May 15, 2020 The ABCs of Glycemic Monitoring: What do the Guidelines Tell Us?

Lori Berard and Dr. Steele – April 10th, 2021

Dr. Lionel Noronha: Good morning, and thanks for being here on such a beautiful, magnificent day outside.  I appreciate your commitment to learning in diabetes.  This is our third and final session talk on the series in patients living with diabetes.  I'm a family physician Southeast Ontario.  I have a great interest in diabetes, and love participating in medical education in many capacities.  I noticed that in medical education events over the years that clinicians are typically speaking to other clinicians, and rarely to patients directly.  With a phenomenal team, we decided to put together these talks directed to patients to not only educate, but to empower and inspire patients to take on their condition and greatly improve their outcomes.  These talks are completely non promotional, yet funding was raised via honoraria for the speakers, and it will be forwarded to the non-profit entity, Diabetes, Canada, which is committed to altering the lives of patients living with diabetes.  I encourage you to interact by typing questions into the question and answer link.  Don't be shy - all the questions are anonymous.  If you ask it, someone else will benefit from the answer.  I will ask these questions to our speakers after each of their talks.

This morning we have an excellent session.  Part one will be on monitoring, essentially, and you know, monitoring allows us to know where we are and how we can help predict our outcomes.  It's critical in diabetes as are many other things in life.  And the second part is a recap of diabetes with you know, a top 10 things patients should know to have better outcomes.  With that in mind, our first speaker is Ms. Lori Berard.  She's a Certified Diabetes Educator with an expertise in diabetes management, education and clinical research.  She has over 30 years experience primarily as a nurse manager for the Health Sciences Center in Diabetes Research - the diabetes research Program.  30 years - I think she must have started when she was 10!  So she has assisted with the Canadian Diabetes guidelines development.  Helped develop many diabetes programs, and received many awards. I believe she was Certified Diabetes Educator of the year in Canada if she wants to put that down, but I believe that was the case.  She is very humble.  So with that, please take it away Lori.

Lori Berard: Good morning, and thank you so much for that kind introduction and welcome everyone.  I would imagine the majority of you are in Ontario, and I was just speaking to one of my kids who lives there, and it's going to be a beautiful day.  So thank you for taking an hour out of your lives and spending it with us, because I get great joy out of having the opportunity to help people with diabetes, and learn about their disease. 

So I have kind of a little bit of an interesting topic.  I was asked to talk a bit about self management education, and about monitoring. So I’ve got the ABC of glycaemic monitoring.  But really what do the guidelines tell us?  So I’ve set some objectives for us for the next 20 minutes or so, in terms of what I’d like to accomplish.

 And what I’d like to do is I’d like to be able, in the next 20 minutes, sorry my clicker didn't work there, is I want to help you understand the ABCDESS as a roadmap to manage your diabetes.  So we're going to talk a little bit about that.  I know Dr. Steele is going to talk a lot more about it, so I’m just going to give you a highlighted version of it.  And want to also talk a little bit about the importance of self management education and support in your diabetes journey.  So recognizing that, you know, this is a lifelong chronic disease, and what you should expect and need to be able to successfully manage your own diabetes.  And then I’m going to touch briefly on the role of glucose monitoring to support diabetes self management decisions.  And, I mean, I say briefly because I could do a whole hour on helping you understand your glucose monitoring, but everyone has, you know, different needs, and are at a different stage in terms of their diabetes.  So it isn't a one size fits all - so just a highlight overview.

So why do we do what we do in diabetes, and why do we set up for diabetes education and support?  And it's because we recognize that we want to help you live the most healthy life possible.  And we recognize that there are complications associated with diabetes.  And if we can follow a roadmap to better care, that we may be able to prevent these known complications.  Things like having poor vessel  blood flow to your feet, and damage to your nerve endings, damage to your kidneys, keeping your eyes healthy.  We recognize that there's also now some issues about diabetes and dementia, so we really want to prevent that from happening.  Not many people think about the oral care in diabetes and their.  potential complication with your teeth.  We know that we want to prevent heart disease and stroke for people living with diabetes.  Recognizing as well that there’s sexual dysfunction that goes along with diabetes.  And a favorite topic of mine is foot ulcers, because we still know that diabetes is associated with the leading cause in non traumatic lower limb amputations.  And something as easy as taking care of your feet and taking a look at your feet we can do something about.

