Canadian Diabetes & Endocrinology Today

Lipoprotein (a) in Cardiovascular Risk Assessment and Management in Diabetes Mellitus

Gordon A. Francis, MDCM, FRCPC, FAHA — Thu, 12 Oct 2023 00:00:00 +0000

Lipoprotein (a) [Lp(a)] is an independent and genetically-determined risk factor for coronary heart disease (CHD) and stroke that is not changed by alterations in lifestyle factors. It is now recommended by Canadian and other national lipid guidelines to be measured once in a person’s lifetime as part of overall assessment for cardiovascular risk, along with family history; presence of hypercholesterolemia; Type 2 diabetes (T2DM); hypertension; and smoking. The presence of elevated Lp(a) confers additional risk to the already high cardiovascular risk in individuals with T2DM. This review summarizes the nature and association of Lp(a) with elevated cardiovascular disease (CVD) risk; the increased cardiovascular risk in individuals with T2DM; potential therapies to lower Lp(a); whether or not to measure Lp(a); and recommendations on how to respond to the finding of elevated Lp(a) in a patient with T2DM.

Approach to the Management of Thyroid Eye Disease

Sabrina Yu, MD, Vivian T. Yin, MD, MPH — Thu, 12 Oct 2023 00:00:00 +0000

Thyroid Eye Disease (TED), also known as Grave’s orbitopathy, is an autoimmune condition characterized by inflammation of the extraocular muscles, orbital fat and periocular tissues. As the most common orbital disease worldwide, its prevalence is estimated to be between 0.5–2% and it disproportionately affects females 4:1. Although the majority of TED cases occur in patients with Graves’ disease (80–90%), it can also be seen with patients with Hashimoto’s thyroiditis (10%), euthyroid individuals (5–10%) and thyroid cancer. At the time of initial Graves’ disease diagnosis, 25% of patients have clinically detectable orbital involvement that is often mild. The natural history of TED typically consists of an initial active inflammatory period lasting 6–36 months, which then plateaus and is followed by a quiescent fibrotic phase with stabilization of disease.

The Role of Plant-Based Diets in the Management of Type 2 Diabetes

Heidi Dutton, MD, MSc, FRCPC, ABOM, ABLM — Thu, 12 Oct 2023 00:00:00 +0000

A whole food plant-based (WFPB) diet is generally defined as a diet rich in fruits, vegetables, whole grains, legumes, nuts and seeds, and herbs and spices. Many define a WFPB diet as being exclusively plant-based with no animal products, excluding all red meat, poultry, fish, eggs, and dairy products. Other sources define it as a plant-forward dietary pattern that may still include small amounts of meat, eggs or dairy. A WFPB dietary pattern focuses on unprocessed plant foods, while avoiding processed foods containing refined grains, refined oils and added sugars. Figure 1 depicts an example of a balanced WFPB meal.

On a practical level, it is important to distinguish a WFPB diet from a vegan diet, which eliminates all animal products but may include processed vegan foods (e.g., plant-based meats, pastries and fried foods). However, in the scientific literature, the term “vegan” is often used, and at times it is difficult to assess the amount of processed food included in diets of vegans included in observational studies. This paper will focus primarily on the evidence for an exclusively WFPB dietary pattern in the prevention and management of Type 2 diabetes mellitus (T2DM) and obesity. However, given certain limitations in the literature, some data on vegan diets and plant-rich but not exclusively plant-based diets will also be included.

Glucagon-like Peptide-1 Receptor Agonist Treatment in Type 1 Diabetes

Michael A. Tsoukas, MD, FRCPC — Thu, 12 Oct 2023 00:00:00 +0000

Type 1 diabetes (T1D) is characterized by a progressive decline of insulin production due to a marked destruction of pancreatic B cells. Intensive insulin therapy is the pillar of T1D management. More recently, continuous glucose monitoring devices, closed-loop systems (CLS) and smarter connected insulin pen systems have all significantly helped individuals to improve glycemic control. Despite these advances, however, more than three-quarters of the adult T1D population does not achieve recommended glycemic targets. In addition, aggressive insulin intensification potentiates weight gain and the risk of recurrent hypoglycemic events. Recent significant increase in rates of obesity has also led to a sharp increase in T1D patients who concurrently have adiposity-based chronic disease, increasing their insulin resistance and predisposition for cardiovascular events. While insulin will remain the basis of T1D management, there is an unmet need for individualized adjunctive therapeutic approaches focusing on the prevention of diabetic complications in addition to glycemic control. One such adjunctive therapy currently being explored in T1D are the glucagon-like peptide-1 receptor agonists (GLP-1 RAs), a popular and robust approach in Type 2 diabetes (T2DM) to mimic the natural endogenous GLP-1 incretin. This brief review will focus on the rationale and existing evidence for the use of GLP-1 RAs in the management of T1D.

Case Report: A First Nation Man’s Journey with Severe Insulin Resistance Syndrome

David B. Miller, MD, Susan Schaefer, RN, CDE, Judith Atkin, RN, CDE — Thu, 12 Oct 2023 00:00:00 +0000

James (a pseudonym) was born in the 1940s near Vancouver Island, British Columbia, to a Coast Salish family. His schooling was the imposed residential school system whereby Indigenous children were removed from their homes and communities and sent to schools in communities far away. His siblings attended various residential schools, so during his three years at such schools he saw them only in the summer time. His treatment during his schooling fostered a deep distrust of physicians and nurses. In addition he lost much of his native language and culture during this time. He graduated from Queen Elizabeth (High) School in North Surrey, British Columbia, where he was the only Indigenous student. James attended Vancouver Vocational School before returning to Vancouver Island to work as a band manager for his First Nation community. He married Mary (a pseudonym) and together they raised four children. Today he works as an Elder in Residence with post-secondary institutions on Vancouver Island.