Do Group Classes Work to Improve Diabetes Control?

As the sheer numbers of people who develop diabetes continues to climb, we as health care providers need to look at creative ways to provide the in depth information and teaching that is required to help patients take the best possible care of their diabetes.   One of these approaches is to teach about diabetes in the form of group classes.  The question is, has the group teaching approach been proven to improve diabetes control?

Many studies have actually been done on this subject, ranging from observational studies to randomized controlled trials.  A meta-analysis in the Canadian Medical Association Journal by Housden et al, which looks at all of the literature on this topic to date, found that the class teaching approach improves hemoglobin A1C (a marker of overall diabetes control) by -0.46%.  While this is only a modest improvement in diabetes control, it is not much different than the A1C improvement we may expect to see in a patient who is close to A1C targets but not quite there, following addition of another oral medication.  

Anecdotally, I have often had my patients report back to me that they have really enjoyed being part of a diabetes education class, as it not only provides excellent information, but it also provides the opportunity for diabetics to support each other, and talk to each other about their experiences.  Knowing that you are far from alone in your diagnosis of diabetes can often go a long way to feeling secure and empowered in your journey towards improving upon your health!

If you are a diabetic and interested in group education classes, ask your doctor what is available.  Most centres of diabetes care (including our own) offer group classes free of charge.  Give it a try!


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2013

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The World's First All-Diabetic Professional Athlete Team!

Here's an inspirational story to make you smile today: The recent BC Superweek's cycling race included an all diabetic racing team!

Anyone who lives with diabetes or cares for people with diabetes knows that managing diabetes in the context of exercise can be a challenge.  Managing diabetes in the context of a gruelling multi-day race is nothing short of impressive and admirable.

The attitude of this go-get-em team reflects exactly how we guide and teach our patients with diabetes:  to learn adapt their diabetes medications to fit their lifestyle, rather than have to change or restrict their lifestyle to fit their diabetes medications or insulin regimen.   Learning how to adjust certain diabetes medications or insulin doses to fit differences in activity levels and eating patterns from day to day can be a very freeing and satisfying experience!

Dr Sue Pedersen www.drsue.ca © 2013 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen 

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An App For Helping Doctors Choose Type 2 Diabetes Treatments - From the Canadian Diabetes Association!

As blogged previously, the Canadian Diabetes Association released the 2013 Diabetes Guidelines in April this year.  As part of the excellent CDA 2013 website, there is an app that can help health care providers choose the best medications to treat each patient with type 2 diabetes.

The reason for this app being developed is because after metformin (which is considered the best first line treatment), all other treatment options for type 2 diabetes are on an even spectrum without one in particular favored over another, with the best choice made in a patient-specific fashion.  It is important to think about each patient's individual characteristics, and medication characteristics, in choosing the next best treatment for your patient.

The app starts by asking the health care provider what the glucose control target is for their patient (A1C).  Next is a quick yes/no checklist asking about other medical conditions that can impact the best choice for medication (eg bone disease, heart failure, pancreatitis history). The health care provider then clicks 'INDIVIDUALIZE', and the app will remove undesirable treatment options from the lengthy list of choices.   The remaining agents in the table are the medications that you can then consider discussing with your patient.  Under the table, the agents that have been removed as choices are listed, and the reason why they were removed is stated.

With all of the different medications available to treat type 2 diabetes (with new drug classes likely just around the corner as well), after metformin, it can seem a daunting task to choose the best agent(s) for our patient.  This app lends a hand to help doctors narrow down the choices in a patient specific manner.


Dr Sue Pedersen www.drsue.ca © 2013 

Follow me on Twitter for daily tips! @drsuepedersen

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Canadian Diabetes Association 2013 Guidelines are Out!

Attention all diabetes health care providers and patients!  The
Canadian Diabetes Association 2013 Clinical Practice Guidelines are
now published and available online.


You can browse the executive summary here.

Helpful information for patients is available here.

Here is a summary of the key changes: (quoted from the guidelines)

• Diagnosis
  • Use of A1C for the diagnosis of diabetes (A1C ≥6.5%)
  • Use of A1C for the diagnosis of prediabetes (A1C 6.0% to 6.4%)
• Organization of Care
  • New “Diabetes Patient Care Flow Sheet”
• Glycemic Targets
  • Individualization of glycemic targets with the vast majority of people with diabetes continuing to target an A1C ≤7.0%
  • Better definition of scenarios in which one may consider a target of A1C ≤6.5% or less stringent target of A1C 7.1% to 8.5%
• Self-monitoring of Blood Glucose (SMBG)
  • Recommendations for frequency of SMBG for those with type 2 diabetes not receiving insulin therapy
• Nutrition Therapy
  • Continued emphasis on balanced, individualized nutritional therapy with the inclusion of alternative dietary patterns as options
• Pharmacological Management of Type 2 Diabetes
  • Achieve target A1C within 3 to 6 months of the diagnosis of diabetes
  • New algorithm for the pharmacological management of type 2 diabetes with emphasis on individualization of agent choice
  • Metformin may be used at the time of diagnosis
  • A1C ≥8.5% at the time of diagnosis should receive immediate pharmacological therapy and consideration for use of ≥2 antihyperglycemic therapies and/or insulin
  • Inclusion of cost table for antihyperglycemic therapies
• In-hospital Management
  • Targets preprandial blood glucose (BG) 5 to 8 mmol/L and random BG <10 for="" i="" ill="" majority="" mmol="" noncritically="" of="" patients="" the="">
  • BG 8 to 10 mmol/L for critically
  • BG 5 to 10 mmol/L in the perioperative period
• Vascular Protection
  • New, simplified definitions of who should receive statins, angiotensin converting enzyme (ACE), angiotensin II receptor blocker (ARB), or aspirin
  • No need to assess for high risk as suggested in 2008
• Chronic Kidney Disease
  • New definition of microalbuminuria of albumin-to-creatinine ratio (ACR) ≥2.0 for both men and women
  • New “Sick Day Management” document for acute illness
• Diabetes Pregnancy
  • New criteria for the screening and diagnosis of gestational diabetes
• Diabetes in the Elderly
  • New recommendation for glycemic targets among the frail elderly A1C ≤8.5%-fasting and preprandial BG of 5 to 12 mmol/L

