PATHWAY TO WELLNESS

ABORIGINAL DIABETES HANDBOOK

FOR COMMUNITY HEALTH

WORKERS

TABLE OF CONTENTS Acknowledgements ……………………………………1 Advisory Committee Members ……………………2 Goal ……………………………………………………3 Diabetes in Aboriginal Population/Communities ……4 Prevalence of Diabetes ……………………………5 Seriousness of Diabetes ……………………………6 Inuit ……………………………………………8 Interdisciplinary Diabetes Health Team (DHC) Wholistic Model ……………………………………9 Possible Team Members ……………………9 Role of Diabetes Health Care Team …………..11 Diabetes Care …………………………………..11 Diabetes: Organization of Care …………………..12 Diabetes: Definition, Classification, Diagnosis, and Screening …………………………………. 14 Definitions …………………………………………. 15 Classification …………………………………..16 Diagnosis …………………………………………. 17 Three Ways a Diagnosis is Made…………………17 Confirmation Test for Diagnosis of Diabetes Mellitus………………………………………….. 17 Glucose Levels Followed for Diagnosis of IFG, IGT, DM, GDM …………………………………. 18 Criteria for Diagnosis to be Made …………. 19 Diagnosis of Gestational Diabetes …………. 20 Gestational Diagnostic Values …………………. 20 Risk Factors …………………………………………. 21 Risk Factors…………………………………………. 22 Risk Factors that can be changed …………………. 23 Risk Factors that cannot be changed …………. 24

TABLE OF CONTENTS cont’d Screening …………………………………………. 25 Screening for Gestational Diabetes Mellitus (GDM) .26 Screening for Type 2 Diabetes …………………. 27 Diabetes Circle Pathway to Wellness …………. 28 Management of Diabetes …………………………. 30 Management of Diabetes …………………………. 31 Health Assessment and Examination …………. 32 Complete Medical Interview …………………. 32 Complete Health History …………………. 33 Directed History Obtained at Initial and Follow-up Visits …………………………. 34 Comprehensive Physical Examination Initial and Follow-up …………………………………. 36 Management Plan …………………………. 38 Clinical Aspects …………………………………. 41 Clinical Aspect Determined During Follow-up Visit …………………………………………. 41 Laboratory Investigations …………………………. 43 Levels of Blood Sugar Control for Adults and Adolescents with Diabetes Mellitus …………. 43 Evaluation of Plasma Lipid Levels (Blood Fats) in People with Diabetes …………………. 44 Treatment …………………………………………. 45 Decisions for Balance and Control for Type 1 and Type 2 Diabetes …………………………. 45 Stepwise Approach to Type 2 Diabetes …. 46 Nutritional Approaches …………………………. 47 Type 2 Diabetes …………………………. 48 Stepwise Increase in Physical Activity …………. 50 Oral Medications: Categories, Main Site of Action, Limitations, Examples …………………. 52 Oral Agent Category: Alpha glucosidase Inhibitor …………. 53 Oral Agent Category: Biguanide …………. 54

TABLE OF CONTENTS cont’d Oral Agent Category: Sulfonylurea …………. 55 Oral Agent Category: Thiazolidinediones …. 56 Insulin Use in Insulin Treatment for Diabetes Type 1 and Type 2 …………………………. 57 Insulin Treatment …………………………. 58 Intermediate Insulin …………………………………. 59 Insulin Injection Devices …………………. 60 Management for Specific Groups …………………. 61 Diabetes in Children and Adolescents …………. 61 Diabetes in the Elderly …………………………. 64 Diabetes and Pregnancy …………………………. 66 Treatment for Women with Gestational Diabetes .67 Women with Gestational Diabetes …………. 68 Complications/Changes …………………. 69 Retinopathy …………………………………………. 70 Screening and Management for Retinopathy …. 70 Nephropathy …………………………………………. 72 Screening and Treatment for Nephropathy …. 72 Actions Taken After Diagnosis of Nephropathy...74 Neuropathy …………………………………………. 75 Screening for Neuropathy …………………. 75 Screening and Management for Peripheral …. 76 Medications Used for Relief of Painful Symptoms …………………………………. 77 Foot Care …………………………………………..78 Use of Monofilaments of 10 gram Force …. 81 Heart Disease and High Blood Pressure …………. 83 Prevention …………………………………. 85 Appendix ………………………………………… 86 Appendix 1 – Complete Medical Interview … 88 Appendix 2 – Complete Health History ………… 89 Appendix 3 – Directed History Obtained at Initial and Follow-up Visits … ………91 Appendix 4 – Comprehensive Physical Examination Initial and Follow-up….. 92

TABLE OF CONTENTS cont’d Appendix 5 – Stepwise Approach to Type 2 Diabetes ………………………… 94 Appendix 6 – Oral Medications: Categories, Main Site of Action, Limitations, Examples ………………………… 95

Oral Agent Category: Alpha glucosidase Inhibitor … 96 Oral Agent Category: Biguanide … 97 Oral Agent Category: Sulfonylurea … 98 Oral Agent Category: Thiazolidine-

diones……….. 99 Appendix 7 – Insulin Use in Insulin Treatment for Diabetes Type 1 and Type 2 … 100 Appendix 8 – Insulin Treatment ………………… 101 Taking Care of Diabetes …………….. 102 Glossary ………………………………………… 106 References ………………………………………… 121

ACKNOWLEDGEMENTS

Diabetes Pathway to Wellness was developed under the guidance of the Advisory Community and their teams. The Advisory committee was comprised of a joint group, with representation from the National Aboriginal Diabetes Association and the Aboriginal Nurses Association of Canada. Acknowledgement goes out to two people who made this possible and this is Kandice Léonard, Executive Director of the National Aboriginal Diabetes Association and Bernice Downey, Executive Director of the Aboriginal Nurses Association of Canada. Acknowledgement and appreciation is given to al the people who served on the Advisory Committee and to their teams who contributed to the development of this handbook. A special thank you goes out to Sam Senecal who provided technical support and assisted with the graphics for the handbook.

ADVISORY COMMITTEE MEMBERS

Kathy Bird ANAC member Peguis, Manitoba

Nellie Erickson ANAC member Manitoba

Elmer Ghostkeeper NADA Board member Aboriginal Health Services, Edmonton, Alberta

Doris Greyeyes NADA Board Chairperson

Saskatchewan

Heather Jacobs-Whyte Diabetes Educator Kahnawake, Quebec

Gail Lindsay Project Coordinator Aboriginal Nurses Association of Canada, Ottawa, Ontario

Lorraine McLeod Diabetes Coordinator Anishinabe Mino-Ayaawin, Manitoba

Onalee Randell Diabetes Coordinator Inuit Tapiriit Kanatami Ottawa, Ontario

Sandra Shade Homecare Coordinator Standoff, Alberta

GOAL:

To promote quality community based diabetes care and management, for application of the 1998 Clinical Practice Guidelines, by Aboriginal community health workers dealing with diabetes.

The term “Aboriginal” used in this handbook refers to First Nations, Inuit and Métis people.

Many Aboriginal people with diabetes have offered their words of wisdom that come from their experience of living with diabetes:

Get over the negative feelings: anger, denial

Come to acceptance, and come to terms with diabetes

Learn more about diabetes

Understanding the seriousness and that it can be managed and prevented

Know the risk factors: obesity, type of food eaten, low activity level, smoking

Prevention is the key

Prevention through proper education in the community and home

Control through a balanced way of eating and changing to lower fat, lower sugar foods

Control through increased level of activity / exercise – walking – becoming more active

Control through regular blood sugar level testing

Self-care skills in learning how to cope and manage stress

Taking responsibility for one self, and one’s health, children and future generations

Re-gaining traditional knowledge on healing strategies and spirituality

Prevalence of Diabetes

Diabetes rates are very high among Aboriginal people and this has been documented by a series of studies. It is at least three times that of the general population. Results from the “Aboriginal Peoples Survey” suggest that rates in First Nation communities are well above the non-Aboriginal average; much less is known about diabetes among the Métis people. Inuit people are below the national average but Inuit have noticed that diabetes is increasing and it is feared that over time the diabetes rates may be as high as those of the other Aboriginal groups.

According to a 1991 Statistics Canada report, the prevalence of diabetes native groups in Canada is as follows:

8.5 % of North American Indian people on Indian reserves and settlements

5.3% of North American Indian people off reserves

5.5 % of Métis people

1.9% of Inuit people

Diabetes In Aboriginal Population / Communities

Seriousness of Diabetes

Lifestyle changes over the past 50 years have had a great and serious impact on the health of Aboriginal people. Type 2 Diabetes is recognized as a major health problem.

Diabetes in Aboriginal communities is an epidemic.

Diabetes is a very serious disease that can lead to serious complications:

It is a major cause of Coronary Artery Disease, increasing the chances of a heart attack.

Coronary Artery disease is the leading cause of death in Canada.

Diabetes is a leading cause of adult blindness, amputations, and kidney disease.

Diabetes requires enormous and special attention especially to children and pregnant women. In recent years, elementary school children have been diagnosed with Type 2 diabetes.

Diabetes must receive high priority in community health planning and in the delivery of culturally appropriate services.

Elders have expressed their sadness because "Diabetes is killing our people” and so this is what it is, a killer.

Seriousness of Diabetes cont’d

Prevention strategies must look at:

Future generations: the children

Pregnant women being diagnosed with Gestational Diabetes.

More aggressive measures in screening for complications

Greater emphasis on control of food and how it affects blood sugar levels

Culturally appropriate educational programs that will help

People discovering a pathway and the "power" to achieve wholistic well-being, mentally, physically, emotionally, and spiritually.

Inuit

Inuit, “people who are alive at this time,” have traditionally passed their values from generation to generation by word of mouth and through story telling. In the Inuit culture, family and family relationships are of great importance as is their strong link with their environment, and relationship with the land. Guidance to deal with mental health, emotional and spiritual wellness is provided by respected elders and shamans. Inuit follow strict rules that govern their behaviour.

Inuit strive to maintain a traditional lifestyle:

“Country foods”:

Fresh caribou, raw artic char, muqtuq, clams

Cultural activities:

Seal hunting, clam digging, drum dancing, hide cleaning

Traditional medicines:

Algae, plants, mosses, use of heated rocks

Prayer and singing at the beginning and end of each day

“The path toward healing must start in the past if it is to lead to wellness for the Inuit in the future.”

- Gail Gray

Interdisciplinary Diabetes Health Care Team (DHC) Wholistic Model

There must be flexibility in makeup of the “team”, taking into consideration what resources are available, and this will be different in each community. The team, as described, may not exist as such in most communities, but there is most likely an informal, not a professional, team made up of a Diabetes worker, Nurse, CHR, and possibly a healer. This team needs to form its links and be recognized and acknowledged as a “team”. The minimum number of team members should be three: the person living with Diabetes, the physician, and the educator, who may be the nurse or the community health worker.

The person living with Diabetes including the family and caregivers is at the center of this team. Ideally, the primary care physician, usually the first doctor and the one seen for all health care, is at the hub of the circle of the interdisciplinary health care team. This may not always be the case nor is it the reality in northern and isolated communities, and certainly not for Inuit communities. The primary care giver may be the nurse in the community.

Possible Team Members:

Person dealing with / living with diabetes

Family: spouse, child, relatives

Primary Care Physician (Family Physician) / Specialists: Diabetes

Ophthalmologist, Cardiologist, Endocrinologist, Neurologist, Nephrologist, Obstetrician

Primary Care Nurse: Nurse Practitioner / Community Health Nurse

Long Term Care Case Manager - Nurse / Home Care Nurse / Clinic Nurse

Registered Dietician / Community Nutritionist

Diabetes Educator / Diabetes Worker

CHR / Personal Support Worker / Home Maker

Spiritual Healer / Elder / Priest / Minister / Deacon / Mandated Lay Worker

Social Worker,

Psychologists / Mental Health Worker /NADAP worker

Pharmacists

Chiropodists / Podiatrists

Optometrists

Role of Diabetes Health Care Team

To increase the commitment and participation of the person dealing with Diabetes through:

Shared wholistic care

Ongoing communication

Participation of whole team

Diabetes Care

Diabetes care is organized around this interdisciplinary diabetes health care team. Primary care giver (physician / educators: nurse /dietician) consults with team members and is responsible for:

Keeping and including current clinical practice guidelines into daily care activities

Arranging and making diabetes care easy: using timely reminders for assessment and direction of care.