So on the right hand side of your screen is the ABCDESS of staying healthy with diabetes.  And Dr. Steele is going to talk a lot more about this.  But it's a roadmap that we set out for your doctors to follow, but you can also be empowered and follow this as well.  So we know that in terms of glucose control we want your three month average A1c to be less than 7.0.  We have a target for your blood pressure to keep you healthy.  We have a target for your cholesterol - specifically your bad cholesterol.  We know that there are drugs that can help to reduce heart disease and kidney disease.  And there are drugs that are used for other things like cholesterol lowering and blood pressure, but they have a benefit in keeping your vessels healthy.

Now here's where I come in.  There's a reminder that diabetes is also about living a healthy lifestyle.  So ease for exercise and healthy eating.  So determining a regular physical activity plan, getting into a healthy eating plan.

Self management.  So diabetes is a chronic disease and you spend all but probably four hours every year on your own managing your diabetes.  That other four hours, if you're fortunate, you're having conversations with your health care provider, or your diabetes educator, or your pharmacist.  And you're getting a little bit of help about your diabetes.  But otherwise, you're on your own.  So you really need to have an understanding and you need to feel supported.  So self management is about setting goals and identifying barriers that will prevent you from reaching your goals.  We know that we have a very comprehensive screening program about what you should do to monitor for complications of your diabetes.  That you and your providers should make sure that you screen for heart disease.  That your feet are checked,  that your kidneys and your eyes are checked.  And if I could ask you to do one thing: if you are a smoker, stop.  STOP smoking.  That is the best thing that you could do for your diabetes.

Now that's a lot of information in terms of that little algorithm.  And if you're looking for a really good resource, Diabetes Canada at www.guidelines.diabetes.ca has a whole bunch of patient resources.

But this one in particular is my absolute favorite.  Staying healthy with diabetes.  In these four stages, there's so much information to help you understand why each of the things that I just talked about are important.  And help you identify you know what the why you may have complications, what you could think about, why you might feel a certain way.  And recognizing that there are symptoms of these different complications that you might identify and be able to have a conversation with your with your health care provider about.  And helping you understand all of the things that can happen with diabetes. So thinking about things like reaching and maintaining a healthy body weight.  I mentioned foot care already.  We also know that people with diabetes have a higher incidence of both depression and anxiety.  So it's okay to not feel okay.  It's part of having diabetes, for some people, but you should have an opportunity to have a conversation about that.  And then of course we're going to hear a little bit more about the medical aspect from Dr. Steele. 

So these are the first couple pages, and then on the third page it reminds you of the different tests that you should be having, and at what frequency you should be having them.  So you know at diagnosis with type two diabetes the screening that should be done.  When you should have your A1c done, what should be done every year, what might be done every one to two years, and then other things that should be thought about.  And then your goals are on the last page, and what the target is and what your goal is.  So why do I say this?  So diabetes is a complicated disease, and it's really important that you feel empowered to make sure that you're getting the absolute best health care possible.  And so if you understand what you need and why you need it, you can advocate or ask on your own to say “hey, you  know I went to a lecture and someone told me that my A1c should be less than 7.0 for most people. Is that my goal?”  Or about your blood pressure, and making sure that you're achieving the goals that are set for you.  So this is just an opportunity for you to become more informed.

And another really nice tool that Diabetes Canada has for you should you choose to download it and use it, is a tracking sheet.  So again it's your diabetes vital signs, you know, where you are, and any advice or comments that you may need from your healthcare professional.  So all of the things I’ve talked about are listed, and then you can have little notes about it.  And why we do something like this is because it's really important that, you know, diabetes is managed by a bunch of different health care professionals. And so if we help you be in charge of your own diabetes, you can make sure that you're sharing your information with some of your other health care providers.  So when you see your eye doctor, or you happen to see your, maybe you see a specialist like a cardiologist, or a nephrologist.  And just to make sure that everybody's always on the same page, you can be in charge of that yourself as well.

So I really am here to talk to you a little bit more about what I call the softer side of diabetes.  But I think the most important part of diabetes is that as a chronic disease, you need to have self management education and support.  So education is about helping you understand, and support is helping you achieve your goals.  Diabetes Canada has a whole chapter in the clinical practice guidelines that is a is a roadmap for healthcare professionals to be able to understand what should be provided to people living with diabetes, how to provide it, and then how to provide ongoing support.  So I’m going to just give you a few highlights about what I think you should understand in this area.

