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The cost of staying healthy

Know Your Rights

By Alexis Campbell

Seema Nagpal

To stay healthy, people with diabetes require more medical care than most: regular doctor’s appointments and lab tests to measure blood sugar (glucose), as well as regular dental, foot, and eye exams. They may also take a number of different medications, from insulin to oral diabetes pills.

“Managing diabetes is complicated,” says Seema Nagpal, an epidemiologist, and public policy director with Diabetes Canada. “People need to keep their blood sugar from going too high or too low. They also need to work hard to prevent or delay complications like foot problems, heart disease, and stroke.”

Provincial and territorial governments pay for doctor’s visits and hospital stays, but when it comes to medication, supplies (such as test strips) and devices such as glucose meters, most people depend on private insurance—or pay out of their own pockets if they do not have insurance or their policy does not cover all of their diabetes care needs. According to Diabetes Canada’s 2015 Report on Diabetes—Driving Change, 15 per cent of Canadians with diabetes lacked health insurance to pay for their prescription medications, 30 per cent had no insurance to cover equipment and supplies for blood glucose monitoring, and more than half had no dental insurance.

Twenty-five per cent of people with diabetes surveyed reported that the cost of treatment made it difficult for them to follow treatment recommendations. For those earning less than $35,000 per year, nearly half had to decide between buying food, paying their rent or utilities, or buying their medications, and almost one in five said they either did not fill prescriptions or did not take medication because of the cost.

However, there are some good news stories. The challenges have inspired action and, in some cases, have changed government policy. Tammy MacLaren of New Glasgow, N.S., started an online petition urging the provincial government to fund insulin pumps for children. She took that step after learning that a local family had to fundraise to pay for a new insulin pump for their 10- year-old daughter, Madison Moulton, who relied on several insulin injections each day. MacLaren’s efforts helped put the issue in the spotlight and in September 2013, Nova Scotia launched the province’s first pediatric insulin pump program.

“It is important to strengthen people’s voices, individually and collectively, through organizations like Diabetes Canada,” says Nagpal. “We can inform, influence, and shape public policy and decision-making, practices, and public opinion to better support those living with diabetes.”

The last word

“People [who can’t afford medications] end up thinking of creative ways to make their prescription last longer—like skipping doses or not taking the full dose to ‘stretch it out’ so they can postpone paying for a refill. This does not allow them to get the most out of their treatment.” – Seema Nagpal, epidemiologist, and public policy director, Diabetes Canada

Did You Know?

Today, more than three million Canadians are living with diabetes—a number that has more than doubled since 2000 and is expected to increase to more than four million by 2025. Read more from the 2015 Report on Diabetes— Driving Change now.

How can you help us fund projects and campaigns that change lives? Donate now!

The Diabetes Charter for Canada supports people living with diabetes and their care. Sign the Charter here.

Combo diabetes management therapy offers benefits

picture of various diabetes medications

By Elizabeth McCammon

For more than 90 years, people with type 1 diabetes have been treated with insulin. In recent years, researchers have been studying whether the addition of oral diabetes medications might improve blood sugar levels.

A small study at the University of Buffalo suggests that a combination of insulin plus dapagliflozin (Forxiga) and liraglutide (Victoza) may do just that. The group of 30 participants with type 1 diabetes were already taking liraglutide and insulin to manage their diabetes; the researchers randomly chose 20 people in the group to receive dapagliflozin as well. After 12 weeks, the participants taking all three medications had significantly lower blood sugar levels compared to the liraglutide+insulin participants, and had lost an average of 1.9 kg (about four pounds), while the others experienced no weight change.

Although these were positive results, on the downside, the three-drug therapy increased urinary ketones, which are created when fat is broken down for use as energy. The body normally gets rid of extra ketones, but when it does not, they can build up in the body and lead to diabetic ketoacidosis, a dangerous complication that occurs when ketones and blood sugar levels are high (as was the case with two of the participants in the three-drug group).

“Our study sheds light on potential strategies for preventing diabetic ketoacidosis, but more research is still needed in this area,” says Dr. Paresh Dandona, chief of endocrinology, diabetes, and metabolism in the Department of Medicine in the Jacobs School of Medicine and Biomedical Sciences, and senior author of the study, which was published in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism.

Did You Know?

You can develop a blood sugar testing plan that is right for you with Diabetes Canada’s interactive “Self Monitoring of Blood Glucose Tool.”

Faster healing possible for foot injuries?

picture of feet

By Elizabeth McCammon

Foot problems are common in people with diabetes, and even a small cut or sore can lead to very serious complications, including treatment-resistant infections and amputation.