Making sure there is good communication among all team members.

Everyone involved in the care must take it upon themselves to become knowledgeable about provincial and national laws related to people living with diabetes and eliminate diabetes as an unnecessary cause of workplace injury, illness, disability. The education and advocacy would then be focused on the rights and responsibilities of people living with diabetes.

Develop a comprehensive information system to support interdisciplinary delivery of care.

View initial and ongoing education very important, and not something added to treatment

Diabetes: Organization of Care

Diabetes is a complicated long lasting disease that has both short duration and long duration health concerns. Once a person has diabetes, they have it for life, it does not go away but a person can do many things to keep it under control.

The care for Diabetes depends on:

Commitment everyday by the person living with Diabetes to balance appropriate choices in their way of life with their prescribed treatment of medicine,

To take responsibility for personal health care,

To accept who they are, and to respect their life.

To participate fully and be active in the health care delivery planning on the Diabetes Health Care team

To be responsible for their personal health care delivery

View every bit of education very important, and not something added to treatment

All aspects of life of people living with diabetes, their families, and caregivers are affected by diabetes:

Ability to function in everyday life, in their personal life

With improvements in what can be used and how to improve care for one's health, they may now function in their work life well and have better control with blood sugar levels.

To achieve balance they: Must learn to use a variety of complicated skills

Must have the support of the interdisciplinary team, the Diabetes Health Care team (DHC) made of health professionals and others who are experts in the wholistic care for Diabetes.

Diabetes: Definition, Classification, Diagnosis And Screening

Definitions

Diabetes Mellitus is a condition where the “beta cells within the Islets of Langerhans” in the pancreas, do not produce the right amount of insulin or the body is unable to use the insulin correctly that is produced, or both. The result is high blood sugar levels and over a long period of time will result in serious changes / complications - abnormal functioning and failure of different organs: kidney, eye, nerves, heart and blood vessels.

Traditional Healers / Medicine men have said that Diabetes is "the inability to process the sweetness of life".

Type 1 is when the pancreas makes little or no insulin,

therefore requiring insulin injections everyday and a carefully planned healthy way of eating. Type 1 occurs most often in childhood.

Type 2 is when the pancreas is either not releasing enough insulin or the insulin is not working as it should, not performing its proper job. This is treated by a healthy way of eating, exercise and if blood sugar level goals are not achieved then oral medication and / or insulin are added.

In some communities type 2 diabetes has been referred to as the “sugar” illness or dis-ease, a lifelong, lifestyle condition where the body cannot store sugar properly and cannot use the sugar for energy, and so the person dealing with the diabetes is unable to enjoy life.

Gestational Diabetes Mellitus A type of diabetes, taking the form of type 2, with onset during pregnancy, occurs between the 24th and 28th week and is caused by hormones produced during pregnancy. The body cannot use insulin properly. Sugar is not taken to the cells and builds up at a higher than normal level in the bloodstream. It may be controlled with a healthy way of eating and sometimes with insulin. The blood sugar levels return to normal in about 95% of all cases.

Prevention Of Type 1 Diabetes

• Cannot be prevented so should be left to formal research projects.

Prevention Of Type 2 Diabetes

• Control weight through a balanced meal plan and healthy way of eating and regular activity / exercise

• Stress management

Classification

What was once termed “insulin-dependent diabetes mellitus” (IDDM) is now called "type 1" diabetes. What was once termed "non-insulin-dependent diabetes mellitus” (NIDDM) is now called "type 2" diabetes. The terms IDDM-NIDDM were based on treatment but people with any form of diabetes may require insulin at any stage of their disease. The use of insulin alone cannot be used for classification.

Diagnosis Three Ways a Diagnosis is Made

Classic symptoms of diabetes: fatigue, frequent urination, excessive thirst, blurred vision, unexplained weight loss, plus

Casual plasma glucose level equal to or greater than 11.1 mmol/L

OR

Fasting Plasma Glucose (FPG)

Fasting Plasma Glucose equal to or greater than 7.0 mmol/L

OR

A plasma glucose value in the 2 hour sample (2hPG) of the oral glucose tolerance test (OGTT)

2 hour glucose value equal to or greater than 11.1 mmol/L

Confirmation Test for Diagnosis of Diabetes Mellitus

A second test to confirm the first test must be done on another day in all cases "in the absence of unequivocal hyperglycemia accompanied by acute metabolic decompensation". A second test is not necessary for the diagnosis of diabetes in children or adults with classical symptoms as “metabolic decompensation” may occur quickly.

Glucose Levels Followed for Diagnosis of IFG, IGT, DM, GDM

Category

Fasting Plasma Glucose (FPG); mmol/L

Plasma Glucose (PG) 1 hour after 75-g glucose load; mmol/L

Plasma Glucose (PG) 2 hours after 75-g glucose load; mmol/L

Impaired fasting glucose (IFG)

6.1 - 6.9 Not

Applicable Not Applicable

Impaired glucose tolerance (IGT)

Less than 7.0

Not Applicable

7.8-11.0

Diabetes Mellitus (DM)

Equal to or greater than 7.0

Not Applicable

Equal to or greater than 11.1

Gestational Diabetes (GDM)

Equal to or greater than 5.3

Equal to or greater than 10.6

Equal to or greater than 8.9

Criteria for Diagnosis to be Made

In re-examining population studies, it has been found that:

Fasting Plasma Glucose (FPG) level of 7.0 mmol/L correlates most closely with a 2 hour Plasma Glucose (PG) level of greater than 11.1 mmol/L

and best predicts the development of microvascular disease

Lowering the Fasting Plasma Glucose (FPG) diagnostic level from 7.8 to 7.0 mmol/L ensures:

that both the Fasting Plasma Glucose (FPG) and 2 hour Plasma Glucose (PG) define a similar degree of High Blood sugar

and risk for microvascular disease.

People with Fasting Plasma Glucose (FPG) levels between 6.1 and 7.0 mmol/L:

are considered to have "impaired fasting glucose" (IFG).

These people do not have the diabetes-associated risk for microvascular disease,

but people with “impaired fasting glucose” (IFG) and "impaired glucose tolerance" (IGT) have a greater risk for the development of diabetes and cardiovascular disease than the general population.

Diagnosis Of Gestational Diabetes

(The 75g OGTT is completed only if the numbers from the 50g screening done at 24 – 28 weeks are elevated)

Fasting Plasma Glucose (FPG) level and plasma glucose levels are measured at 1 and 2 hour after drinking 75-g of glucose.

If 2 out of 3 of the values are met or higher, then the diagnosis of gestational diabetes mellitus (GDM) is made.

If one (1) value is met or higher, then the diagnosis is impaired glucose tolerance of pregnancy (not to be confused with impaired glucose tolerance, IGT, in non-pregnant person):

Gestational Diagnostic Values

Fasting

Greater than 5.3 mmol/L

1 hour

Greater than 10.6 mmol/L

2 hour

Greater than 8.9 mmol/L

Risk Factors

A way of eating and the lifestyles of how one lives all contribute to the risks of diabetes. Risk factors are risk estimates or guesses based on people who live similar ways of life or who share similar physical characteristics.

Risk factors as accepted by the Canadian Diabetes Association and the Clinical Practice Guidelines are:

Over age 45

Obesity

Aboriginal, Asian, African or Hispanic descent

Being a close relative of someone with diabetes

Gestational diabetes

Have history of giving birth to a baby with a birth weight over 9 pounds (4 kg).

History of impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)

Abnormal cholesterol

Low level of high-density lipoprotein (HDL) cholesterol (less than 0.9 mmol/L or

Elevated fasting level of triglycerides (greater than 2.8 mmol/L)

High Blood Pressure

Risk Factors that can be changed: Obesity – weighing twenty percent more than the ideal

weight for height and age.

Suggestions:

Lose weight at slow rate

Make exercise part of regular routine

Include vitamins found in non-green fruits and vegetables.

High cholesterol – can lead to narrow arteries leading to a heart attack.

Suggestion:

Control diabetes and cholesterol levels return to normal.

Hypertension – High blood pressure – blood pressure is the pressure of the blood flowing from the heart into the arteries, pressing against the artery walls. “Hyper” means “too much tension”. Hypertension can be made worse by tobacco, alcohol and too much salty foods; can also be caused by kidney disorders, pregnancy, and medications such as birth control pills, cold remedies and other drugs.

Suggestions: Change eating habits

Exercise

Decrease alcohol

Limit salty foods

Increase calcium and potassium foods

Lower stress level

Get enough sleep.

Risk factors that cannot be changed

Age – menopause and estrogen loss leads to osteoporosis (brittle bones)

Genes – Type 2 diabetes is genetic:

Ethnicity: Aboriginal, Asian, African or Hispanic descent

Family history: being a close relative of someone with diabetes

Think of risk factors as being rocks that are carried in a knapsack. The more risk factors, the more rocks, and the more weight that is being carried. People with diabetes need to lighten the knapsack and prevent the knees from buckling by taking out of their knapsack the rocks or risk factors they are carrying; thereby lowering or eliminating the risk factors and helping to control the blood sugar levels.

Screening For Gestational Diabetes Mellitus (GDM)

Screening is the method that is employed to diagnose diabetes. This refers to venous blood testing by a laboratory, and it is not capillary blood sugar testing done by blood glucose meter.

All pregnant women should be screened between 24 and 28 weeks gestation

The screening test that should be done is a measurement of the plasma glucose level 1 hour after drinking 50-g oral glucose given at any time of day

If level at 1 hour is equal to or greater than 7.8 mmol/L, then a glucose tolerance test is done

If the level at 1 hour is equal to or greater than 10.3 mmol/L, then the diagnosis of GDM is made.

All pregnant women who are obese, Aboriginal, have family history or previous history of diabetes or have history of giving birth to babies with a birth weight over 4 kg should be screened regardless of their age.

It is not necessary to screen for gestational diabetes in the low risk group who are the lean Caucasian women less than 25 years of age with no personal or family history of diabetes and no history of large babies.

Screening

Screening For Type 2 Diabetes

Community wide capillary blood testing is being recommended for Aboriginal communities and that this be linked with other community events

Fasting Glucose Tolerance (FGT) testing should be done every 3 years in those over 45 years of age

More frequent and earlier testing should be done in those with additional risk factors:

First degree relative with diabetes

Member of high risk population: Aboriginal people (others: Hispanic, Asian and African descent)

Low level of high-density lipoprotein (HDL) cholesterol (less than 0.9 mmol/L or

Elevated fasting level of triglycerides (greater than 2.8 mmol/L)

Annual testing should be done in those with one or more of the following more predictive risk factors (regardless of above factors) such as:

History of impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)

Presence of complications associated with diabetes mellitus

History of Gestational diabetes mellitus (GDM) or baby with birth weight over 4 kg

Presence of high blood pressure

Presence of coronary artery disease (CAD)

Diabetes Circle Pathway to Wellness

As an organized method, the concept of the circle and the four directions is being used in many communities to deliver education and care. The circle is a traditional teaching tool used to help people understand the changes that occur in one's journey in life. It is used to explain a wide variety and sometimes very difficult concepts. It helps people to see and understand things that cannot be seen or understood. It shows how things are connected within oneself and with the rest of creation. It provides a wholistic way of looking at life. It is based on cultural values, traditions and spirituality. It symbolizes completeness, wholeness, interdependence, unity and strength.

This pathway will bring into focus the wholistic approach, a pathway that will allow the people living with diabetes:

To discover what they can do for themselves.

To do the healing themselves by coming to know their sense of self-worth.

To come to make positive healthy choices for change and the choice is up to the person!

To make commitments to change their lifestyle.

To come to respect and take responsibility by taking care of what the Creator has given, LIFE.

To walk in balance by living a way of life "doing as one ought to the best of one's ability”.

To live in harmony with other people by involving family and community.

A Medicine Man once remarked that when someone has decided to go for healing, 70% of the problem is already taken care of, representing a major portion of the journey to healing and recovery has taken place. This is done by the humble acknowledgement of the need for help. The healer does 10% of the healing by the teachings he shares. The individual who is requesting the healing does the remaining 20% by putting the teachings into practice.