So self management education is about actively involving you the patient.  And I’ve talked a lot about this already.  We want you to have self monitoring capacity, so that you're involved in making sure that you're monitoring your own health.  There's a lot of things to manage in diabetes and that your understanding that WHAT, and HOW and WHEN.  And that also I always say, “my job is to help you understand your diabetes.  You can make whatever decisions you want about your health care, you can use that knowledge and skills to whatever suits you best.  As long as you're informed and you're making these decisions, it's up to you how you're going to do what you do to manage your diabetes?”

So it's active participation that you're learning about your diabetes, and then you're making decisions.  And why is all of this really important is that we understand that knowledge is power.  And when we help individuals living with diabetes understand what affects their glucose control, how they can keep themselves healthy, what kind of monitoring they should do?  We know that there's evidence that education will improve your A1c or your three month blood sugar average.  That you have a better quality of life when you understand and can take charge of your diabetes.  That there's an increased weight loss that's associated with diabetes education.  And we've demonstrated over the last 10 years for sure that we can help people have better overall cardiovascular fitness.  So helping people understand the ABCs of diabetes.  The glucose control, the blood pressure and cholesterol control has led to having better outcomes in terms of heart disease.  And that's been amazing.  When I first started in diabetes, we used to say that 80% of people with diabetes would die of a heart attack.  And now we know that about 40% of heart attacks are associated to people living with diabetes.  So we've done a really great job in changing that, and that's been amazing because it improves your quality and quantity of life.

So what are some of the basic knowledge and skills?  So remember I said there are certain things that you should be taught?  But, and that is how you would apply them to managing your diabetes.  So it's important that you understand monitoring your different health parameters as I mentioned, including glucose monitoring.  It's important that you understand what healthy eating is.  It's important that you understand what physical activity is, and the benefits.  Diabetes can include a lot of medications, so important that you understand what your different medications are for, and how you might adjust them on your own.  We know that there are highs and low glucoses that are that are associated with living with diabetes.  So what causes low glucose, how to prevent them, how to manage them.  What causes high glucose, how to prevent them, how to manage them.  And then, of course, prevention and surveillance of complications.  So screening - as I mentioned early.  And then you live with diabetes for 364 days and 20 hours by yourself all the time.  So it's important that you feel that you have the knowledge to be able to identify problems, and do some solutions on your own.  So these are things that as a diabetes educator I would be really hoping that in our time together that we would cover all of this.

Once we have talked about the things that are important for you to know and have as a skill, we want you to then work together.  So diabetes education now is collaborative - its interactive.  Back in the day it used to be that you went to a Diabetes Center for five days, and they taught you everything that you needed to know, and sent you on the way.  But we don't do that anymore.  We want to work with you.  We want you to be at the centre.  We want to individualize your education for you.

We, as I mentioned, there are certain things that it's important for us to know that you understand in terms of knowledge and technical skills.  But what's more important is that you can figure out what's going on in your own diabetes, and change what's happening to improve your glucose control.  We know that diabetes is a disease that changes with time, that your life situation changes with time, that what you learn today may not be helpful for what's going on in six months from now.  So that you are repeatedly being able to understand more.  That when you have a question that it's a needs-based discussion, “hey this is going on in my diabetes.  How come/what could I do to fix it?”  And that we reinforce all of the positives that you've made in your life.  And so we no longer just talk about educating people with diabetes, we want to support them in terms of their journey, and we also want to help you to change your behavior to be able to improve your outcomes, such as glucose control.

So, how would this happen for you?  So in your journey with diabetes, you may have had the opportunity to be with an inter-professional team, so your physician, and nurse, a dietitian and a pharmacist perhaps.  Or maybe along the way you've seen a group a support group run by somebody like Diabetes Canada where you've gone and you've spent time with like minded people.  That works.  An inter-professional team works.  Learning from your peers works.  We also know that every time that you have a conversation with someone about your diabetes, there's an opportunity for you to learn more.  And I always say to my pharmacist friends, “a five minute conversation with your diabetes patients can make a difference in their lives.”  We recognize that diabetes is well suited to learn in a group.  As Dr. Noronha said right at the very beginning, if you have a question, someone else is going to learn from it.  So when we do group sessions for people living with diabetes, often they talk amongst themselves, and we know that's very effective.  I would just work as the group leader, to make sure everybody stays on the same track and provide expert answers when asked.  But also some people do much better in a one on one session.

