When it comes to diabetes, small changes can make a big difference — even in the middle of an epidemic that currently affects more than 2 million Canadians, and costs us an estimated $13.2 billion per year. Earlier prevention, earlier diagnosis, and very aggressive treatment of diabetes by controlling blood glucose levels, blood pressure, and lipid (i.e. cholesterol) levels have proven to prevent or significantly delay the damage that uncontrolled diabetes can cause to the body's blood vessels.These encouraging research findings from around the world have spurred some important changes in the Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada . In terms of both the onset of diabetes and its complications, “The 2003 Guidelines have a much stronger focus on prevention throughout the lifespan of diabetes,” notes Donna Lillie,Vice President, Research and Professional Education. “Diabetes doesn't wait. Individuals need to ask, 'Am I at risk and what can I do?'”
To help Canadians answer that question, the Canadian Diabetes Association's 2003 Guidelines have lowered the age considered at-risk for diabetes by five years. That means an additional 2.5 million Canadians aged 40 to 44 are now recommended for screening for high blood glucose (sugar). The change was prompted by “solid clinical evidence that type 2 diabetes is preventable, as the 2003 Guidelines' new title suggests, ” explains Dr. Stewart Harris, Chair of the Expert Guidelines Committee, Associate Professor and McWhinney Chair for Family Medicine Studies at the University of Western Ontario. “Recent research is showing that we're missing a lot of people by waiting until age 45 to screen for diabetes.”
The urgent need to identify people at risk is fuelled by expectations that the number of people diagnosed with diabetes will increase by up to 50% over the next 10 to 20 years, Dr. Harris says. “We're in the midst of an epidemic that is going to get a lot worse before it gets better, because the baby boomers are now entering their 5 th decade when the highest prevalence rates of diabetes occur.”
Currently, about half of those diagnosed have already had diabetes for as long as 7 years, so the clock has already been ticking for some time, Dr. Harris notes; long enough that 20% to 30% of individuals have already developed complications affecting the heart, eyes, feet, or kidneys.
“We want to avoid the common scenario where someone finds out they have diabetes only when they're admitted to the hospital with a heart attack.” Given that four in five people with diabetes die of cardiovascular disease such as heart attack and stroke, “We need to recognize that diabetes is a cardiovascular disease.This is another new focus of these guidelines.”
Screening for high blood glucose is important because it identifies individuals who are at risk of developing not only diabetes, but cardiovascular disease (because of the damage high blood glucose can inflict on their arteries). “In people with diabetes, we often see a clustering of cardiovascular risk factors such as high blood pressure, high cholesterol, and obesity.What we've learned in the last few years is that [compared to the general population] people with diabetes are at greater risk for all these complications.That's why having diabetes is about more than managing blood glucose.You need to manage all these risks aggressively.
And targets are more aggressive (i.e. lower) for individuals with diabetes because they are at greatest cardiovascular risk,” says Dr. Harris. Evidence over the last ten years clearly proves that like elevated cholesterol and blood pressure, high blood glucose is a continuous risk, Dr. Harris explains. “That means the higher your levels, the greater your risk of problems.” The connection may be difficult to make, since all three conditions are often silent, so people don't necessarily feel their ill effects. Still, he says Ontario data show that individuals with diabetes die 13 years earlier than those in the general population. Lowering elevated blood glucose, blood pressure, and cholesterol levels significantly reduces individuals' risk for developing diabetes or later complications, and their longerterm risk of dying prematurely.
Your future is in your hands
EATING WELL WITH DIABETES doesn't need to be complicated, says Sharon Zeiler, a dietitian and Senior Manager of Nutrition Initiatives and Strategies for the Canadian Diabetes Association. “Like all Canadians, individuals with diabetes are advised to eat a balanced diet that's high in fibre, so it includes plenty of whole grains, fruits and vegetables, and low in fat, so it provides protein from lean meat, fish, and vegetable sources.” As a rule of thumb, portion food so that one-quarter of the plate has some kind of whole grain, such as brown rice or whole wheat pasta, another quarter contains a protein like lean meat, fish, or tofu, and the remaining half of the plate should be taken up with vegetables and fruits.The 2003 Guidelines advise that of your daily energy intake, 50-55% should be from carbohydrate, 15-20% from protein, and less than 30% from fat (with less than 10% from saturated fats).
Sharon Zeiler encourages people to concentrate on vegetables and fruits because they are a great source of vitamins, minerals, and fibre, as well as filling you up. Most fruits and vegetables tend to be high in fibre and low on the Glycemic Index (GI), a system which ranks common foods according to how quickly and to what degree they cause an increase in blood glucose. “In general, high-fibre, low-GI foods (e.g. many vegetables) cause a smaller and more gradual rise in blood glucose, so you can avoid spikes and valleys and maintain blood glucose levels within a healthy range.”
Moderation is the key to healthy eating as well as to healthy weight loss. “People who are overweight may believe they need to lose 50 pounds, but you only need to lose 5 to 10 percent of your body weight to dramatically improve control of your blood glucose, blood pressure, and lipid levels,” notes Dr. Harris. “By eating just 500 fewer kilocalories per day, you can lose 5% to 10% of your body weight over 6 to 12 months, which translates into a loss of 1 to 2 kilograms per week.” Individuals who lose weight gradually have a better chance of keeping it off, Dr. Harris says.And weight loss efforts must include physical activity if they are to succeed, he adds.