Diabetes Circle Pathway to Wellness

Person living with

diabetes and family

Way of life. Food is Medicine – Traditional Food / Feasts. Walk For Life –Physical Activity. Glucose Monitoring –

better & tighter control. Prevent connectedchanges / complications

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meditation

MANAGEMENT OF DIABETES

Goal of Diabetes Management: maintain wellness in diabetes

"Health is the power, the energy to exist in balance of body, mind and spirit, and the function in harmony with the environment and with other people"

- Dr. Frank Clarke

Factors for Consideration: Key member of DHC team

Management Plan: sample format to follow as a guide begins on page 38.

Blood sugar goals established to meet the needs of the individual

Include consideration of family and other psychosocial factors

Avoidance of acute and long-term complications / changes

Quality of life

Overall sense of well-being

MANAGEMENT OF DIABETES

Note: for the following sections, information has been divided:

Each box provided acts as a guide to look at specific areas for assessment

Each tick bullet provided acts a guide for specific directions

Health Assessment and Examination

Health Assessment on the first visit with newly or previously diagnosed diabetes by a primary care giver: physician, nurse practitioner, community health nurse requires:

1. Complete medical interview

2. Complete health history

3. Complete physical examination

1. Complete Medical Interview: Asks questions about diabetes symptoms and the focus is on what symptoms are present and how long they have been present. Symptoms:

When did symptoms of high blood sugar begin

Progression of symptoms of high blood sugar

Acute and long-term complications / changes of diabetes

Eye

Kidney

Heart and blood vessels

Nerves

Skin problems

2 a). Complete Health History

Health History Importance of Potential Risk Factors For Chronic Disease

Past History Endocrine disorders: Hormone

secretion of other glands Infections Heart Disease Surgery (e.g., pancreas) Pregnancies – gestational (if a

woman)

Family History Diabetes

Heart Conditions Abnormal blood fat level High Blood pressure, kidney disease Insulin resistance Sterility, excessive body hair Alteration of function of body’s

defense system

Risk Factors High blood pressure Abnormal blood fat: LDL Central obesity Cigarette smoking

Social and Psychological Factors

Family dynamics Coping skills Education Employment Lifestyle

Drug History Current medications

Alcohol Possible drug interactions

2 b). Directed History obtained at initial and follow-up visits Lifestyle Details of nutrition counselling,

meal plans, keeping with prescribed meal plan, ethnic, and cultural influences and weight changes

Diabetes education received in the past (location and level of program), current understanding of diabetes and its management

Level of physical activity / exercise (type, duration, intensity, frequency, and time of day)

Monitoring (of blood sugar levels)

Method used and technique

Frequency, timing in relation to meals, records (log books)

Quality control of meter (measurements closely related with laboratory)

Diabetes Medications

Oral medications (type, dose adherence), any adjustment in response to monitoring

Insulin (type, source, dose, injection sites), understanding of dose adjustments in response to food, activity

Social and Psychological factors

Support of family and friends

Household income management

Medic alert - A form of identification that contains confidential, critical medical information, provided only to professional health practitioners to help diagnose and treat in an emergency. It speaks for an individual when that individual cannot speak for him / herself. Payment or Reimbursement (with receipt) Applications for “one standard medic alert product per lifetime” may be made at any zone office, health centre and / or pharmacy and sent to Ontario Region, FNIHB for all of Canada.

Medical Insurance

3. Comprehensive Physical Examination Initial and Follow-up

BODY SYSTEMS

SPECIAL ATTENTION

General Height

Weight

Waist circumference (central obesity) M > 94 cm; F > 80 cm should not

gain more weight M > 102 cm; F > 88 cm should

reduce weight

BMI 20 – 25 healthy weight range 25 – 27 at risk for certain

problems

Blood pressure (lying and standing)

Pulse

Head and neck Eyes: Reactions of pupils, muscles

controlling eye ball movement, cloudiness of lens, examination of innermost base of interior of eye

Mouth, gums, and teeth: hygiene and cavities

Thyroid assessment

Chest Routine

Heart and blood Vessel (Cardiovascular System)

Signs of congestive heart failure

Pulses

Bruits: Blood flow through arteries is silent except in someone with occlusive arterial disease. Auscultation of blood flow in this person usually produces a blowing sound called a “bruit”

Abdomen Enlargement of /or abnormal organs

Genital and urinary Rule out fungal infections: yeast, kidney infections

Muscle, joints and bones (Musculoskeletal System)

Foot inspections,

Signs of limited joint mobility and any abnormal condition affecting joints of hands,

Colour and temperature of lower limbs.

Brain and spinal cord (Central nervous system)

Routine evaluation for feelings in touch, change in position sense of body, vibration

Light touch (using Monofilament), and reflexes

Evaluation for autonomic neuropathy (abnormalities in involuntary muscles and function of glands), if appropriate

Skin Inspection for skin infections

Problems with injection sites.

Signs of abnormal blood fats.

Management Plan

Discussion Areas Plan Discussed During Initial Visits

Nutritional counselling

Balanced healthy way of eating

Increased insulin sensitivity – lowers blood sugar because body cells take in glucose readily

Healthy lipoprotein profile

Physical activity counselling

Goals for lifestyle change aiming for an active lifestyle

Cardiovascular fitness – strengthens the heart, improves circulation, lowers blood pressure

Well-being – feel good, relax

Helps to burn up calories, normalize and maintain weight

Monitoring for Blood Sugar Control

Frequency of testing Target Optimal blood sugar levels: Fasting of 4-7 mmol/L 2 hour after meal 5-11 mmol/L

Self-monitoring of blood glucose level essential for: Type 1 All pregnant women with pre-

existing diabetes or GDM Type 2 insulin treated Type 2 treated with oral

medications; May be useful for type 2 not

treated with oral medications but controlled by a healthy way of eating

Glycated hemoglobin

Monitoring for Blood Sugar Control - continued

Measured every 3 months

The person with diabetes must be educated on: the use of a glucose meter, interpretation of results, where possible how to modify

treatment according to blood sugar levels;

and comparing the meter’s result to the lab’s (should be within 10- 15 % accuracy of the lab)

Medication and counselling (oral agents and / or insulin)

Oral Diabetes Medications:

Are not insulin Are not a cure for diabetes Help to control blood sugar Only one part of diabetes type 2

treatment, are not a substitute. A healthy eating plan, increased

physical activity, and blood sugar monitoring must remain as important parts of the whole treatment for diabetes.

These are started when changes in a healthy way of eating with a goal of losing weight to a healthy body weight, and in lifestyle do not reach target blood sugar levels in 2-4 months or if Fasting Plasma Glucose remains greater than10 mmol/L. If blood sugar levels cannot be controlled despite all this, then this means there is continuing insulin resistance which means that the body cannot use insulin made by the pancreas, causing the pancreas to work harder (gets tired after time), making too much insulin and

may shut down. This is a natural thing to happen over time as the disease progresses. 40% - 50% of people with Type 2 often require insulin after 10 years on medication.

Metformin is usually the first medication of choice

Medication: Oral Agents

Refer to table on Oral Medications: Categories, Main site of Action, Action, Limitations, Examples

Medication: Insulin

Refer to table on Insulin Use In Insulin treatment for Diabetes Type 1 And Type 2

Diabetes Knowledge Knowledge of value of blood sugar

control Low Blood Sugar: prevention,

recognition and treatment Determination of individual target

goals Appropriate use of medication as

prescribed Appreciation of lifestyle

considerations Stress management Recognition of further educational

or motivational needs Self-care practices to prevent or

delay changes (complications): eye examinations / foot inspections

Clinical Aspects

Clinical Aspect Determined During Follow-up Visits Routine clinical care

Routine visit at 2-4 months with directed history for diabetes

Blood pressure, foot examination at each visit

Evaluation of progress toward reduction of risks of long-term complications

Adjustment of treatment plans

Blood Sugar control

Glycated hemoglobin (HbgA1c) every 3 months: a test that measures how much sugar is attached to the Red Blood Cells. Provides a good indication of “average” blood sugar level over a period of 120 days (life of Red Blood Cells)

Laboratory - meter glucose measurements closely related with laboratory done at least annually

Fasting Plasma Glucose (FPG) level, preferred for correlation, as needed

Complication and risk evaluation

Annual Fasting lipid profile (see following section) including: Total High-density lipoprotein (HDL) Calculated Low-density

Lipoprotein (LDL) Cholesterol

Triglycerides (TG) levels

Dipstick urinalysis to screen for gross proteinuria:

If negative, microalbuminuria screening with random daytime urinary albumin:creatinine ratio yearly in type 2 and yearly after 5 years of post pubertal type 1 diabetes

If positive, a 24 hour urine test for endogenous creatinine clearance rate and microalbuminuria every 6-12 months

Resting or exercise electrocardiogram (ECG) if appropriate (for age over 35)

Laboratory Investigations

• Forms the basis for long term care plan • To ensure optimum health

Levels of Blood Sugar Control for Adults and Adolescents with Diabetes Mellitus

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Major Risk Factors: smoking, hypertension, low LDL – less

than/equal to 0.9 mmol/L and Men and Women over 30 years of age. CAD – Coronary Artery Disease

Treatment

Decisions For Balance and Control For Type 1 And Type 2 Diabetes

Type 1: blood sugar control depends on coordination of insulin, food intake, activity

Type 2: treatment has to be progressively increased over time as follows:

Stepwise Approach To Type 2 Diabetes

Nonpharmacologic Therapy (Non-drug therapy)

Lifestyle, Healthy way of eating, Physical activity / Exercise, Self-monitoring of blood sugar level

If individualized goals for blood sugar are not met within 2-4 months, (if symptoms or severe high blood sugar levels continue) reassess action for lifestyle changes for further improvement.

Advance to next level of therapy.

Single Oral Drug Therapy (Oral agent monotherapy)

If individualized goals for blood sugar are not met within 2-4 months, reassess action for lifestyle changes for further improvement.

Advance to next level of therapy

Oral Combination Therapy

(Combination of oral drugs therapy – One or more medications added until maximum dose

reached)

If individualized goals for blood sugar levels are not met within 2-4 months, reassess action for lifestyle changes for further improvement.

Advance to next level of therapy

Bedtime Insulin Plus or Minus Oral Medications

Insulin Injections 1-4 / Day

If, at any point, the patient becomes metabolically decompensated (symptomatic hyperglycemia and ketosis)

Nutritional Approaches

"Foundation of Diabetes Care"

Ideally everyone should receive individual advice about food from a registered dietician, nutritionist who will:

Assess individual nutritional needs

Empower people with diabetes to achieve treatment goals

Consider factors:

Type of diabetes

Lifestyle

Life situation

Presence of obesity

How disease is progressing

Type of treatment

Personal preferences

Nature of any changes / complications

Provide education on one to one basis or in group settings

Provide for development of skills to promote balanced healthy eating habits

Continue support as necessary through follow-up appointments

Provide on-going nutritional counselling with stepwise increase from simple to finer details of information given

Type 2 Diabetes

If obese, beginning with way of eating plan plus lifestyle changes including increased physical activity can lead to improved blood sugar control and weight loss.

Culturally appropriate and enjoyable Physical activities: walking, hiking, traditional dancing, boating (rowing), gardening, snow—shoeing, skating.

Choose the activity and do it at a good time.

Healthy balanced way of eating is same as for general population, choosing from four food groups

Traditional foods: whole grains, wild edibles, berries, greens, and wild game, fish “Country foods”

Eat food as medicine. Take only what you need.

Eat foods that will give energy, vitality, healing and strength.

No need to buy or cook special “diabetic” diet food. Follow healthy eating guidelines.

Reaching a healthy body weight

Balanced and healthy way of eating: traditional foods as medicine Walking for life and appropriate traditional physical activities /exercises: chores and choosing enjoyable activities

Decreasing saturated fat intake to 10% of calories

Choose "fast foods" from animals that are fast (deer, elk buffalo, rabbit)

Do not eat meat from animals that have been boxed in (pigs: bacon ham pork, sausages)

Fried bread in not traditional. Bread baked in an oven or done over an open fire.

Enough carbohydrate, protein, vitamins and minerals

Recognize nutritional value of traditional foods

Use local food plants from the wild or garden: vitamins and carbohydrates enhance nutritional quality.