And last but not least, especially after this last year, we're really embracing the idea that we spend a lot of time in the virtual world.  And so you may have been finding information about your diabetes on the website, and that can be very helpful.  So you might be learning on your own and then asking questions.  So a combination of self-directed learning and then having conversations.

So this is the way that we - there's no right or wrong answer - it's whatever works best for you, whatever access you have.  But certainly, you know, if you have an opportunity to join a peer group, it's a great place to learn from others, and so are group sessions as well.

We also recognize that it's not a one stop shop, that you should have your education reinforced.  That you should have follow up.  That you should have ongoing contact with an educator, and sometimes we use automated reminders such as text messages or emails to remind people about things that they need to do about maybe it's checking your glucose. 

Okay.  So what you should expect in your diabetes journey is that at some point you've had the opportunity to learn about your diabetes.  And that as you live with diabetes, that you're also provided support.  That you always feel like you know where to turn to, who you can talk to, that someone's asked me how you're doing, helping you change your goals, take down the barriers that are in the way for you managing your diabetes.

Alright.  So identify your personal needs, figure out your own options, collaborate, make a plan and then look for long term success support.  And that is the steps to success in self management of diabetes.  These are the basic education and skills.  I’ve given you the official version, but monitoring your health, healthy eating and moving, taking medications, what you're taking, why you're taking them, how you're taking them.  High and low blood glucose, what they are, what we can do to prevent them, and how to treat them.  Preventing complications, and coping.  So these are the things that you want to know about in terms of managing your own diabetes.

In terms of physical activity, we recommend that you get about 150 minutes a week of something that raises your heartbeat. That maybe you feel like you're sweating a little bit, and that you raise your heartbeat.  And it could just be something as simple as walking five days a week 30 minutes a day.  And work towards that goal.  Doing some resistance exercise.  So doing some things like yoga, some people will do chair exercises, doing you know, using soup cans to just build up some resistance in their, some muscle in their body - so things that build muscle.  Setting…

Dr. Lionel Noronha:  One brief second for all the participants, if you can mute your volumes there's a little background noise someone coughing or something like that.  So somebody can just all mute your lines I’d appreciate that. Thank you.

Lori Berard: Dr. Noronha, I have to apologize.  That's my geriatric dog that's coughing.

So set physical activity goals and work with your health care professionals. 

Follow a healthy diet.  So we don't want to go into a whole lot of, you know, complexities about fats and proteins and carbohydrates.  We just know that there are dietary patterns, such as the Mediterranean diet, being vegetarian, following the portfolio diet, or the DASH diet.  But talk to someone about understanding how food affects your glucose control, and what changes you can make to your diet.  I always say that sometimes people have had things slip into their diet that they didn't recognize were high in glucose.

And last but not least, monitor glucose levels.  So I mentioned that everyone will have an A1c done.  It's your three month average, you get it done usually every three months.  And it should be 7.0 or less for most people.  The second part of that is doing finger stick glucose monitoring.  So 4.0 – 7.0 before meals. 5.0 – 10.0 after meals is our target.  So A1c is one way, so you will have a blood test done, but then you may do self monitoring of glucose.  So many of you are used to the traditional finger stick capillary glucose monitoring.  And we're really excited that we now have a different way of monitoring glucose where a filament goes under the skin and measures glucose from the interstitial fluid.  And another system where there's a transmitter so it actually pushes the information to a reader.  So these are new way of monitoring glucose.  And why that might be something that's helpful is that when you poke your finger, you only see one second of one minute of one hour of one day.  So here's six seconds for that person.  But when you have a sensor reading your glucose, it reads every minute, you just have to scan it every at least every eight hours or it pushes the information to you.  But you can see how it fills in the blank and tells us exactly what happened every minute of the day.  So this is really valuable information that helps us catch your highs and lows, and it really tells us what it's like for you living with diabetes.  And so maybe this is something that would be good for you.

So why it's important to manage your glucose has diabetes does not cause complications per se. Uncontrolled diabetes does.  So monitoring your health parameters.

Other things to think about is good foot care.  Are you safe when you drive with diabetes?  Do you understand sick care?  And remember I said diabetes is hard, so maybe you feel a little distressed, or maybe you're having difficulty coping.  These are things that you should talk to your healthcare professional about.  And there could be many people in your team.  And you can see all the different people: your pharmacist, your dietitian, your nurse or doctor, your kidney doctor, your cardiologist, your eye doctor.  It's important you develop an action plan.  So when you talk to someone, they're going to help you identify what change you want to make, how you're going to make it.  You're going to set goals.

