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Health Canada Approves New Obesity Treatment

>> Monday, March 2, 2015








Hot on the heels of the FDA's recent approval, Health Canada has now also approved the use of a diabetes medication called liraglutide as a weight loss medication for people with or without diabetes.

  
Liraglutide is a medication that has been in use in Canada to treat type 2 diabetes for several years (called Victoza).  As an obesity treatment, it will have a different name, Saxenda; the medication is the same, but the dose to treat obesity is a little higher (based on clinical trials, which you can read more about here).  

Liraglutide can now be used as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of:
-      30 kg/m2 or greater (obesity), or;
-      27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes, or high cholesterol);

and who have failed a previous weight management intervention.

Liraglutide is a derivative of a human hormone called GLP-1, which is released in response to meals.  It works to tell the pancreas to release insulin, and suppresses another hormone involved in blood sugar regulation, called glucagon.  It helps with weight loss by sending a message to the satiety (fullness) centre of your brain, and it has an effect, particularly in the early weeks of treatment, to slow down the stomach.

As for any medication, there are potential risks with using liraglutide.  Common side effects include stomach upset, particularly nausea as the stomach is slowed initially, but this usually improves in the first weeks on the medication.  As for more severe side effects, the question has been raised as to whether this class of medications could cause inflammation of the pancreas (called pancreatitis), but to date, a causative connection has not been established (see more from the FDA and European Medicines Agency on this here).  Liraglutide has been shown to cause a rare form of thyroid cancer in rodents; this has not been seen in humans but is being monitored.  (For further discussion of side effects, see the FDA press release on Saxenda). 

My take on this? The approval of liraglutide for obesity is a landmark, in that this is the first time that a human gut hormone has been approved for obesity treatment.  There are many gut hormones involved in the feeling of fullness, many of which are being actively studied; combinations of these hormones look promising as well.   This is also a landmark decision for Health Canada, in that it has been almost twenty years since a medication was approved for the treatment of obesity in Canada.    


Please refer to my blog post on the FDA's approval last month for my further thoughts on this topic.  

Disclaimer: I was involved in the research trials of liraglutide as an obesity treatment.  I receive honoraria as a continuing medical education speaker and consultant from the makers of liraglutide (Novo Nordisk). I am involved in research of medications similar to liraglutide for the treatment of type 2 diabetes. 


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2015


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Pick the 'Diet' That Works For You!

>> Sunday, February 22, 2015




For those of you who have been following my blog posts about some of the popular diet plans out there, you may be wondering.... where does this leave you?!

To round out this discussion, I'd like to draw your attention to a recent meta-analysis of data in the Journal of the American Medical Association, which compared data on a wide range of weight loss diets of 3 months' or longer duration.   They found that there was very little difference between the weight loss on each diet, on the order of a couple of pounds or less.

The point is that there is no one particular diet plan that works best for everyone - it is a matter of finding the diet plan that will work for you, on a permanent basis.  To engage in a temporary diet is most often pointless and often even a setback in the longterm, as most often these efforts result in weight regain (and then some) after the diet plan is stopped.

So, when you are looking at permanent lifestyle changes to make, ask yourself - are these changes that you can make and stick to for the rest of your life?  Finding the right personalized formula for you, to best answer this question, is key.  Bringing a nutritionist or dietitian on board can be helpful to get you set in the right direction.  Remember to speak with your family doctor before making any changes, particularly if you take medication to treat diabetes, or if you have any medical problems such as kidney or heart problems.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2015

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Sniffing Out Inhaled Insulin

>> Monday, February 16, 2015






In an effort to find alternative ways to administer insulin apart from the current standard of injecting it under the skin, a new inhaled insulin has recently been made available in the United States.

Called Afrezza, the inhaled insulin is taken at mealtime, and is used instead of fast-acting insulin injection at mealtimes (it does not replace the need for long acting insulin in those who need it).  It is rapidly absorbed by the lungs, has its peak action at under an hour, and is gone in 2.5 to 3 hours (a little faster than the fast acting mealtime injectable insulins currently available).

While clinical trials have been done, showing that the inhaled insulin is comparable in efficacy to mealtime injectable insulin in type 1 and type 2 diabetics, these studies have been criticized in that diabetes control in these studies was not as tight as recommended by diabetes guidelines (ie, hemoglobin A1C of 7% or less).  


There are a number of additional concerns with inhaled insulin, including:

1.  Dose increments are large (it has to be adjusted by 4 unit increments, whereas injectable insulin can be adjusted by as little as 0.5 unit increments).  This makes it harder to fine-tune blood sugar control.

2.  Inhaled insulin cannot be used in smokers or people with lung disease (such as asthma).

3.  Inhaled insulin causes a small decrease in lung capacity (forced expiratory volume).   Lung function has to be monitored in people using inhaled insulin.


My take:  Due to the concerns above, I don't see this as a game changer in diabetes care.  Should this inhaled insulin become available in Canada, I will continue to recommend the currently available injectable mealtime insulins to my patients.  That being said, for people who are very resistant to the idea of taking an injectable mealtime treatment, this could offer an (inferior) alternative way to give insulin to those people - ie, it may be a better alternative to no mealtime insulin at all in people who need it.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2015



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Jenny Craig - Dr Sue's Review

>> Sunday, February 8, 2015







This week, I’m reviewing one of the most popular diet plans out there – Jenny Craig. 