Stepwise Increase In Physical Activity • May improve blood sugar control • Reduce need for medications in people with type 2

diabetes • Avoid exercise during any period of poor blood sugar

control – when blood sugar levels are above the mid-teens (15 mmol/L and above)

• Avoid activity / exercise in extreme hot or cold conditions

Ability to increase activity

Plan to include activity / exercise as part of everyday life, everyday

For consideration when planning activities

Consult with physician, diabetes educator, or health care worker (Health Care Team) before starting an exercise / activity program that is suited to lifestyle and general health condition. Have tests recommended.

Be aware if limitations of existing changes / complications: kidney, eye, heart, foot problems

Monitor blood sugar level before exercise (every time muscles are worked they use up blood sugar for energy). Normal blood sugars may be too low after exercise unless some food (carbohydrate) is eaten before the exercise.

Be aware of low blood sugar: shaky, dizzy, sweaty, weak, hungry. Carry fast acting glucose: 3 glucose tablets / 3 tsp. Sugar, ½ can regular pop, 4-6 lifesavers, 1 tbsp. Honey, ½ cup of juice, 1 cup milk

On insulin treatment

Changes to way of eating, insulin routine, injection sites and self-monitoring be appropriate for general level of physical activity

Or specific for those with:

Blockage blood vessels (or at high risk of mild but with no symptoms)

Significant sensory nerve damage or advanced changes with the smaller blood vessels such as eye, kidney, nerves, feet.

Refer to sections Health History and Insulin Use

For vigorous exercise program

Appropriate detailed history

Physical examination

Specific lab work (e.g., exercise-stress graphically recording of heart movements for over age 35)

Oral Medications: Categories, Main site of Action, Action, Limitations, Examples

If your goal to reach “optimal” level of blood sugar control

is not achieved with a healthy way of eating, getting down

to a healthy weight and lifestyle changes, then the doctor

may prescribe diabetes pills. Pills are meant to go along

with a healthy way of eating, activity / exercise routine,

and monitoring of blood sugar. Pills are not a substitute.

If insulin resistance continues, the individual may stop

responding to the pills. After 10 years on pills, the

individual may often need to go on insulin therapy.

Following are the details on the categories, where the

action takes place, what is happening and side effects or

limitations there are, and examples of names of

medications for each category.

Oral Agent Category : Alpha glucosidase inhibitor Main site of Action

Action: How it Controls Blood Sugar

Limitations/ Side Effects

Example

Intestines (gut)

Delay breakdown of sugar in meal and slows absorption of starch and sucrose in the gut reducing blood sugar levels after the meal. No major hypoglycemia- may reduce episodes in the night especially if on insulin. Must be taken with first bite of food at mealtime. Prescribed for those who cannot get their post meal blood sugar level to acceptable levels.

Hypoglycemia must be treated with Dextrose (Dextrosol or Monoject -not juice, sugar). In itself does not cause hypoglycemia Gastrointestinal side effects: gas, diarrhea, cramps Should not be taken by anyone who: •inflammation/ulceration

of bowel • bowel obstruction • gastrointestinal disease •kidney or liver disorder • hernias •pregnancy or lactation • type 1

Generic name: Acarbose (short acting) Brand name: Prandase

Oral Agent Category: Biguanide

Main site of Action

Action: How it Controls Blood

Sugar

Limitations/ Side Effects

Example

Liver

Helps the insulin, made by the body, work better. It stops the liver from releasing too much glucose, which helps to lower blood sugar levels and increase glucose uptake by muscle tissue. This helps the tissues to respond better to insulin made by the body. Biguanides are associated with less weight gain and lower frequency of low blood sugar than sulfonylurea. Appropriate for those who are obese and have milder levels of high blood sugar.

Gastrointestinal side effects: no appetite, nausea, abdominal discomfort, diarrhea may be a limiting factor. If there is pregnancy, kidney, liver failure, severe heart/lung condition, or alcoholism, biguanides are not used (may cause lactic acidosis)

Generic name: Metformin Brand name: Glucophage

Oral Agent Category: Sulfonylurea

Main site of Action

Action: How it Controls

Blood Sugar

Limitations/ Side Effects

Example

Pancreas

Stimulate pancreas to release more insulin. Makes insulin producing cells more sensitive to sugar and stimulates them to secrete more insulin to lower blood sugar.

First oral agent of choice for those who are not obese and/or have high blood sugar levels

Hypoglycemia (dangerous for over age 70, hypoglycemia may occur more frequently), weight gain, secondary failure in 5 to 10% patients per year.

Generic names: Acetohexamide* chlorpropamide * – long acting glyburide**- medium acting

Gliclazide**- short acting

Tolbutamide* - short acting

Brand names: Dimelor

Diabinese

Diamicron

Diabeta

Orinase

(First generation – not prescribed very much* Second generation – more commonly prescribed**)

Oral Agent Category: Thiazolidinediones

Main site of Action

Action: How it

Controls Blood Sugar

Limitations/ Side Effects

Example

Muscle cells

Makes muscle cells more sensitive to insulin and reduces insulin resistance.

Liver enzymes be done before starting this, every month x 8 months, bimonthly for next 4 months and then periodically.

High doses lower white blood count therefore not recommended for those who are immune suppressed. May trigger infection.

Headache

May raise LDL (abnormal, “bad”) cholesterol.

Not to be used by anyone with liver, heart problems

Generic name: troglitazone

Brand name: Rezulin

Insulin Use in Insulin Treatment for Diabetes Type 1 And Type 2

Treatment Type 1 Type 2

Insulin treatment

Essential for life

Blood sugar control depends on coordination of insulin doses, food intake and physical activity.

May be required for a short duration in times of illness or stress

For blood sugar control when there is poor response to treatment with way of eating and oral medications.

Along with oral medications, can be added as a single injection of intermediate-acting (acting slower but lasting longer) insulin at bedtime. This approach may result in better blood sugar control with smaller insulin dose and may result in less weight gain than the use of insulin alone.

Intensified therapy (tight control) to achieve target blood sugar levels

Multiple daily injection (3-4 / day)

or

Continuous subcutaneous insulin infusion (CSII) insulin pump

Regular or Lispro insulin can be used before meals. Lispro is preferred for CSII.

In cases of poor response to way of eating and oral medications, then insulin doses (frequently high) and the number of injections (1-4) should be adjusted to reach target blood sugar levels.

If poor blood sugar control continues regardless of insulin, then one of following oral medications may be added: Acarbose, Metformin, Troglitazone

Insulin Treatment

Insulin Treatment

Trade Name Onset Peak Duration

Very fast acting (absorbed more rapidly – works in 5-15 minutes)

Lispro (Humalog) Insulin Analogue (copycat)- clear

0.1 hour 1.5 hour 3-4 hours

Short acting (regular)

Humulin R Novolin ge Toronto – clear

0.2 hour 3-4 hours

6-8 hours

Intermediate acting NPH (N) Lente (L)

Humulin N Novolin ge NPH- cloudy Humulin L Novolin ge L- cloudy

1.5 – 2 hours 1.5 – 2 hours

4 – 12 hours 4 – 12 hours

18 – 24 hours 18 – 24 hours

Premixed short /intermediate acting R/NPH 10/90; 20/80; 30/70; 40/60; 50/50

Humulin Novolin ge

0.5 hour 2 – 12 hours

18 – 24 hours

Premixed Insulin Analogue 25% Lispro and 75% NPL (simililar action to NPH)

Mix 25 15 minutes (Lispro portion)

1 Hour 10 – 14 hours (NPL portion)

Long Lasting Ultra Lente (U)

Humulin U Novolin ge UtraLente

4 – 6 hours

10 – 24 hours

36 hours

(ge = genetically engineered)

Intermediate Insulin

Given at bedtime begins to work in 1.5-2 hours after injection, peaks in 4-12 hours (usually around 8 or less), and continues for 18-24 hours.

Bed time Breakfast Lunch Supper Bedtime (10-10:30 p.m.)

4 hours 8 hours 12 hours 24 hours • Bedtime blood sugar test reflects the tail end action of

the intermediate acting insulin given the evening before.

• Breakfast blood sugar test reflects the action of the intermediate acting insulin.

• In an attempt to prevent the blood sugar dropping too low, the body (alpha cells of Islets of Langerhans in the pancreas) releases a hormone, glucagon, to stimulate the liver in converting stored sugar (glycogen) into glucose, which may cause a n increase in the blood glucose level and give a high reading in the morning. An “insulin reaction” may have occurred in the night/early morning and clues are: bad dreams, damp bed sheets, morning grumpiness, and /or headache.

• A blood glucose test should be done at this time and may need to be done over a few early mornings and a decrease of the intermediate acting insulin may be required.

Insulin Injection Devices Insulin Pens: are replacing syringes and vials of

insulin

pen-sized pens with insulin cartridges that are easier to change, easier to use and read, provide quick, accurate insulin dosing

Continuous subcutaneous insulin infusion (CSII) pump. Lispro, a very fast acting insulin, is the preferred insulin to be used in pumps.

Management for Specific Groups

Diabetes In Children And Adolescents

Type 1 Type 2

Management therapy

Flexibility in insulin and distribution of carbohydrates to allow for normal growth and development balancing or control of blood sugar levels.

Extreme caution required to avoid low blood sugar in children under 5 years of age (permanent damage to the brain so child is unable to acquire knowledge, and unable to think, learn, reason and abstract may occur)

Blood sugar control goals and therapeutic strategies of adolescence over 12 years of age same as for adults

Unknown

Most children show no symptoms but devastating early-onset complications

Regular surveillance for complications

Aboriginal children be screened – appropriate screening guides have not been developed. Contact local pediatric centre for blood sugar levels

Intensive programs: Increase physical activity Actions for improvement in way of eating healthy and balanced food be encouraged in home and community - improve blood sugar control

No different from those used for general population

Oral hypoglycemic agents and insulin are being researched and still being clinically tested for Type 2 diabetes in Aboriginal children. Oral medications have not been approved for use in children to date.

Type 1 Type 2

Education On-going to achieve age-appropriate knowledge and skill, leading to self-sufficiency

It is critical for classroom teachers and coaches to learn more about diabetes, and to be familiar with symptoms, treatment and prevention of hypoglycemia (low blood sugar)

Illness management is the responsibility of parents and should be notified for appropriate action to be taken

School age children should be encouraged to participate in all school activities such as sports, trips, etc.

Culturally appropriate community based prevention strategies and programs

Use of Audiovisual aids

Self-awareness

Recognition of, respect for and sensitivity for language, culture and geographic issues

It is critical for classroom teachers and coaches to learn more about diabetes, and to be familiar with symptoms, treatment and prevention of diabetes.

Illness management is the responsibility of parents and should be notified for appropriate action to be taken

School age children should be encouraged to participate in all school activities such as sports, trips, etc.

Intensive education for parents

Ongoing reinforcement: Sick-day management Prevention of diabetic ketoacidosis Use of glucagons

Prevention of diabetes in future generations

Particular attention for children

Ongoing reinforcement: Sick-day management. Use of glucagons

Type 1 Type 2

Counselling

Disordered eating patterns

Smoking, Alcohol, Drug abuse

Contraception

Driving

Transitional planning child to adult

Sensitivity to adolescent needs

Recognition of factors predicting not keeping medical follow-up

Disordered eating patterns

Smoking, Alcohol, Drug abuse

Contraception

Driving

Transitional planning child to adult

Sensitivity to adolescent needs

Recognition of factors predicting not keeping medical follow-up

Screening for associated autoimmune diseases

Hypothyroidism Test: thyroid stimulating hormone (TSH) levels.

Celiac disease: Selected children with poor growth, poor blood sugar control or unpredictable frequent low blood sugar be screened Test: antigliadin antibodies

Addisons disease Test: adenocorticotropic hormone (ACTH) level

Diabetes In The Elderly Elderly refers to people over 70 years of age.

Kidney thresholds for glucose increase with age, and so elderly do not always have classic symptoms of high blood sugar (frequent urination, thirst) until the blood sugar levels are very high blood.