You're going to develop a plan.  You're going to figure out what resources you need.  You're going to recognize how important it is, and how confident you are.  And that's what we do in diabetes self management, education and support.  We help you develop a plan. 

So, on my final slide I just want to remind you that that there's a variety of ways that you can learn about your diabetes.  But most important is ASK.  If you feel like you need more information, ask your health care professional.  It's important that you access self management, education and support throughout your lifetime with diabetes.  It's not one and done.  Everything changes with time, and so does our knowledge and understanding, and so does how you live with diabetes.  And really having a diabetes team, you have a collaborative relationship, you can set goals, and you can figure out the best way for you to manage your diabetes.  And any resources that you might be interested in – guidelines.diabetes.ca, and you can see right here for patient resources, its got great educational tools  And I’m going to stop there.  And again, I apologize for my dog.

Dr. Lionel Noronha: Not at all!  Thank you so much, Lori.  You know I’ve worked with you in different capacities.  I believe that's actually the first time I’ve heard you talk.  You're an incredible speaker.

We have some questions that have come through the question & answer link, and some very Internet savvy people have directed them to myself, too.  So there's one question here to start:  Can you talk about an example of where a patient follows the best practice, and had a great improvement in their A1c?  And then the follow up to that was what sort of actions they do to help improve that?

Lori Berard: You know, thank you for that very insightful question. I have been working with people living with diabetes, since 1987 and there's nothing better than seeing a light bulb go on.

So one of the things I think, is that diabetes education used to be a knowledge dump, and people just didn't know what to do with it.  And I think what's been really important is when individuals learn from each other or from someone, something that might work for them.  So a good example is someone who said to me one time, “I read a great book.”  I’m like oh really what book is that?  I read a book on the glycemic index.  And this person had lost about 20 pounds, and I’ve been working with them for 15 years.  And the dietitians that work with me we're groaning - they're like “we've been talking to them about that for 15 years!”  And it was when HE was ready to make the change.  HE made the change that was ready working for HIM.  And I always say to people that you never know when that light bulb is going to go on and something works for somebody.  My job is to continue to support you.  And the fact that you continue to come to an appointment even though you haven't made any changes, means that you still are interested in your diabetes.  So I believe the best thing is to provide information to people, and they'll figure out what works for them, and when they're going to incorporate it.  So I have lots of great examples of - I call it light bulbs going on.  But again it's just having conversations, and when something clicks that they want to work on - helping them to work on it.

Dr. Lionel Noronha: Thank you.  There's a great question on - very technical questions for patient: “How does my type two diabetes affect congestive heart failure?  So what I think we can do with that question is just leave it, and I’m pretty sure Dr. Steele is going to cover that in his talk.  But very good question.

Another question here is, “can you talk a little bit more about this new monitoring system that you referred to instead of finger pricks - like the Freestyle Libre?”

Lori Berard: So there are two - they're called sensor based technology - so there are two different kinds: 1) flash glucose monitoring 2) Freestyle Libre

I do this [waves her hand around] because you flash your reader over the sensor, and then there's a continuous glucose monitoring - Dexcom or Medtronic.  And these systems are, I think, game changers for people living with diabetes that are using glucose monitoring to manage their disease.

Again, what happens is a sensor reads interstitial glucose.  It reads it every minute.  And all you need to do is flash to see what you are currently.  Again I could do a whole hour on it, but you can see where you are, where you're going, how you got there, how much time you've spent in your target range, and important information.  And that's enough for, you know, every time you scan you can see that, and you can change your behavior based on that.  And then there's lots of great data inside there that you and your healthcare professional can use to make longer-term changes.

Dr. Lionel Noronha: Fantastic.  That's great.  Thank you so much Lori.  We're going to move on to Dr. Steele.  Our second talk is going to be a wrap up for this series of three on “The Top 10 Things a Diabetic Should Know.”  I thought “What a wonderful way to end it!”  And our speaker is Dr. Andrew Steele.  He's a nephrologist, which is a kidney doctor, who started his career at St Mike's Hospital in Toronto.  And for the last 20 years plus he's been at Lakeridge Health in Oshawa.  He recently stepped down as a medical director and section chief in nephrology and diabetes at Lakeridge.  Dr. Steele served as the executive and regional lead nephrologist for the Ontario Renal Network.  He has served on the Canadian Diabetes Association Guidelines Committee, and he's a busy nephrologist and very busy clinical investigator with a vast amount of experience.  Dr. Steele.