PHYSICAL ACTIVITY is another cornerstone of treatment, especially in type 2 diabetes, according to Lynn Baughan; every small step counts. “Try to find opportunities to increase activity in each day. Take the stairs instead of the elevator, or get off the bus a stop earlier and build a walk into your day.” As Manager of the Canadian Diabetes
Association's Diabetes Education Programs and Strategies, and a Certified Diabetes Educator who has type 1 diabetes, Baughan practices what she teaches. She has started to wear a pedometer to track the distance she walks each day.
All Canadians can benefit from more physical activity – it helps build a healthy heart and lungs, keeps your body toned and fit, and helps to relieve stress in a positive way, notes Baughan. “When you have diabetes, it helps your body burn blood glucose more effectively for energy, particularly if you get regular activity at least every other day. It can help lower your blood glucose and keep it controlled.”
In some cases, it could reduce the amount of medication you need.
Exercise is a big help for people who want to lose weight, because as you become more active, you build muscle, which burns more calories, says Sharon Zeiler. It needn't be a 45-minute workout to be beneficial – even periods of activity as short as 10 minutes several times a day will help. Start small and gradually increase the length of time or the intensity of your activity – if you start too vigorously, you won't stick with it, Baughan advises.
“The 2003 Guidelines recommend that people with type 2 diabetes accumulate 150 minutes of moderate intensity exercise per week in the form of an aerobic exercise like brisk walking. Resistance activities three times a week, exercise that helps strengthen specific muscle groups, are also recommended in the 2003 Guidelines .” Individuals should talk to their health care provider before starting an exercise program more vigorous than brisk walking, especially those who have heart disease or hypertension or have been inactive for a long time.
Keep your eye on your targets
Know your target levels, and remember that every small improvement you achieve in your blood glucose, blood pressure, and lipid levels can make a significant contribution to your long-term health.The 2003 Guidelines provide targets that are more aggressive (i.e. lower), simpler in that they use single numbers and fewer categories, and are consistent with those of other national organizations, Dr. Harris says. Individuals with diabetes should aim for a blood pressure of 130/80 mmHg. Suggested lipid targets are a low-density lipoprotein (LDL) cholesterol of below 2.5 mmol/L, and a total cholesterol (TC) to high-density lipoprotein (HDL) cholesterol ratio of less than 4.
Blood glucose targets are also lower than those recommended in the previous guidelines, says Dr. Harris. “In terms of daily monitoring, pre-meal blood glucose targets are 4 to 7 mmol/L, and post-meal targets are less than 10.” The glycosylated hemoglobin (A1C) measurement represents an average of your overall blood glucose levels over the past 60 - 90 days, and is reported as a percentage. Dr. Harris says, “We're asking people to keep their AIC to less than 7, and if possible, less than 6, which is normal. That would be ideal, but is harder for many people to achieve, particularly those taking anti-diabetes medications, since it may increase their risk for [too] low blood glucose, or hypoglycemia.We need to achieve a balance, but all patients should be asking their doctors, 'What is my A1C, and what can I do to get it down to less than 7%?' .”
Recommended targets for glycemic control *†
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Achieving even small reductions in A1C is well worth the effort. A large study (UKPDS) of individuals with type 2 diabetes found that each 1.0% reduction in A1C was associated with a 37% decline in the risk of small blood vessel complications, a 14% lower rate of heart attack, and fewer deaths from diabetes or any cause. Another study (DCCT) of individuals with type 1 diabetes found that a 10% reduction in A1C (e.g. from 8.0 to 7.2%) was associated with a 40% to 50% lower risk of eye disease (retinopathy) progression.
Another small but important measure you can take to maintain your health is to have regular medical check-ups to head off complications. Ask your healthcare provider to check your feet at every appointment,and see your dentist regularly. Have your eyes checked by an eye specialist at least once every two years.Your physician will also monitor your kidney function regularly for signs of kidney-related complications.
How the Canadian Diabetes Association can help you
The Canadian Diabetes Association plays a leading role in supporting the over two million Canadians who are directly affected by diabetes and their families, through research, education, service, and advocacy.The Association provides a variety of educational programs and resources for the wide range of health care professionals that work with individuals who have diabetes. The 2003 Guidelines are a prime example, as Dr. Harris explains. “The Canadian Diabetes Association brought together experts from around the world to produce the only truly evidence-based diabetes guidelines in the world – they are held up as a gold standard.”
Dr. Harris reports with pride that in the first month (January) that the 2003 Guidelines were accessible, there were almost half a million hits to that section of the site, 40% of which were international. The web site ( www.diabetes.ca) is also an excellent source of current information about diabetes management and prevention for individuals with diabetes, and anyone interested in learning more.
Another great way to stay up-to-date on diabetes is to subscribe to Diabetes Dialogue , the quarterly magazine published by the Canadian Diabetes Association, which offers articles on diabetes-related topics including nutrition, research, exercise, medical updates, lifestyle management, advocacy, and resources.
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