Presenting symptoms generally non-specific: Fatigue, Depression Failure to thrive

There are factors affecting ability to follow treatment schedules:

Limited abilities due to some disability,

Limited resources, (money, means of transportation, translator, escort – someone to accompany the elderly)

Motivation

Other diseases: arthritis, asthma

Limited lifespan

Treatment Blood Sugar levels targets same as younger people:

Avoid high blood sugar Avoid low blood sugar

Refer to Diabetes Health Care team: educator, doctor

Moderate activity / exercise but other diseases may prevent aerobic training (mild to moderate exercise classes) and increasing activity level may be difficult.

Risk of high blood sugar increases with age

Sulfonylureas (preferred is gliclazide) is used with caution – risk of hypoglycemia

Beginning doses are half those for younger people

Slowly increased

Pre-mixed insulin as an alternative to mixing insulin to minimize dosage errors

High blood pressure treatment goals for elderly are

adapted to the individual. To prevent cardiovascular disease:

Low dose diuretics –“water pills” Beta-blockers – block response to beta

stimulation

Foot self-care limitations: could benefit from foot care given by others:

Forgetfulness Vision problems Hip joint, knee and ankle problems Mobility issues Family responsibilities

Diabetes And Pregnancy

Things to consider when planning for a pregnancy:

Counselling to plan pregnancy carefully preferably with a high risk “prepregnancy” clinic

Aim for “ideal” blood sugar control for a minimum of three months before becoming pregnant

Avoid glycated hemoglobin levels greater than 140% of upper limit of non-pregnant values (associated with increased risk for spontaneous abortion and malformations).

Any eye and kidney changes be evaluated and followed carefully (may progress during pregnancy)

Things to aim for and avoid during pregnancy:

Aim for ideal blood sugar levels without significant low blood sugar

Oral medications are not recommended during pregnancy and so insulin is frequently required even for women with Type 2 diabetes.

Avoid ketosis especially during third trimester. Monitor weight gain with goal being normal weight gain. Avoid “diets” to lose weight.

Regular retinal examination: once in first trimester and as needed according to severity of retinopathy.

It is important that a Diabetes team with experience in dealing with diabetes and pregnancy is involved in all management.

Treatment For Women With Gestational Diabetes

Dietary Counselling

Ensure well-balanced way of eating

Normal blood sugar levels for mother

Normal weight gain in mother and unborn child

Weight-reducing diets not recommended (risk of ketones in blood)

Monitor

Blood Sugar (Glucose) levels on a daily basis including fasting as well as after meals:

Fasting Plasma Glucose (FPG): less than 5.3 mmol/L

1 hour after a meal: less than 7.8 mmol/L

2 hour Plasma Glucose (PG): less than 6.7 mmol/L

Insulin started if target blood sugar levels not reached with way of eating

Physical Activity / Exercise

Regular, moderate, especially upper body

Follow-up for Gestational Diabetes Mellitus (GDM)

Achieve healthy body weight

Being active and exercising regularly after birth of baby to reduce risk of diabetes

Oral Glucose Tolerance Test (OGTT) done 6 weeks to 6 months after delivery of baby to rule out presence of glucose intolerance or diabetes

Women who have previously had gestational diabetes should be screened for diabetes annually.

Women With Gestational Diabetes Gestational Diabetes Mellitus (GDM) indicates

increased risk for future diabetes in the mother The children of mothers with Gestational Diabetes

Mellitus may have an increased risk of childhood obesity and diabetes as young adults.

Diabetes and pregnancy (Type 1, Type 2 and gestational diabetes) may be associated with an increased risk of:

Fetal macrosomia: high blood sugar levels cross the placenta and the unborn baby too much blood sugar, causing it to grow too fat and large for its gestational age.

Neonatal hypoglycemia: the extra glucose the baby received can make its pancreas to work harder, causing low blood sugar after being born.

Hyperbilirubinemia: excess of bilirubin in the baby’s blood.

Hypocalcemia: not enough calcium in the baby’s blood.

Polycythemia: abnormal increase in the number of red blood cells in the baby’s blood.

Perinatal mortality (death rare from 28 weeks gestation to 4 weeks after birth) rare today.

Children of mothers with Gestational Diabetes Mellitus (GDM) may have an increased risk of childhood obesity and diabetes as young adults.

Complications / Changes

Major Acute Complications / Changes:

Low Blood Sugar

High Blood Sugar

Long-lasting Complications / Changes in type 1 and type 2

Macrovascular complications:

Heart problems (Coronary Artery Disease - CAD):

Heart attack

Risk factors: high cholesterol, high blood pressure

Aggravating: obesity, smoking, lack of activity / exercise

Cerebrovascular disease:

Stroke

Peripheral vascular disease (PVD):

Microvascular complications:

Eye (retinopathy)

Kidney (nephropathy)

Nerves (neuropathy)

Foot problems

Retinopathy Retinopathy is impairment or loss of vision due to blood vessel damage in the eyes.

Major cause of adult blindness - most feared of long-term complications

The progression of retinopathy is best predicted by:

Longer duration of diabetes

Higher level of glycated hemoglobin

More severe retinopathy

Higher blood pressure

Higher blood fats (lipid) levels

At increased risk of developing cataracts

Screening And Management For Retinopathy

Type 1 Type 2 Intensive Diabetes Management

To prevent development and progression of retinopathy:

Aim for desirable blood sugar control

Treatment of elevated blood pressure or blood fat (lipid) levels

Intensive insulin therapy

To prevent development and progression of retinopathy:

Aim for desirable blood sugar control

Treatment of elevated blood pressure or blood fat (lipid) levels

High blood sugar, an independent risk factor for incidence and progression of eye complications (benefits of insulin therapy not completely established)

Type 1 Type 2 Screening

For Sight-Threatening Retinopathy:

Proliferative retinopathy: growth of new blood vessel that are deformed, or abnormal or

Macular edema: leakage of water and protein into centre of retina

Performed by experienced highly trained professionals: ophthalmologist, optometrist or physician experienced with assessment of diabetic changes, through dilated pupils, or retinal specialists

For Sight-Threatening Retinopathy:

Proliferative retinopathy: growth of new blood vessel that are deformed, or abnormal or

Macular edema: leakage of water and protein into centre of retina

Performed by experienced highly trained professionals: ophthalmologist, optometrist or physician experienced with assessment of diabetic changes, through dilated pupils, or retinal specialists

Screening and evaluation

For retinopathy:

Every 5 years after the onset of diabetes for age 15 years or over

Interval for follow-up assessments tailored to severity

For retinopathy:

Everyone at time of diagnosis

If no or minimal retinopathy, recommended interval is 2 to 4 years

Eye (Ophthalmic) assessment

Done before conception in a planned pregnancy, in first three months (trimester) of pregnancy and follow-up as needed during pregnancy

Low-vision Evaluation and Rehabilitation

Visually disabled

Visually disabled

Nephropathy

Nephropathy is kidney disease due to blood vessel damage to the kidneys, the body’s filtering system.

Number one cause of end stage kidney failure

High illness and death rates due to heart problems

Screening And Treatment For Nephropathy

Type 1 Type 2 Screening And Detection

Urine dipstick test: If negative or trace proteinuria then screen for Microalbuminuria

Urine dipstick test: If negative or trace proteinuria then screen for Microalbuminuria

Frequency Of Screening

Every year for 15 years of age and over with 5-year history

At the time of diagnosis and then every year

Screening Method

Albumin:creatinine ratio random daytime urine

Albumin:creatinine ratio random daytime urine

Values Repeat test if values

are:

Greater than 2.8 for females

Greater than 2.0 for males

Microalbuminuria is confirmed with 2/3 measurements over 3 months

Repeat test if values are:

Greater than 2.8 for females

Greater than 2.0 for males

Microalbuminuria is confirmed with 2/3 measurements over 3 months

Type 1 Type 2

Medical Treatment

Elevated microalbuminuria (30-299 mg albumin in 24 hours or 20-200 g/min) with ACE inhibitor to decrease albuminuria, even in absence of high blood pressure (BP goals same as for hypertension)

With overt nephropathy (greater than 300 mg albumin in urine in 24 hours) with ACE inhibitor

Best possible blood sugar control - intensive - with type 1 for prevention of onset and delay

Elevated microalbuminuria (30-299 mg albumin in 24 hours) may benefit from ACE inhibitor to decrease albuminuria

With overt nephropathy (greater than 300 mg. Albumin in urine in 24 hours) should be treated with ACE inhibitor. Blood pressure goals should be the same as for people with hypertension.

Referral

To specialist associated with a dialysis and kidney transplant centre for adequate, well-planned long-term management when there is a decrease in creatinine clearance rate of greater than 50%

To specialist associated with a dialysis and kidney transplant centre for adequate, well-planned long-term management when there is a decrease in creatinine clearance rate of greater than 50%

Actions Taken After Diagnosis Of Nephropathy Progress Prevention

Management of high blood pressure

Treat BP equal to or greater than 140/90 mmHg

Target BP less than130/80 mmHg

Medication, started or adjusted, if necessary

ACE inhibitors for kidney protective effect

Reinforce physical activity

Aim for desirable blood sugar level control

Improve way of eating

Healthy food choices

Reducing amount of protein eaten

Salt restriction with high blood pressure may be useful

Fat restriction in presence of lipid abnormalities and microalbuminuria may be useful

Self blood sugar monitoring

Aim for desirable blood sugar level control

Eliminate of all heart (cardiovascular) risk factors

Stop smoking

Follow - up Treat hypertension: target Blood pressure less than

130/80 mmHg

Monitor serum creatinine and potassium at routine follow-up visits for those taking ACE inhibitors or AT II Blockers,

A 24 hour urinary protein and creatinine clearance test every 6-12 months

Neuropathy

Neuropathy is nerve damage caused by too much blood sugar being stored by the nerves creating a build up of poisons. Nerves affected are:

Motor – nerves that help in movement, control muscles

Sensory – nerves in feet and legs that help in feeling hot, burning, cold, rough, smooth, tingling, numbness

Autonomic – nerves that help parts of body work automatically (heart, lungs, digestive system, sweating, sexual organs, bladder).

Detectable neuropathy will develop within 10 years of onset in 40-50% in people with both type 1 and type 2. Type 2 may have Neuropathy at time of diagnosis, uncommon in Type 1 within 5 years of onset.

Screening for Neuropathy: Identifies those at risk of developing foot ulcers

Prevent amputations

Screening And Management For Peripheral Neuropathy

Type 1 Type 2 Screening Annually to

identify those at high risk of developing foot ulcers

Annually to identify those at high risk of developing foot ulcers

Detection Assessment for:

decrease of loss of ability to sense vibration or loss of sensitivity to a 10-g monofilament at areas of feet

absent or decreased ankle reflexes

Assessment for:

decrease of loss of ability to sense vibration or loss of sensitivity to a 10-g monofilament at areas of feet

absent or decreased ankle reflexes

Intensive Management

Primary prevention or secondary intervention

To prevent onset and progression - lower blood sugar levels

Referrals For additional

neurological evaluation and to other specialists may be helpful

For additional neurological evaluation and to other specialists may be helpful

Medications Used For Relief Of Painful Symptoms:

Tricyclic antidepressants

Topical non-systemic treatment but effect less certain

Non-addictive analgesics may also be used

FOOT CARE Key elements of preventive care

Foot examination every year by a health care provider

Examination of high risk feet at every visit

Education on self-care of feet

Careful blood sugar management

Protection of feet

Foot problems Major cause of illness and death

Increase health care costs

Lower-extremity (foot / leg) amputation with neuropathy or peripheral vascular disease (PVD)

Minor trauma can lead to skin ulceration to infection to gangrene resulting in amputation.