Dr. Andrew Steele: Thank you very much!  And thanks [Lori] - that was a great talk that I also learned some things from there, I was do.  And we're going to fit sort of hand-in-glove together, I think, so.  Yeah I was sort of asked to do talk to patients and that’s obviously who we’re talking to today.  And, you know, my job is a very technical one, and obviously I look after patients, but I thought maybe just sort of take it back a step, and just sort of think, “look if I was a patient, what are some of the things that maybe I would think of?”  And I obviously think about things differently, as a doctor.  But I try to sort of bring it back to “how can you take control of this?”  And it fits very nicely with what you just heard from Lori.  So I think it's excellent.

So, you know, diabetes is on the rise in Canada, and depending on how you count the numbers, we get some, you know, data sets - 6% or 7% of adult Canadians have diabetes.  Others say 10% or 11% in Ontario and in Winnipeg, actually, or in Manitoba.  We've got very good observational data sets where we look at all of the patients who see physicians or hospitals, or any point of healthcare, and we look at the diagnostic codes.  And looking at things like this.  Around about 11% of adults in Ontario, and probably across Canada, have diabetes.  And why is this number increasing?  Why's it, you know, why was it 5% or 6% back in the 90s, and now it's 10 or 11%?  Well there's a couple of reasons.  First of all we're probably picking the diabetes up a little bit earlier, the definitions of what we now call diabetes is slightly changed, and the sugar values that we use, and the diagnostic criteria for diabetes.  But also we as a population are growing older.  And the older you get, the more prevalence there is a diabetes in elderly people.  So if you're over the age of 70-75, it's about 20% to 25% of people who will actually have abnormal glucose levels or even, in fact, diabetes.  But we're also growing heavier, and unfortunately, two thirds of Canadians are heavy.  You know, their body mass index or their weight-to-height ratio is above 27.  And that's increasing, actually.  And you know we thought for a while it was decreasing, but it's increasing.  And insulin resistance occurs more commonly in people that are older, as well as people that are heavier.  And fat cells, or adipose cells as they’re called, we used to think they were inert cells, they didn't really do much, but they actually do.  They make a lot of other hormones, and those hormones block insulin.  And when you don't have enough insulin effect, even though you have a lot of insulin levels but it's not working, you can’t sort of burn that sugar and store it away and use it properly.  And so those sugar levels increase, and that sort of leads to some of the damage from diabetes.

So that's a big issue.  And so, you know, at a population level - and that's really not what I’m talking about today - we need to a better job at educating the population. 

Limiting our portion sizes.  I mean, we all eat now on bigger dinner plates than we did, our grandmother had a dinner plate, it was nine inches.  You know, when I grew they were 10 or 11 inches.  Now often 12 or 14 inch plates in your cupboard.  My wife bought plates that were so big I couldn't even close my cupboard!  And, you know, your wife and or me, or I also fill up the plate, and my kids always want to serve up please prepare to eat everything that's on it.  And so we eat more calories.  We on average about 500 more calories a day in the current day than we did back in the 1960s 1970s.  So it's no wonder that we are getting heavier.

And although this increase in diabetes, we think of it as a blood sugar disease as Lori explained, really is the complications of diabetes that we worry most about.  And most of those complications are blood vessel complications.  Either the large blood vessels in your bodies, or the small blood vessels.  And we'll talk a bit about that.

And it turns out that if you actually look at the complications of diabetes, you can actually prevent almost all of them, or you can at least delay or maybe prevent them completely if we had good screening practices.

As well as lifestyle intervention: diet, exercise, etc.  And, you know, weight loss going along with that.  And medical therapy.  And then the medical therapy part I will talk a little bit about more today.

On the positive side, we've seen a very large decline in the rates of heart attacks and strokes, and some of the other vascular events that have occurred within diabetes.  But we've also seen a bit of a overtaking or an upsurge in some of the other complications.  And one of the questions earlier was about heart failure, and heart failure is one of the things that we now see very commonly in diabetes.  In fact it is the most common reason that a person living with diabetes will turn up to the emergency department.  Not a heart attack.  Not a stroke.  Those things are actually on the decline, because we're doing better at controlling blood pressure, we're doing better controlling cholesterol, we're doing better at you know some of the cardiac manifestations.  But the heart failure as well as the kidney complications of diabetes haven't really declined that much.  So there's still a lot of room for improvement.  And so what are some of the things that we can do?