Now, a new type of bandage developed by an engineering team at Northwestern University in Illinois may offer improved healing for foot injuries. The “regenerative bandage” imitates the repair process that happens in a healthy body: It slowly releases a protein into the wound that speeds up the body’s ability to repair itself, by directing stem cells to the wound and creating new blood vessels to increase blood circulation.

According to the study, which was published in the September issue of the Journal of Controlled Release, the bandage heals diabetic wounds four times faster than a standard bandage. Says lead researcher Guillermo Ameer, professor of biomedical engineering in the McCormick School of Engineering and Surgery in the Feinberg School of Medicine, “The repair process is impaired in people with diabetes. By mimicking the repair process that happens in a healthy body, we have demonstrated a promising new way to treat diabetic wounds.”

Did You Know?

A good daily foot care routine will help keep your feet healthy. Read more from “A Step Towards Good Health” now.

Can oral diabetes drugs help type 1 diabetes?


By Elizabeth McCammon

Metformin is often used by people with type 2 diabetes to lower their blood sugar levels. Now, a study by scientists at Newcastle University in England shows the drug may help people with type 1 diabetes slow or delay the development of heart disease—a common long-term complication of both type 1 and type 2 diabetes. It is caused when high blood sugar levels damage blood vessels.

In the study, a group of 23 adults with type 1 diabetes and no evidence of heart disease were treated with metformin (in addition to insulin) for eight weeks; they were compared to another group that was treated with insulin only. The researchers found that the stem cells of the patients who took metformin were able to help with repairing the blood vessels. (A stem cell is a “blank” cell that can become another, more specific, cell type, such as a nerve or blood vessel cell.) Plus, these patients showed an improvement in how blood vessel stem cells worked, which could help delay or slow down heart disease. Researchers hope the study, published in the August issue of Cardiovascular Diabetology, will lead to a much larger clinical trial.

“Importantly, this study showed that metformin has the potential to directly affect the blood vessels of patients with type 1 diabetes. Thus, it may be useful for reducing cardiovascular disease in this patient population,” says Dr. Jason Dyck, director of the Cardiovascular Research Centre at the University of Alberta.

He adds, “Although these findings may have significant importance, the extent to which metformin can reduce the risk of cardiovascular disease in these patients will need to be confirmed in long-term clinical studies that directly assess cardiovascular outcomes.”

Stress S.O.S. – strategies for coping

Stress S.O.S. - strategies for coping

By Gabrielle Bauer

Photo (above): Speaking up for people with diabetes: (From left) Helena Macario, CDA information and support services representative; Kelsey MacPherson, CDA community initiatives coordinator (Sault Ste. Marie office); Charlene Lavergne, CDA advocate; and Nickel Belt MPP France Gélinas (NDP health and long-term care critic) at a “Diabetes Day” for Ontario legislators.

Charlene Lavergne

Charlene Lavergne worries about her feet. Her church gave her a treadmill so she can exercise at home, but what if she loses a foot? She worries about her eyes. What if her vision gets worse and she cannot afford new glasses? She worries about having a heart attack. “Every time I do something, like hop on the treadmill, I worry about whether I’ll be able to do it tomorrow,” says Lavergne, 61, who lives in Oshawa, Ont. “The stress never leaves me, not even at night.”

Lavergne has lived with type 1.5 diabetes—type 2, with some features of type 1, known as LADA (Latent Autoimmune Diabetes in Adults)—since she was a teenager. Adding to her stress is the stigma of the disease in her Métis community. (She has shared her story with Ontario Members of Parliament on behalf of the Canadian Diabetes  Association/CDA.) “I can’t tell my relatives that I shouldn’t be eating a certain food,” she says. “I can’t tell them my blood sugar is high. Even my children don’t want to know.” The lack of openness compounds her stress, which “makes my blood sugar climb still higher. You can see it in my logbook.”

What kind of stress are you dealing with?

While life throws stress at just about everyone, there are some particular challenges for people with diabetes:

Michael Vallis

  • Diabetes self-management “Most people aren’t wired to pay attention to something 24/7,” says Michael Vallis, a health psychologist and associate professor at Dalhousie University in Halifax. “Even the things we enjoy, such as golf or knitting, we enjoy in spurts.” Having to think about diabetes every time you eat, exercise, or change your routine can create significant stress over time, says Vallis. “It’s not for nothing we talk about diabetes distress.”
  • Health Diabetes-related complications such as vision problems and foot ulcers can make day-to-day activities more challenging. Even if you are not dealing with complications now, they are a long-term concern.
  • Financial “Every month I worry about whether I’ll be able to afford the insulin I need,” says Lavergne, who gets a modest disability pension with a limited drug plan. When she was employed, the fear of losing her job kept her up at night. “I had a supervisor who had a problem with me injecting insulin in view of others,” she says. “I dreaded going to work and kept worrying I would get fired.”
  • Social “If you have diabetes, you’ll likely have some stress dealing with people in your social circle, particularly around food,” says Vallis. He gives the example of getting a dinner invitation, where you tell your host that you need to eat by 7 p.m. to keep your blood sugar on an even keel. “The host may say, ‘Sure, no problem,’ but then you get there and dinner isn’t ready until 8:30 p.m. That’s stressful.” Not only can the delay affect your blood sugar levels, the stress of being delayed can also worsen your physical health.