Prevention of amputations:

Regular foot examination

Evaluation of amputation risk:

Previous ulceration,

Increased age,

PVD (Peripheral vascular disease),

Nerve damage,

Shape deformity,

Kidney transplant,

Poor living conditions,

Smoking

Patient education

Give detailed recommendations Demonstrate and practice foot care procedures

State instructions precisely: “Do not go bare foot indoors” Wash, dry between the toes Inspect the feet twice a day for those with

high risk feet and after each exercise session – “use a good light and mirror to see bottom of feet”

Do not attempt to cut own toe nails if peripheral neuropathy, vascular disease, or eye disease

Select suitable and proper footwear to protect the feet – avoid injury

Contact the doctor or nurse if problems (cut, bruise, blister) do not heal after one day

Early referral to foot specialist, if problems occur

Request a commitment Communicate persistent message that “foot

complications can be avoided by self-care”

Early detection and treatment of diabetic foot ulcers Footwear modifications: custom molded shoes,

properly constructed, well fitting, room to accommodate any deformities, depth inlay, extra-wide, custom orthotics - inserts, insoles, waking shoe, athletic shoe

Walking aids Do not walk on open ulcers – healing will be

prevented

Blood vessel surgery, if necessary

Foot Examination Essential part of diabetes management

Decreases risk of foot ulcer and amputation

Includes assessment:

Shape abnormalities,

Nerve damage

Blood vessel disease

Ulcerations

Evidence of infection

Performed annually for 15 years of age and over, and at more frequent intervals for those at high risk

Prevention of foot ulceration and amputation requires:

Foot care education

Reinforcement of foot care education for those at high risk of foot ulceration

Development of foot ulcer requires treatment by experienced health professionals who have expertise in diabetes foot care.

Any infection must be treated aggressively.

Use of Monofilaments of 10 gram force

Used for identifying those at risk for neuropathy or those at risk for developing diabetic foot ulcers.

Reliable

User friendly

Disposable for clinical use

Reusable for self-testing

Cost effective method of testing for presence or absence of protective sensation

Method of Sensory foot exam

Use a quiet and relaxed setting.

The individual having the exam must not watch the person applying the monofilament.

First test the monofilament on the individual’s hand so he / she knows what to expect.

4 to 10 sites chosen on plantar surface on each foot (the 4 recommended sites are the third and fifth toes, and the first and third metatarsal heads), and the chosen areas are marked on a screening form.

The nylon monofilament mounted on a handle is applied perpendicular to skin surface (A)

Apply enough force to make the monofilament bent or buckle (B)

Total contact time should be about 1-11/2 seconds.

Place the monofilament in skin sites in random fashion throughout the test.

The monofilament should by applied along the perimeter and not on an ulcer site, callus, and scar or necrotic tissue.

The monofilament should not be allowed to slide across the skin or touch it more than once.

The individual identifies at which time they were touched

Result of examination – Share the results

If the individual incorrectly identifies the stimulus at any of the 8 sites on the plantar surface of either foot, then it is considered to be an abnormal examination.

Share results:

If you do not feel the stimuli at any of the sites tested than you are at a higher risk for foot problems, therefore pay special attention to the feet.

An individual who can feel the 10-gram monofilament in the selected sites is at reduced risk for developing ulcers.

Share results:

If you feel the stimuli at all the sites tested you are at a reduced risk for foot problems, but continue with regular testing.

Heart Disease And High Blood Pressure

Heart disease is major cause of illness and abnormal conditions and death in both type 1 and type 2

2 to 4 times higher than non-diabetic population.

Risk of Coronary Artery Disease (CAD) and risk of stroke 2 times among men with diabetes; 3-4 times among women with diabetes

Unknown decreased blood supply to the heart (silent ischemia) and heart attack (myocardial infarction) more common and outcome of heart attack worse than in non-diabetic people

In Ontario native communities, there is an increasing trend of ischemic heart disease (IHD), according to a study presented by Baiju Shah, Janet Hux, Bernard Zinman, Department of Medicine, University of Toronto, Toronto Ontario, at the CDA Professional Conference in Calgary, October 1998. In comparison to all of Ontario and Northern Ontario, the study showed the increasing trend from 1981 to 1996 as follows:

Ischemic Heart Disease Events Per 1,000

1981 1986 1991 1996

All Ontario 10.2 10.0 9.2 8.6

Northern Ontario 12.4 13.0 12.3 11.6

41 Ontario Native Communities

13.8 17.8 26.9 31.7

After a heart attack (acute myocardial infarction) both men and women with diabetes are at greater risk for:

Congestive heart failure

4 times greater risk for another heart attack

2 times greater risk for abnormal heart rhythms (arrhythmias)

Higher short- and long-term mortality (death) rates than non-diabetic people

Lower overall survival rate

Higher risk of Peripheral Vascular Disease (PVD), contributing to high rate of gangrene and leg and feet amputation

High blood pressure complicates diabetes in all populations and is more frequent with advancing age:

Type 1

Blood pressure usually normal at time of diagnosis.

High blood pressure develops with onset of kidney disease, characterized by rise of both top and bottom readings in blood pressure measurement, systolic / diastolic.

Type 2 High blood pressure usually present at time of

diagnosis and increase in blood pressure is closely related with obesity, decreased physical activity and older age.

Isolated systolic high blood pressure particularly common.

Prevention Adopt healthy way of life to lower risk of heart

disease:

Healthy eating habits

Desirable weight

Regular physical activity / exercise

Stop smoking

Fasting blood fat (lipid) profile (total cholesterol, triglycerides, HDL cholesterol and calculated LDL cholesterol) be done and repeated every 1 to 3 years as clinically indicated

Appropriate treatment of abnormal blood fat (dyslipidemia) for primary and secondary prevention of heart disease

Treatment of high blood pressure to target less than 130/85 mmHg

First-line oral medication treatments for high blood pressure for people with diabetes and without observable kidney damage:

ACE inhibitors

Alpha-blockade agents

Angiotensin II receptor antagonists

Calcium channel antagonists

Choice of medication is adapted to individual and effects of the medication on heart, blood sugar and kidney results taken into consideration.

Primary prevention therapy in high-risk patients over age 30 years and secondary prevention for large vessel disease: low dose of Aspirin (acetylsalicylic) 81-325 mg/day.

APPENDIX

The Appendix section contains specific information from the Diabetes Pathway to Wellness: Aboriginal Handbook for Community Health Workers. Each appendix can be removed separately, and laminated, and can be used as a:

quick reference guide desk reference.

APPENDIX 1

Complete Medical Interview Asks questions about diabetes symptoms and the focus is on

what symptoms are present and how long they have been

present. Symptoms:

When did symptoms of high blood sugar begin

Progression of symptoms of high blood sugar

Acute and long-term complications / changes of diabetes:

o Eye

o Kidney

o Heart and blood vessels

o Nerves

o Skin problems

APPENDIX 2

Complete Health History Health History

Importance of Potential Risk Factors For Chronic Disease

Past History Endocrine disorders: Hormone

secretion of other glands

Infections

Heart Disease

Surgery (e.g., pancreas)

Pregnancies – gestational (if a woman)

Family History Diabetes

Heart Conditions

Abnormal blood fat level

High Blood pressure, kidney disease

Insulin resistance

Sterility, excessive body hair

Alteration of function of body’s defense system

Risk Factors

High blood pressure

Abnormal blood fat: LDL

Central obesity

Cigarette smoking

Health History

Importance of Potential Risk Factors For Chronic Disease

Social and Psychological Factors

Family dynamics

Coping skills

Education

Employment

Lifestyle

Drug History Current medications

Alcohol

Possible drug interactions

APPENDIX 3

Directed History Obtained at Initial and Follow-up Visits

Lifestyle Details of nutrition counselling, meal plans, keeping with prescribed meal plan, ethnic, and cultural influences and weight changes

Diabetes education received in the past (location and level of program), current understanding of diabetes and its management

Level of physical activity / exercise (type, duration, intensity, frequency, and time of day)

Monitoring (of sugar levels)

Method used and technique

Frequency, timing in relation to meals, records (log books)

Quality control of meter (measurements closely related with laboratory)

Diabetes Medications

Oral medications (type, dose adherence), any adjustment in response to monitoring

Insulin (type, source, dose, injection sites), understanding of dose adjustments in response to food, activity

Social and Psychological factors

Support of family and friends

Household income management

Medic alert - A form of identification that contains confidential, critical medical information, provided only to professional health practitioners to help diagnose and treat in an emergency. It speaks for an individual when that individual cannot speak for him / herself. Payment or Reimbursement (with receipt) Applications for “one standard medic alert product per lifetime” may be made at any zone office, health centre and / or pharmacy and sent to Ontario Region, FNIHB for all of Canada.

Medical Insurance

APPENDIX 4

Comprehensive Physical Examination Initial and Follow-up

BODY SYSTEMS SPECIAL ATTENTION

General Height

Weight

Waist circumference (central obesity)

M > 94 cm; F > 80 cm should not gain more weight

M > 102 cm; F > 88 cm should reduce weight

BMI

20 – 25 healthy weight range

25 – 27 at risk for certain problems

Blood pressure (lying and standing)

Pulse

Head and neck Eyes: Reactions of pupils, muscles controlling eye ball movement, cloudiness of lens, examination of innermost base of interior of eye

Mouth, gums, and teeth: hygiene and cavities

Thyroid assessment

Chest Routine

Abdomen o Enlargement of /or abnormal organs

Genital and urinary Rule out fungal infections: yeast, kidney infections

BODY SYSTEMS SPECIAL ATTENTION Muscle, joints and bones (Musculoskeletal System)

Foot inspections,

Signs of limited joint mobility and any abnormal condition affecting joints of hands,

Colour and temperature of lower limbs.

Brain and spinal cord (Central nervous system)

Routine evaluation for feelings in touch, change in position sense of body, vibration

Light touch (using Monofilament), and reflexes

Evaluation for autonomic neuropathy (abnormalities in involuntary muscles and function of glands), if appropriate

Skin

Inspection for skin infections

Problems with injection sites

Signs of abnormal blood fats.

Heart and blood Vessel (Cardiovascular System)

Signs of congestive heart failure

Pulses

Bruits: Blood flow through arteries is silent except in someone with occlusive arterial disease. Auscultation of blood flow in this person usually produces a blowing sound called a “bruit”

APPENDIX 5 Stepwise Approach To Type 2 Diabetes

Nonpharmacologic Therapy (Non-drug therapy)

Lifestyle, Healthy way of eating, Physical activity / Exercise, Self-monitoring of blood sugar level

If individualized goals for blood sugar are not met within 2-4 months, (if symptoms or severe high blood sugar levels continue) reassess action for lifestyle changes for further improvement.

Advance to next level of therapy.

Single Oral Drug Therapy (Oral agent monotherapy)

If individualized goals for blood sugar are not met within 2-4 months, reassess action for lifestyle changes for further improvement.

Advance to next level of therapy

Oral Combination Therapy

(Combination of oral drugs therapy – One or more medications added until maximum dose is reached)

If individualized goals for blood sugar levels are not met within 2-4 months, reassess action for lifestyle changes for further improvement.

Advance to next level of therapy

Bedtime Insulin Plus or Minus Oral Medications

Insulin Injections 1-4 / Day

If, at any point, the patient becomes metabolically decompensated (symptomatic hyperglycemia and ketosis)

APPENDIX 6

Oral Medications: Categories, Main site of Action, Action, Limitations, Examples If your goal to reach “optimal” level of blood sugar control is not achieved with a healthy way of eating, getting down to a healthy weight and lifestyle changes, then the doctor may prescribe diabetes pills. If insulin resistance continues, the individual may stop responding to the pills. After 10 years on pills, the individual may often need to go on insulin therapy. Pills are meant to go along with a healthy way of eating, activity / exercise routine, and monitoring of blood sugar. Pills are not a substitute. Following are the details on the categories, where the action takes place, what is happening and side effects or limitations there are, and examples of names of medications for each category.

Oral Agent Category : Alpha glucosidase inhibitor Main site of Action

Action: How it Controls Blood Sugar

Limitations/ Side Effects

Example

Intestines (gut)

Delay breakdown of sugar in meal and slows absorption of starch and sucrose in the gut reducing blood sugar levels after the meal. No major hypoglycemia- may reduce episodes in the night especially if on insulin. Must be taken with first bite of food at mealtime. Prescribed for those who cannot get their post meal blood sugar level to acceptable levels.