Well, as we mentioned, diabetes, although it's a blood sugar disease, it's really a blood vessel disease.  And you know, it took, I don't want to say anything negative at all about endocrinologists or diabetes specialists, but really diabetes specialists until the first set of Canadian guidelines, first set of guidelines in the world ever for diabetes.  That were evidence based guidelines.  That looked at the literature and said, “yeah, this is what for sure what we should do, because we have this, this and this trial, was 1998.  And those were the first evidence-based diabetes guidelines in the world.  But they were very glucose-centric, and they really focused a lot on the blood sugar.  And I wrote the kidney chapter of that, those guidelines back in 1998.  But, you know, the next set of guidelines in 2003 and in 2008 moving forward, we've started to realize, look, we're not focusing just on sugar here.  We have to focus on the other aspects of people living with diabetes:  The blood vessels, the organs, the kidneys, the eyes, the cholesterol, the blood pressure, etc.  And so really when you think about diabetes as a doctor, you know, we always screen for damage to the big vessels, damage to the small blood vessels, and as a patient you want to make sure that you do everything in your power to try and protect with blood vessels.  And part of that, of course, it's controlling your sugar.  But part of that is some of the other things that I’m going to talk about today.

So Top 10 things to know to stay safe and healthy in the context of your - and we are focusing mainly on type two diabetes - but there's mostly also applies to type one diabetes which is very similar, just different mechanisms of why the sugars are relevant, but really a lot of the same overlap. So, you know, these are the things that I am going to talk about briefly. 

1.Now getting screened for diabetes if you’re at risk is something that we talked about, to a degree, or at least the sugar aspect of it

2.Taking control of your blood sugar we'll talk a bit about that

3.Following up with your diabetes team regularly which, again, Lori talked a lot about

4.Healthy eating and exercise which Lori talked a lot about

5.Managing your blood pressure

6.And focus a little bit more on the medical side the cholesterol

7.Stopping smoking

8.Making sure your SCREENED regularly for complications: again that was part of that flow sheet.

9.If you have certain conditions or certain factors make sure on the best therapy: this is the what we’ll focus more on because this is sort of the more the medical side

10.And then back to an overall summary with a bit more medical drill down on those ABCDESSs

So again, getting screened if you're at risk.  And again, you know, the first thing is that you know when you say, well, there's 6% or 8% or 9% of the population have diabetes.  How do you really know?   Are you really screening?  And, in fact, people like Larry Leiter at St. Mike’s have done projects where they’ve just gone into family doctors offices, and they've screened everybody that came through.  Like if you’re coming in for a sore knee, or you're coming in for a bit of a cough or cold or whatever, we're just going to screen you anyway.  And it turns out like 25 to 30% of people who come to a family doctor's office on any given day have abnormal blood sugar.  Now they may not have frank diabetes, but they might have a high sugar that's borderline diabetes (what we call impaired fasting glucose) or pre-diabetes if they have an A1c that’s elevated.  So there's a lot of people out there who even have undiagnosed pre-diabetes or undiagnosed diabetes.  So how do we know?  Well, get screened?  And who do we screen?  Well, we should be screening everybody over the age of 40 every couple of years.  And there's risk calculators that are available.  Again, this is something that your family doctor would know, and you can also find that out on the Diabetes Canada website.  And we screen more frequently, at least every six months to every year if you have other factors: like you have a family history of diabetes, if you yourself are very overweight, if you've got a history of cardiovascular disease, if you're from a certain ethnic population, perhaps indigenous populations, if you have other risk factors.  So again, these are things that you and your family doctor should know, and you make sure that we get screened. 