Enjoy!

Dr Sue Pedersen www.drsue.ca © 2013 

Follow me on Twitter for daily tips! @drsuepedersen


Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 188 Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2013;37(suppl. 1). S1-SXX.

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Survival of the Fattest? The Obesity Paradox in Type 2 Diabetes

We know from population studies that obesity is a risk factor for the development of a long list of medical problems, including heart disease.  Interestingly, a number of research studies suggest that obesity actually has a protective effect in patients who already have established heart disease, and a recent study shows that this protective effect includes patients with type 2 diabetes and heart disease.

The study by Doehner and colleagues, which is an analysis of data from the PROactive trial (a study of a diabetes medication called pioglitazone, vs placebo), they found that over a follow up period of almost 3 years, patients with type 2 diabetes and heart disease had the lowest mortality rates if their body mass index (BMI) at the start of the study was between 30-35.  (A BMI of 30 or greater is considered as 'obese'. You can calculate your own BMI in the right hand column of www.drsue.ca .)

They also found that weight loss was a predictor of mortality, and that weight gain was NOT associated with increased death rates.  In patients taking pioglitazone, a medication that is known to cause weight gain, those who did gain weight on pioglitazone had improved survival compared to those who did not gain weight.

This phenomenon, which has also been shown in several studies of nondiabetics, is what we refer to as the Obesity Paradox - that people with cardiovascular disease seem to be protected by higher body weights.  How is this possible?

The theory is that people who are sick are often losing weight, because they have lost their energy or appetite to eat, or because their illness causes such a high calorie burn that they can't keep up with food intake (this is seen in cancer patients as well).  Thus, the people who gained weight or didn't lose weight in the study were likely more 'well' in general, whereas the people who were thin or losing weight were likely to be sicker with their heart disease, and therefore had a higher rate of death during the study period.   Perhaps it could also be a better 'starting point' to have extra fat tissue on board before a person becomes sick - thereby giving that person more energy stores to draw from while overcoming a period of illness.

All in all, this information reminds us that fat tissue isn't all bad - it actually evolved over millions of years to help us survive periods of famine, and probably periods of illness as well.

Dr Sue Pedersen www.drsue.ca © 2013 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

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DrSue.ca Product Review - Glucose Meters

So, your doctor has told you that you need a glucose meter to check your blood sugars at home.  You arrive at the pharmacy to find yourself standing in front of a shelf with a confusing array of options.  What should you do?

There are dozens of meters out there, and rather than bore you with a long list of every single one, I've highlighted some of the new and unique features that are available amongst some of the most commonly used meters (in alphabetical order):


Accu-Chek:

The Accu-Chek Mobile glucometer is unique in that it has the meter, testing strips, and lancets all niftily packaged into one device.  So, after a blood sugar test, there's nothing to dispose of.

BGStar:

Techie alert: the iBGStar connects directly to your iPhone or iPod Touch!  Very cool.

Contour:

Another Tech Alert here: The USB Meter's name tells you what's unique about this one - namely, that you can plug the meter directly into your computer to download data.

FreeStyle:

The InsuLinx meter is a newer meter that can help you calculate how much mealtime insulin you need.  It is programmed to fit your insulin needs by your diabetes educator.

I have many patients who are taking mealtime insulin, who have found the meter's dosing suggestions to be very helpful.  REMEMBER, however, that your brain is still better than your meter - if there is a particular situation where your own experience tells you differently than what the meter suggests - listen to your spidey sense.

OneTouch:

The newest member of this family is the VerioIQ, which is the only meter with a full color screen.  A really cool feature is that it will alert you if it detects a pattern of high or low blood sugars.

A few other considerations:

Super small, discreet meters:  Consider the OneTouch UltraMini, the Contour USB , or the Freestyle Lite  (though most meters are pretty compact these days).

Meters that use the least blood:   Freestyle and Accu-Chek meters are amongst those that use the least amount, around 0.3 microlitres.

Meters with big numbers on screen:  Freedom Lite, VerioIQ, Accu-Chek Mobile

Accuracy:  Some meters claim to be a bit more accurate than others, but the differences are small.  Your doctor should send you to the lab periodically to check the accuracy of your meter in any case.


BOTTOM LINE:  Choose a meter that fits your lifestyle, and that you enjoy using!


Dr Sue Pedersen www.drsue.ca © 2013 

Follow me on Twitter for daily tips! @drsuepedersen

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