Hypogycemia must be treated with Dextrose (Dextrosol or Monoject -not juice, sugar). In itself does not cause hypoglycemia Gastrointestinal side effects: gas, diarrhea, cramps Should not be taken by anyone who: •inflammation/ulceration

of bowel • bowel obstruction • gastrointestinal disease •kidney or liver disorder • hernias •pregnancy or lactation • type 1

Generic name: Acarbose (short acting) Brand name: Prandase

Oral Agent Category: Biguanide

Main site of Action

Action: How it Controls Blood

Sugar

Limitations/ Side Effects

Example

Liver

Helps the insulin, made by the body, work better. It stops the liver from releasing too much glucose, which helps to lower blood sugar levels and increase glucose uptake by muscle tissue. This helps the tissues to respond better to insulin made by the body. Biguanides are associated with less weight gain and lower frequency of low blood sugar than sulfonylurea. Appropriate for those who are obese and have milder levels of high blood sugar.

Gastrointestinal side effects: no appetite, nausea, abdominal discomfort, diarrhea may be a limiting factor. If there is pregnancy, kidney, liver failure, severe heart/lung condition, or alcoholism, biguanides are not used (may cause lactic acidosis)

Generic name: Metformin Brand name: Glucophage

Oral Agent Category: Sulfonylurea

Main site of Action

Action: How it Controls

Blood Sugar

Limitations/ Side Effects

Example

Pancreas

Stimulate pancreas to release more insulin. Makes insulin producing cells more sensitive to sugar and stimulates them to secrete more insulin to lower blood sugar.

First oral agent of choice for those who are not obese and/or have high blood sugar levels

Hypoglycemia (dangerous for over age 70, hypoglycemia may occur more frequently), weight gain, secondary failure in 5 to 10% patients per year.

Generic names: Acetohexamide* chlorpropamide * – long acting glyburide**- medium acting

Gliclazide**- short acting

Tolbutamide* - short acting

Brand names: Dimelor

Diabinese

Diamicron

Diabeta

Orinase

Oral Agent Category: Thiazolidinediones

Main site of Action

Action: How it

Controls Blood Sugar

Limitations/ Side Effects

Example

Muscle cells

Makes muscle cells more sensitive to insulin and reduces insulin resistance.

Liver enzymes be done before starting this, every month x 8 months, bimonthly for next 4 months and then periodically.

High doses lower white blood count therefore not recommended for those who are immune suppressed. May trigger infection.

Headache

May raise LDL (abnormal, “bad”) cholesterol.

Not to be used by anyone with liver, heart problems

Generic name: troglitazone

Brand name: Rezulin

APPENDIX 7

Insulin Use in Insulin Treatment for Diabetes Type 1 And Type 2

Treatment Type 1 Type 2

Insulin treatment

Essential for life

Blood sugar control depends on coordination of insulin doses, food intake and physical activity.

May be required for a short duration in times of illness or stress

For blood sugar control when there is poor response to treatment with way of eating and oral medications.

Along with oral medications, can be added as a single injection of intermediate-acting (acting slower but lasting longer) insulin at bedtime. This approach may result in better blood sugar control with smaller insulin dose and may result in less weight gain than the use of insulin alone.

Intensified therapy (tight control) to achieve target blood sugar levels

Multiple daily injection (3-4 / day)

or

Continuous subcutaneous insulin infusion (CSII) insulin pump

Regular or Lispro insulin can be used before meals. Lispro is preferred for CSII.

In cases of poor response to way of eating and oral medications, then insulin doses (frequently high) and the number of injections (1-4) should be adjusted to reach target blood sugar levels.

If poor blood sugar control continues regardless of insulin, then one of following oral medications may be added: Acarbose, Metformin, Troglitazone

APPENDIX 8

Insulin Treatment

Insulin Treatment

Trade Name Onset Peak Duration

Very fast acting (absorbed more rapidly – works in 5-15 minutes)

Lispro (Humalog) Insulin Analogue (copycat)- clear

0.1 hour 1.5 hour 3-4 hours

Short acting (regular)

Humulin R Novolin ge Toronto – clear

0.2 hour 3-4 hours

6-8 hours

Intermediate acting NPH (N) Lente (L)

Humulin N Novolin ge NPH- cloudy Humulin L Novolin ge L- cloudy

1.5 – 2 hours 1.5 – 2 hours

4 – 12 hours 4 – 12 hours

18 – 24 hours 18 – 24 hours

Premixed short /intermediate acting R/NPH 10/90; 20/80; 30/70; 40/60; 50/50

Humulin Novolin ge

0.5 hour 2 – 12 hours

18 – 24 hours

Premixed Insulin Analogue 25% Lispro and 75% NPL (simililar action to NPH)

Mix 25 15 minutes (Lispro portion)

1 Hour 10 – 14 hours (NPL portion)

Long Lasting Ultra Lente (U)

Humulin U Novolin ge UtraLente

4 – 6 hours

10 – 24 hours

36 hours

(ge = genetically engineered)

Taking Care of Diabetes

GUIDELINES PROCEDURE

All

Everyone in Aboriginal communities More frequent and earlier testing

Ove

r

45 Fasting Plasma Glucose every 3

years FPG

Add

ition

al

Ris

k Fa

ctor

s

Testing more frequently & earlier First degree relative HDL less than 0.9 mmol/L Triglycerides (fasting)

greater than 2.8 mmol/L

HDL Fasting Triglyceride

SCR

EE

NIN

G

Pred

ictiv

e R

isk

Fact

ors

Test every year:

History of impaired glucose tolerance

Presence of complications History of gestational

diabetes mellitus Presence of high blood

pressure Presence of heart disease

IGT: IFG: BP Resting or exercising ECG for over age 35

Med

ical

In

terv

iew

Primary Care Giver: The focus is on what symptoms are present What are you feeling How long have the symptoms been present

Hea

lth

His

tory

Physician / Nurse Practitioner: Special importance placed on looking for potential risk factors for chronic disease

HE

AL

TH

ASS

ESM

EN

T A

ND

E

XA

MIN

AT

ION

Phys

ical

E

xam

inat

ion Physician / Nurse Practitioner:

Special attention to body systems affected

Taking Care of Diabetes cont’d GUIDELINES PROCEDURE

MA

NA

GE

ME

NT

PL

AN

Initi

al v

isits

and

re

view

ed e

very

6

mos

/clin

icia

n;s

disc

retio

n

Dietician / Educator: Nutritional counselling Physical activity

counselling Blood sugar monitoring Medication counselling:

oral or insulin Diabetes knowledge

Target optimal fasting (before meal): 4-7 mmol/L and 1-2 hours after meals: 5-11 mmol/L

Review blood sugar records with your team

HgAlc lab test target less than 0.07 Equal to or greater than 115% of upper limit

HGA1c lab test

Blo

od S

ugar

Reduce frequency of low blood sugar

Review with your team how often you have low blood sugars

Target goal: equal to or less than 130/80 mmHg Goal for those with kidney complications: equal to or less than 125/75mmHG

BP

Blo

od P

ress

ure

You may require 1 or more medications to help control blood pressure

BP medications if needed

Maintain a healthy body weight Goal body mass index (BMI) healthy range: 20-25

Weight BMI

Have your doctor and/or nurse educator inspect your bare feet for sores, cuts and calluses at every visit

Foot exam

3 T

O 6

MO

NT

HS

Oth

er

Healthy lifestyle choices: Healthy eating Keep active Stop smoking Decrease stress

Review healthy lifestyle choices

Fasting lipid profile Goal less than 4.0

Total Cholesterol

Goal less than 2.5 LDL Goal greater than 1.0 HDL Goal less than 2.0 Triglycerides Goal less than 4.0 Total

Cholesterol/HDL ratio E

VE

RY

YE

AR

A

ND

/OR

AS

IND

ICA

TE

D

Blo

od F

ats

Medications if needed

The level measured in capillary blood using glucose meter should be within 15% of a simultaneous laboratory measurement of a fasting venous blood sample

Fasting blood sugar meter/lab comparison Microalbumin urine screen (albumin: creatinine ratio) (MAUR)

Kid

ney

Screen for kidney problems Type 1 every year for 15 years of age and

over with 5 year history Type 2 at diagnosis and then every year

If kidney problems are detected early you can slow down the progression with medication, tight blood sugar control, tight blood pressure and a special diet of reduced protein.

24 hour Microalbumin as indicated

Eye

s

Ophthalmologist / Optometrist Dialated eye exam: Type 1 every year for 15 years of age and

over with 5 year history Type 2 at diagnosis then every 2-4 years or

as recommended

Sens

atio

n

Your Health Care Team can test for loss of sensation in your feet with a 10 gram monofilament on the circled areas noted Mark “+” if positive response (can feel) ⊕ Mark “-“ if negative response (cannot feel) Ø

Sensory testing on feet

Ask for a referral to your nearest educator / education program You need the support of the Health Care Team

Teachings on diabetes/lipids

EV

ER

Y Y

EA

R A

ND

/OR

AS

IND

ICA

TE

D

Edu

catio

n

Influenza vaccine every year Pneumococcal vaccine once in a lifetime Other

Keep a record

Adapted from Chinook Health Region and Alberta Clinical Practise Guideline Program.

GLOSSARY

This list contains some terms that are used throughout the handbook, along with a brief explanation of what they mean.

ADDISONS DISEASE

Low functioning of Adrenal gland. The Adrenal glands (2) are located one on top of each kidney, each having an inner part and an outer part that secrete hormones. Where there is an under production of the hormone from the outer part, it can lead to serious illness.

AEROBIC ACTIVITY

An activity that makes the heart pump harder and faster, make the person breathe faster, increasing the amount of oxygen in the blood.

ALPHA-GLUCOSIDASE INHIBITORS

Delay breakdown of sugar in meal and slows absorption of starch and sucrose in the gut reducing blood sugar levels after the meal. Examples: Acarbose, Prandase

ARTERY

Large blood vessel that carries blood from the heart to all parts of the body. The walls of arteries are thicker, stronger and more elastic than walls of veins.

AUTOIMMUNE DISEASE

An autoimmune disease involves immune reactions in which something triggers the immune system to react against the body’s own tissues and to produce abnormal antibodies that attack these tissues. An example is Type 1 diabetes.

BIGUANIDES

Help the insulin, made by the body, tow work better. It stops the liver from producing glucose, which helps to lower blood sugar levels and increase glucose uptake by muscle tissue. This helps the tissues respond better to insulin made by the body.

Biguanides are associated with less weight gain and lower frequency of low blood sugar than sufonylurea, but gastrointestinal side effects may be a limiting factor. If there is kidney or liver failure biguanides are not used (may cause lactic acidosis). Example: metformin.

CAPILLARY

The smallest blood vessels with walls so thin that oxygen and glucose can pass them and enter the cells. Carbon dioxide, a waste product, can pass from the cell and into the blood, to be carried away and taken out of the body. People who have had diabetes for a long time have capillaries that become weak, especially in the eye and kidney.

CARBOHYDRATE

Sugar and starch in food breaks down into glucose (sugar), the main source of fuel for muscles and affect blood sugar more than any other nutrient.

CARDIOLOGIST

A medical doctor, one who is a heart specialist.

CASUAL

Refers to any time of day, without regard to the interval, since the last meal eaten.

BODY MASS INDEX

BMI: healthy range 20 – 25; at risk 25 -27+

CELIAC DISEASE

Poor food absorption and intolerance of gluten – children with poor growth, poor blood sugar control or unpredictable frequent low blood sugar.

CHOLESTEROL

A whitish, waxy fat-like substance made in large amounts by the liver and found in the blood, muscle, liver, brain and other tissues. The body needs some cholesterol but too much may build up on the walls of arteries and cause blood to slow down or even stop the flow. Examples: Butter and eggs have a lot of cholesterol.

CONGESTIVE HEART FAILURE

Quantity of blood pumped by the heart each minute is not enough to meet the body’s normal requirements for oxygen and nutrients. Signs: tiredness, shortness of breath, engorgement of neck veins that feel rigid and show exaggerated pulses, enlarged liver, rapid breathing, racing of heart, unexplained steady weight gain, nausea, chest tightness, slowed mental response, loss of appetite, sweating, little urine output, swelling with indentation that remains for a short period after pressing with a finger on area.

CREATININE

A waste product produced by the muscles and put out by the kidneys.

DIABETES

Classic symptoms: fatigue, frequent urination, excessive thirst, blurred vision, unexplained weight loss.

DIABETIC KETOACIDOSIS (DKA)

Refers to a build up of ketones in the body as a result of faulty carbohydrate metabolism, an emergency condition that may lead to death.

