The “Diabetes Canada 2018 clinical practice guidelines for the prevention and management of diabetes in Canada” were published in April 2018.8 As part of the dissemination effort, a series of readable articles summarizing high-priority recommendations for primary care providers and outlining easy-to-apply practices were planned. This article summarizes the new guidelines, focusing on high-priority recommendations for FPs managing people who live with type 2 diabetes. Herein, we present these guideline recommendations and link these recommendations to approaches and tools that will help FPs put them into practice.
Type 2 diabetes: Type 2 diabetes affects the way the body uses insulin. While the body still makes insulin, unlike in type I, the cells in the body do not respond to it as effectively as they once did. This is the most common type of diabetes, according to the National Institute of Diabetes and Digestive and Kidney Diseases, and it has strong links with obesity.
Insulin is vital to patients with type 1 diabetes - they cannot live without a source of exogenous insulin. Without insulin, patients with type 1 diabetes develop severely elevated blood sugar levels. This leads to increased urine glucose, which in turn leads to excessive loss of fluid and electrolytes in the urine. Lack of insulin also causes the inability to store fat and protein along with breakdown of existing fat and protein stores. This dysregulation, results in the process of ketosis and the release of ketones into the blood. Ketones turn the blood acidic, a condition called diabetic ketoacidosis (DKA). Symptoms of diabetic ketoacidosis include nausea, vomiting, and abdominal pain. Without prompt medical treatment, patients with diabetic ketoacidosis can rapidly go into shock, coma, and even death may result.
Diabetes Canada is a health charity and advocacy organization that produces comprehensive national guidelines for the prevention and management of diabetes in adults and children, with a focus on special populations (those with renal failure, Indigenous peoples, women of child-bearing age, etc). Following a rigorous methodology,9,10 a guideline writing committee, composed of interprofessional diabetes experts, posed then answered clinically relevant questions, resulting in a series of recommendations.10 The evidence supporting the recommendations ranges from levels I to IV and grades A to D.8 The Diabetes Canada guideline committee includes primary care practitioners, endocrinologists, diabetes educators, other specialists, and people living with diabetes from across Canada. The resulting diabetes guideline is reviewed and launched in a 5-year cycle, with interim revisions in the event of important practice-changing evidence and treatment options. For the 2018 guidelines, 9 of the 10 authors responsible for developing recommendations for pharmacologic management of type 2 diabetes had no conflicts of interest with industry. In the case of disagreement about conflicts or outright conflicts of interest, committee members removed themselves from discussions. This article does not attempt to revise or critique the Diabetes Canada guideline recommendations but presents a family medicine–oriented approach to applying relevant recommendations in practice.
Kidney damage from diabetes is called diabetic nephropathy. The onset of kidney disease and its progression is extremely variable. Initially, diseased small blood vessels in the kidneys cause the leakage of protein in the urine. Later on, the kidneys lose their ability to cleanse and filter blood. The accumulation of toxic waste products in the blood leads to the need for dialysis. Dialysis involves using a machine that serves the function of the kidney by filtering and cleaning the blood. In patients who do not want to undergo chronic dialysis, kidney transplantation can be considered.
A random blood sugar of greater than 11.1 mmol/l (200 mg/dl) in association with typical symptoms or a glycated hemoglobin (HbA1c) of ≥ 48 mmol/mol (≥ 6.5 DCCT %) is another method of diagnosing diabetes. In 2009 an International Expert Committee that included representatives of the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) recommended that a threshold of ≥ 48 mmol/mol (≥ 6.5 DCCT %) should be used to diagnose diabetes. This recommendation was adopted by the American Diabetes Association in 2010. Positive tests should be repeated unless the person presents with typical symptoms and blood sugars >11.1 mmol/l (>200 mg/dl).
The Winnipeg Regional Health Authority acknowledges that it provides health services in facilities located on the original lands of Treaty 1 and on the homelands of the Metis Nation. WRHA respects that the First Nation treaties were made on these territories and acknowledge the harms and mistakes of the past, and we dedicate ourselves to collaborate in partnership with First Nation, Metis and Inuit people in the spirit of reconciliation.
Type 2 diabetes is different. A person with type 2 diabetes still produces insulin but the body doesn't respond to it normally. Glucose is less able to enter the cells and do its job of supplying energy (a problem called insulin resistance). This raises the blood sugar level, so the pancreas works hard to make even more insulin. Eventually, this strain can make the pancreas unable to produce enough insulin to keep blood sugar levels normal.
Choosing Wisely, an educational campaign aiming to reduce unnecessary medical tests and procedures, advises against routine home glucose monitoring for patients with Type 2 diabetes who are not on insulin. It says there is no benefit, and that there are potential harms (a study has shown an association with increased anxiety and depression). This argument is supported by the American Academy of Family Physicians, the Society of General Internal Medicine and the Endocrine Society.
^ Jump up to: a b Cheng J, Zhang W, Zhang X, Han F, Li X, He X, Li Q, Chen J (May 2014). "Effect of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on all-cause mortality, cardiovascular deaths, and cardiovascular events in patients with diabetes mellitus: a meta-analysis". JAMA Internal Medicine. 174 (5): 773–85. doi:10.1001/jamainternmed.2014.348. PMID 24687000.
This diabetes-management and weight-loss app (it works similarly on Apple and Android devices, despite the separate names) features a log for blood glucose readings, A1C results, food, exercise, blood pressure levels, and medication use plus reminders to check your blood glucose. Upgrade to the “maximum” version for integration with fitness trackers (such as Jawbone and Fitbit) and extra features—nutrition planning and more charts and reports. This is for people with type 1 or type 2 diabetes and for those seeking to lose weight.
Triglycerides are a common form of fat that we digest. Triglycerides are the main ingredient in animal fats and vegetable oils. Elevated levels of triglycerides are a risk factor for heart disease, heart attack, stroke, fatty liver disease, and pancreatitis. Elevated levels of triglycerides are also associated with diseases like diabetes, kidney disease, and medications (for example, diuretics, birth control pills, and beta blockers). Dietary changes, and medication if necessary can help lower triglyceride blood levels.
Research has shown that there are some ways of preventing type 2 diabetes, or at least delaying its onset. Lifestyle changes such as becoming more active (or staying active, if you already engage in regular physical activity) and making sure your weight stays in a healthy range are two ways to help ward off type 2 diabetes, but talk to your doctor about what else you can do to prevent or manage the disease.