Stress: it’s not just in your head

Stress causes your body to produce cortisol and adrenalin—hormones that raise your blood sugar and give you the energy to “run from danger,” also known as the “fight or flight” response. These hormones also raise your blood pressure. If this happens just once in a while, your body can recover. But if stress becomes chronic, it can contribute to conditions such as chronic pain, digestive problems, and even heart disease. That is because high blood pressure can damage the blood vessels, causing them to form plaque that limits the flow of blood.

Norbert Schmitz

Trying to cope with chronic stress can also mean you are less likely to maintain behaviours that can help you stay healthy; that can raise your risk of developing diabetes complications over time, says Norbert Schmitz, an associate professor of psychiatry at McGill University. (Schmitz was featured in “Research Brief,” Autumn 2013.) These complications can create more stress, which can worsen your health and lead to what Schmitz calls a negative feedback loop. “Getting the stress under control can break the cycle and improve your ability to manage your diabetes effectively,” he says.

What can you do about stress?

Exercise Some research suggests that exercise increases a chemical in the brain that reduces stress and anxiety—as long as it is an exercise you enjoy. If you do not like walking on a treadmill, you might walk around a mall instead, or buy a badminton racket and find a buddy to play with.

Dr. Howard Nathan

Relaxation techniques Yoga, meditation, deep breathing, and progressive relaxation therapy (tensing and relaxing your muscles in sequence) are popular options. “Focusing on your breathing for a period of time has been shown to decrease activity in the stress centres of the brain,” says Dr. Howard Nathan, a CDA-funded scientist based at the Ottawa Hospital Research Institute. (Nathan was featured in “Research Brief,” Summer 2015.)

Mindfulness A related approach, called mindfulness-based stress reduction, involves paying attention to what is happening in your mind and body at the moment. For example, lie down and notice the sensations in your right foot—is it hot, cold, sore, tingly, or itchy?—without judging or reacting to them. “If we develop the ability to be with unpleasant sensations or emotions without reacting to them, our quality of life improves,” says Nathan, whose research has shown that mindfulness and other relaxation techniques improve physical and mental functioning as well as quality of life. There is also evidence that “mindfulness leads the body to produce less cortisol,” he adds.

Positive self-talk When Lavergne feels down about her diabetes, she reminds herself that “other people have it worse, and I’m lucky to be alive.” At other times, “I need a good cry,” she says. “The important thing is to carry on.”

Social support Research continues to find links between a strong social network and physical health. Lavergne draws strength from her weekly Bible study group. For others, friendships based on common interests may help. A word of caution from Vallis: “If your current friends don’t have time to hear about your struggles, seek out other friends.”

Doctor support According to Vallis, negative experiences with your doctor can add to your stress. If he or she never asks you how diabetes is affecting your quality of life, Vallis suggests you make the first move. “Tell the doctor how you’re feeling—including if you’re feeling judged for not being the perfect patient—and what you need.”

Mental-health support If you cannot manage your stress on your own, a psychologist, social worker, or stress-reduction program can help you identify and cope with the sources of stress in your life. Contact your doctor or a CDA branch to help you find the right support.

So where do you begin? Vallis suggests choosing one of these strategies, getting comfortable with it, and going from there. “The more sources of support you have, the better,” he says.

The last word

“Every time I do something, like hop on the treadmill, I worry about whether I’ll be able to do it tomorrow. The stress never leaves me, not even at night.” – Charlene Lavergne, person living with type 1.5 diabetes

“Getting the stress under control can break the cycle and improve your ability to manage your diabetes effectively.” – Norbert Schmitz, associate professor of psychiatry

 “Focusing on your breathing for a period of time has been shown to decrease activity in the stress centres of the brain.” – Dr. Howard Nathan, physician and researcher

“Tell the doctor how you’re feeling—including if you’re feeling judged for not being the perfect patient—and what you need.” – Michael Vallis, health psychologist and associate professor

Did You Know?

What you experience as stress is your body’s response to something you consider threatening. Read more from “Stress Management & High Blood Pressure.”

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