Signs are: frequent urination, excessive thirst, excessive hunger, and a fruity smell to breath

DIALOSTIC PRESSURE

Refers to the pressure of blood against the inside wall of the artery that occurs when the heart rests between beats. It is one (bottom) of the readings in a blood pressure measurement.

END-STAGE KIDNEY DISEASE

A term used to describe kidney failure.

ENDOCRINOLOGIST

A medical doctor, one who specializes in treating people who have problems with endocrine glands. Example: the pancreas in an endocrine gland.

FASTING

To have some blood tests done, no food must be eaten for at least 8 hours.

FATS

One of the main classes of food and a source of energy for the body that help the body use some vitamins and keep the skin healthy. The body stores this energy in this form. There are three types of fats in foods: saturated, unsaturated and polyunsaturated.

FATTY ACIDS

A basic unit of fat. Fatty acids are burned for energy when insulin levels are too low or there is not enough sugar to use for energy.

GESTATIONAL DIABETES MELLITUS (GDM)

A type of diabetes, taking the form of type 2, with onset during pregnancy, occurs between 24th and 28th week and is caused by hormones produced during pregnancy. The body cannot use insulin properly. Sugar is not taken to the cells and builds up at a higher than normal level in the bloodstream. It may be controlled with a healthy way of eating and sometimes with insulin. The blood sugar levels return to normal in about 95% of all cases.

GLUCAGON

A hormone, made by the alpha cells in the islet of Langerhans of the pancreas, when the body needs to put more sugar to raise the level of sugar in the blood.

Glucagon, a preparation, is used as an injection for severe low blood sugar (insulin shock), to raise the level of sugar in the blood. The cells react by using what insulin is available to make energy from the higher amount of sugar in the blood.

GLUCOSE

A simple sugar found in the blood that comes from food eaten and is the body’s main source of energy.

HDL

High-density lipoprotein, known as good cholesterol.

HYPERGLYCEMIA

Hyper=high; glyc=glucose; emia=blood.

A condition where blood sugar levels are too high as defined by a fasting blood sugar level of over 7.0 mmol/l, signifying that diabetes is out of control. This happens when the body does not have enough insulin or cannot use the insulin.

HYPERTENSION

High blood pressure.

HYPERTENSIVE MEDICATION

Medication used to lower blood pressure.

HYPOGLYCEMIA

Refers to low blood sugar and is defined by a blood sugar level less than 4 mmol/l, any time. Precipitating causes (what brings it on): This may occur when a person living with diabetes has injected too much insulin; glyburide; has not understood onset, peak, duration; eaten too little food, skipping or delaying a meal or snacks; drinking alcohol; has done some extra activity or exercise without extra food.

Symptoms: This person may feel: nervous, shaky, hungry, weak, dizzy, sweaty, numb, have tingling in tongue or lips, mood changes, blurred vision and may have a headache.

Treatment: Test blood sugar. Eat or drink small amounts of sugar, juice or food containing fast acting sugar: 4 oz. (1/2 cup) of juice; 2-3 teaspoons of sugar; 3 glucose tablets or one package of glucose gel; 8 oz. (1) cup of milk. This will help the person feel better within 10-15 minutes. Repeat blood sugar test after 15 minutes; repeat treatment if necessary.

Prevention: follow plan; understand medication, not drinking alcohol, check blood sugar before and after exercise.

HYPOTHYROIDISM

Not enough thyroid hormone.

IMPAIRED FASTING GLUCOSE (IFG)

A new term established to identify another in between stage of a steady state of abnormal blood sugar (glucose) using levels of 6.1-6.9 mmol/l.

IMPAIRED GLUCOSE TOLERANCE (IGT)

Ranges most frequently from insulin resistance with relative insulin deficiency to most frequently a defect in secretion with insulin resistance. Depends on measurement of plasma glucose 2 hours after drinking 75-g glucose.

INADEQUATE

Inadequate glucose level is associated with acute symptoms of high blood sugar level and a markedly increased risk of chronic complications and these levels require a re-assessment and re-adjustment of therapy.

INJECTION SITES

These are places on the body where persons living with diabetes can inject insulin most easily. These are:

• The outer area of the upper arm.

• The area just above and below the waist except a 2-inch circle area around the navel.

• The upper area of the buttock, just behind the hipbone.

• The front of the thigh, midway below the top of the thigh to 4 inches above the knee.

INSULIN

A hormone made by the islets of Langerhans, a small island of cells in the pancreas that regulate blood sugar levels.

INSULIN LISPRO

Synthetically made insulin, a copycat that is very short acting.

INSULIN DEFICIENCY

The pancreas is producing not enough insulin.

INSULIN RESISTANCE

This is when insulin cannot open the door to the cell, and the body is unable to use the insulin. This leads to a condition where the pancreas becomes overworked, making too much insulin and eventually may not make enough insulin or any insulin. The body becomes more increasingly resistant to the insulin the pancreas is making.

INSULIN REACTION

When the level of sugar in the blood becomes too low, because too much insulin has been injected, not enough food has been eaten, or exercised without extra food. The person may feel hungry, nauseated, weak, nervous, shaky, confused and sweaty. Taking small amounts of sugar will help the person feel better within 10-15 minutes.

INSULIN SHOCK

A severe condition when the blood sugar level drops too quickly. This may happen if too much insulin has been injected, too little food eaten, or exercised without extra food. Signs are: shaking, sweating, dizziness, double vision, convulsions and collapse.

INTENSIVE INSULIN THERAPY

The use of insulin in multiple daily injections (3 or 4 per day) or by a pump to achieve target glucose levels.

ISLETS OF LANGERHANS

A small island of cells in the pancreas.

KETONURIA

Ketones present in the urine, a warning sign of diabetic ketoacidosis (DKA).

LDL

Low-density lipoprotein, abnormal “bad” cholesterol.

LIPID

A term used for fat. The body stores energy as fat for future use. When it needs energy, it breaks down the lipids into fatty acids and burns them like sugar.

LIPOPROTEINS

This is the form taken by the cholesterol ester (organic chemistry that combines cholesterol with a fatty acid) and triglyceride which are insoluble in water, to be transported in the blood. LDL is the major circulating cholesterol-rich lipoprotein. HDL is the smallest but important in reverse cholesterol – taking free cholesterol back to the liver.

LIPOPROTEIN PROFILE

Please refer to the Target Lipid Levels found in table: Evaluation of Plasma Lipid Levels (blood fats) in the People with Diabetes.

MACROSOMIA

This condition happens in gestational diabetes when high blood sugar levels cross the placenta and feed the unborn baby too much blood sugar, causing it to grow too fat and large for its gestational age.

MACROVASCULAR COMPLICATIONS

Damage body-wide (systemic) to large blood vessels.

METABOLIC DECOMPENSATION

Results from metabolism failure with symptomatic hyperglycemia: symptoms of high blood sugar levels; and ketosis; abnormal build up of ketones in the body due to inadequate use of carbohydrates; fatty acids are metabolized instead.

METABOLISM

A term used to describe the way the cells chemically change food so that it can be used to keep the body alive. There are two parts to the process:

• Catabolism – the body uses food for energy

• Anabolism – the body uses food to build or mend cells.

MICROVASCULAR DISEASE

A problem with smaller blood vessels (capillaries) that connect to various parts of the body.

MINERALS

Sodium, potassium, calcium, phosphorus, magnesium, iron, are important for regulating many body functions. Sources: table salt, milk, meat, cheese, eggs.

MMOL

“Millimole” refers to a measurement that counts how much sugar is in a specific amount of blood – one litre.

NEPHROPATHY

Kidney disease due to blood vessel damage to the kidneys, the body’s filtering system.

OBESITY

When body weight is over by 20% of ideal body weight for age and height.

OPHTHALMOLOGIST

A medical doctor, one who is an eye specialist.

OPTIMAL

Most favourable, the best. Optimal levels refers to those glucose levels that approach the normal range and are associated with a low risk of developing chronic complications of diabetes.

PANCREAS

A bird-beaked shaped gland that lies just behind the stomach. It secretes insulin and glucagons produced by the islets of Langerhans.

PEAK ACTION

Refers to the time period when the most effect of insulin on sugar in the blood is as strong as it can be.

PERIPHERAL VASCULAR DISEASE (PVD)

Body wide circulation problems – blood flow to limbs (arms, legs, feet) is blocked, creating cramping, pains or numbness.

PODIATRIST

A doctor who treats and takes care of people’s feet.

POLYDIPSIA

Unusual thirst lasting for long periods of time.

POLYPHAGIA

Unusual hunger.

POLYUNSATURATED FAT

Are liquid at room temperature and come from vegetable oils, tend to lower the level of cholesterol in the blood. Examples are corn, cottonseed, sunflower, safflower, and soybean.

POLYURIA

Very frequent urination.

PREMIXED INSULIN

When both a short acting and long acting insulin are mixed together.

PRIMARY CARE DOCTOR

One who is the first patient contact, one who usually takes care of person for care of a given health problem.

PROTEIN

Are necessary for growth and repair of body tissue and they come from meat products, fish, poultry, eggs, lentils, legumes, milk.

RETINOPATHY

Refers to impairment or loss of vision due to blood vessel damage to the eye.

SATURATED FAT

Are solid at room temperature and come mainly from animal food products. They raise the level of cholesterol in the blood. Examples: butter, lard, and meat fat.

SUBOPTIMAL

Suboptimal level refers to the glucose level that may be the best that is safely attainable, range being between 7.1 and 10 mmol/L before a meal and between 11.1 and 14 mmol/L after a meal.

SUPHONYLUREAS

Stimulate the pancreas to release more insulin. Makes insulin producing cells more sensitive to sugar and stimulates them to secrete more insulin to lower blood sugar. Examples are: Acetohexamide, chlorpropamide, glyburide, gliclazide, tolbutamide, tolazamide.

SYSTOLIC PRESSURE

Pressure against the inside wall of arteries when the heart (contracts) pumps out blood and is one of the readings (top) in a blood pressure measurement.

THIAZOLADINEDIONES

A new drug for type 2 diabetes that makes cells more sensitive to insulin. Found to be effective in just a single daily dose of 200-, 600-, 800-mg. tablets, and doses can be split into two and taken twice a day. Examples: Troglitazone or Rezulin.

TRIGLYCERIDE

Three fatty acids: saturated, unsaturated, polyunsaturated; plus glycerol. Causes: excessive calories in diet; acute alcohol abuse; severe uncontrolled diabetes, kidney failure, certain drugs: estrogens, oral contraceptives, corticosteroids, thiazide diuretic; heredity.

TYPE 1 DIABETES

Type 1 diabetes, an autoimmune disease, is primarily a result of the pancreas not making any insulin to take the sugar to the cells. The body does not get any energy because the sugar stays in the blood stream. People with Type 1 diabetes always need to have insulin by needle every day to stay alive. Young adults and children usually develop this type of diabetes. The cause of this diabetes is unknown.

TYPE 2 DIABETES

A genetic disease, triggered by environmental factors: stressors (substance abuse), inactive lifetstyle (20 minutes of activity / exercise less than once a week), or obesity. Ranges most frequently from the body cell not letting the sugar inside (insulin resistance) with the pancreas not making enough insulin (relative insulin deficiency) to most frequently a combination of both conditions (defect in secretion with insulin resistance).

UNEQUIVOCAL

Clear, plain.

UNSATURATED FAT

Also called monounsaturated fat are neutral as it does not raise nor lower blood cholesterol. Examples are: olive oil and peanut oil.

UROLOGIST

A medical doctor who treats urinary and genital conditions.

VEIN

A blood vessel that carries blood from other parts of the body to the heart.

VITAMINS

Are important for metabolism and normal functioning of the body.

REFERENCES

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Black, Joan. “Diabetic Dilemma: Traditional or Western Medicine?” Windspeaker Contributor, Edmonton, Internet Wind-diabetes.

1998 Clinical Practice Guidelines for the Management of Diabetes in Canada. Supplement to CMAJ 1998, Canadian Diabetes Association, Canadian Medical Association

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Coggins, Kip. Alternative Pathways to Healing: The Recovery Medicine Wheel. Health Communications Inc., Florida, 1990.

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Elliot, Louise. “Cases of Diabetes Expected to Triple.” Windspeaker Contributor, San Diego, California, Internet Wind-diabetes.

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