!

Dr. Suehttp://www.drsue.ca/ © 2009 drsuetalks@gmail.com

What IS Diabetes?

2009-04-30T04:55:00.004-06:00

Diabetes mellitus, usually referred to simply as diabetes, is a condition characterized by abnormally high blood glucose (sugar) levels. Blood glucose is normally controlled by a complex interaction of several hormones, the most important of which is insulin, which is produced in the pancreas and works to assist the movement of glucose out of the bloodstream and into our cells.

There are two types of diabetes. Type 1 diabetes (T1DM) is a condition where the pancreas stops producing insulin. This happens because of a glitch in the immune system, where the immune system mistakes the insulin producing cells of the pancreas (called beta cells) as foreign, and attacks them, causing failure and eventually absent insulin prodution. T1DM has onset most commonly in children or young adults.

Type 2 diabetes (T2DM) is caused by a problem that we call 'insulin resistance'. This means that the body's cells need higher levels of insulin to assist movement of glucose into the cells. This puts the pancreas into a state of overdrive, in that it has to work extra hard to make enough insulin to push glucose into the cells and thereby maintain normal blood glucose levels. When the pancreas simply cannot make enough insulin to overcome the insulin resistance, blood sugars start to climb and T2DM results. One of the most important risk factors for T2DM is obesity, because the more a person weighs, the higher their insulin resistance. The onset of Type 2 diabetes has traditionally been seen amongst older individuals, but with the prevalence of obesity on the rise, we are seeing T2DM in younger adults, and even in children.

Dr. Sue © 2009 drsuetalks@gmail.com