Jenny Craig essentially works by taking the thinking out of eating – you eat prepackaged food in accordance with a planned menu that is provided to you.  Members have access to individualized, private counselling sessions, and a combination of recommendations for both nutrition and physical activity is provided.

As members move along in the program, the diet loosens up a little bit, allowing 1-2 days per week with non-Jenny foods.

The Jenny program has been shown to be effective in clinical trials.  A two year randomized clinical trial has shown that the Jenny diet is effective to reduce weight compared to a control group who received standard dietary counselling.   Jenny Craig has also been studied in type 2 diabetics, showing better diabetes control and more weight loss at 1 year, compared to a group receiving standard care.

The biggest plus I see about the program is that it teaches portion control, in that members can see from the portions provided what an appropriate meal size should be.  It is also a balanced diet, with the menu plans created in accordance with the USDA Dietary Guidelines.

The biggest downside I see is that this is not a permanent lifestyle change.  A person cannot order Jenny's food for the rest of their lives (nor would it be recommended to, particularly re the salt content).  So what happens when a person stops the diet?  The vast majority return to previous cooking and eating habits, and the weight goes back up.  Yes, if a Jenny Craig graduate takes the learnings about portion control into the future and continues this in a lifelong fashion, it may be possible to keep the weight off afterwards – but this isn’t the reality for most.

Another concern is cost.  There’s an enrolment fee of about $50, followed by a monthly fee of about $30, and the daily food cost comes in between $15-22 according to the website.  Another down side is salt intake, which is quite high in some of the meals that are provided.

Dr Sue's bottom line: While it is clinically proven in the short term and does teach portion control -  it's not a permanent lifestyle change, so I don't recommend it.  

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2015

 





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Canadian Obesity Guidelines: What's Missing

>> Sunday, February 1, 2015








Last week, new clinical practice guidelines for the prevention and management of obesity in Canada were published by the Canadian Task Force on Preventive Health Care in the Canadian Medical Association Journal.

Unfortunately, it is not exactly a 'solutions based' document.   The main recommendations are as follows:

1.  Body mass index (BMI) should be calculated by family doctors to help prevent and manage obesity.

2.  Structured programs should not be offered to adults of normal weight, to prevent weight gain.

3.  For adults with overweight or obesity, structured programs should be offered to help with weight loss.

4.  Medications should not be used to treat obesity.


While I could pick apart their focus on BMI, or that not offering preventive programs was (in their words) a weak recommendation based on very low quality evidence, I want to focus on their recommendation not to use medications to treat obesity.

Advising us against using medications to treat obesity may be short sighted.  While Canada currently has very little in terms of medications to treat obesity, several medications have been approved in the last three years by the FDA in the United States to treat obesity, some of which may become approved for use by Health Canada as well.  Will the guidelines be hastily rewritten if/when these medications become available to us? Advising against medications to treat obesity leaves us with lifestyle measures on one end of the spectrum, and bariatric surgery on the other end.  While the US and Europe move forward in accepting obesity as a medical problem with medication options to treat it, is Canada going to stay in the dark ages on this?  Note that while our Task Force is telling us not to use medications to treat obesity, that the Endocrine Society in USA simultaneously released their Clinical Practice Guideline about how to treat obesity with medications.  While I agree that the current singular medication available to treat obesity in Canada (orlistat) is not very useful, a note that options may change in the near future may have given this section a little more balance.

Another concern I have with these guidelines: Discussion of bariatric surgery was conspicuous in its complete absence.  While bariatric surgery is an extreme treatment measure for obesity, it is a valuable one, and of great benefit for some patients.  It is stated that these guidelines are not intended for patients with a BMI over 40 (bariatric surgery is considered an option if BMI is >40, or >35 with complications of obesity), but I feel that at least a head nod to the existence of bariatric surgery should have been given in this document.

And - how does one exclude people with BMI >40 from the guidelines, when one in eight Canadian adults who struggle with obesity fall into this category?

The procedure that leads to creation of guidelines is a rigorous review of evidence, and I get that this is why these guidelines look the way they do - lifestyle intervention studies and evidence are poor, medication options in Canada are currently limited, and availability of bariatric surgery is minimal compared to the number of people who could benefit from these procedures.

However, as an advocate (warrior?) for my patients who struggle with excess weight, I will continue to remain optimistic that more options and accessibility will ultimately become available to Canadians to treat this condition.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2015






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A HEARTFELT WELCOME!

I am excited that you have arrived at my site, and I hope you are too - consider this the first step towards a Healthier New You!! As a medical doctor, Endocrinologist, and obesity specialist, I am absolutely passionate about helping people with weight management. Though there is certainly no magic cure for obesity, there IS a successful treatment plan out there for you - it is all about understanding the elements that contribute to your personal weight struggle, and then finding the treatment plan that suits your needs and your lifestyle. The way to finding your personal solution is to learn as much as you can about obesity: how our toxic environment has shaped us into an overweight society; the diversity of contributors to obesity; and what the treatment options out there are really all about. Knowledge Is Power!!


Are you ready to change your life? Let's begin our journey together, towards a healthier, happier you!!




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