And how do we screen?  Well it is very simple: we typically do a fasting blood glucose or we can do (sorry I’m trying to do, the whole thing, oh no I didn't do it this way okay, let me go back and build it again).  So if you're fasting blood glucose in the morning is less than 5.6, and that's totally normal if you have an A1c, and again what an A1c is we are going to talk a bit about the next time.  You guys know what an A1c is?  That's your sort of red blood cells that are, you know, coated with sugar inside that hemoglobin.  Hemoglobin is a protein - it's inside the red blood cells, it’s about two thirds of the weight of the red blood cell, and red blood cells in your body are broken down about roughly every hundred days, or roughly every three months.  So if you can measure the amount of sugar that's connected to those hemoglobin red blood cells, that gives you an idea of the general three month sugar control.  So this would be considered normal . If you had a either a fasting sugar above 7.0 mmol/L, or an A1c up above 6.5, then you have frank diabetes.  If you have a fasting sugar that's not in the normal range, but not in the frank diabetes range, and your A1c is in that intermediate level but still below 6.0%, then you're at risk, and we should be screening those people more often.  And then if you have sugars that are above 6.0 to 6.9 mmol/L, not quite diabetes but not, you know, lower, and an A1c in that 6.0% to 6.5%, these are know these pre-diabetes patients.  And again, screen more often but also make sure your patients understand this and say, “look, you're at risk of diabetes and if something doesn't change you're getting diabetes for sure.”

So, what are you going to do?  And then, what are you going to do is then, let's change your lifestyle, let's change your diet, let's change your eating strategies, let's change your exercise, let’s screen you more frequently, let's look at other aspects of your health and see do you have any other illnesses going on.  Should we be screening your eyes, should be screening your kidneys, you should make sure we do a thorough cardiovascular assessment head to toe etc.

Now, taking control of your blood sugar.  Again, Lori's obviously talked a lot about that.  Again, this is the A1c story we talked about before, which is this glycated hemoglobin or “Hemoglobin A1c.”  We now actually just say “A1c.”  A1c is easier thing to say.  And again, you know if you look at observational trials, or if you look at clinical trials in this case, these are type one diabetes, but we've got very similar things with type two diabetes, we can see that your risks of eye disease, retinopathy, kidney disease nephropathy, nerve disease, neuropathy, and then microalbuminuria is protein in the urine in small amounts that are starting to increase as a marker of progression of kidney disease.  There's a bit of a rapid uptake in these once you're A1c hits above about 8.0%.  And if you're a once he is less than 7.0% for the most part, these numbers are beginning to flatten out.  In fact, they even continue to go down a little bit - even if you're A1c goes a little bit lower.  Particularly for kidney disease and eye disease.  So we have different targets for A1c but for most people we really aim for A1c of 7.0% or less, because you can see if you 7.0% or less, you're actually having a lot lower risk of these complications than if your A1c is high.  In the UKPDS study, which is the one of the largest studies in diabetes published back in the 90s, they showed that every time you bring your A1c down by 1%, So if you went from 9% to 8%, or you went from 8% to 7%, every time you bring it down by 1%, you reduce your complications of diabetes by 25%.  So if you started at 9% and went down to 7%, which is now at target, you've reduced by 25% plus 25% or 50%.  So yes it's a blood vessel disease, but it's still a very glucose-centric disease in many ways because if we catch people early and we are able to be aggressive with managing blood sugar early, then we can have a big impact on diabetes complications.

So again, for most people with diabetes, we still aim for an A1c target of less than seven.  However, if you've got fairly new onset diabetes, and it’s easy to get your blood sugar's down with either diet, lifestyle modifications, exercise, maybe some oral medications, metformin and other medications.  If you can do this easily and you've not had diabetes for many years, you don't have a lot of other factors going on such as hypoglycemia, then why not get down to less than 6.5%?  And that's what we typically do for those new onset patients.  If we can get your A1c less than 6.5% then there's less eye complications and kidney complications.  In select people, for example, people that are you know are elderly, who are functionally dependent living in a nursing home, or they've got other illnesses in their life that are, you know, that we're dealing with that are really making it hard to get their blood sugar's down, then we have an individualized target.  So these are the types of targets that you would meet and you would discuss with your team whether to physician your diabetes education team, etc.  And so individualized targets in some people.  So again we're not always super strict in getting the blood sugar down, and again we've got to look at the overall sort of patient.  And again, we want to try and really focus more now on avoiding hypoglycemia.  That's a big part of diabetes management now more than it ever has been.  We’ve always wanted to avoid hypoglycemia, but now we're even choosing our drugs that we use - to use drugs that are safer - to try and achieve these goals [less hypoglycemia], rather than just sort of equating all the drugs that we have available as the same.  So um again for most people they want a target of less than 7%.  And, again, you know you know that typically means sort of pre- and post-prandial blood sugars in the ranges I show here.  You guys have known this, and again it's available on the Diabetes Canada website, and we've heard again from Lori.

How are we going to get there? Well again obviously it's a combination of lifestyle, you know changes, diet changes, exercise, weight loss.  Oral medications with I’m not gonna go into detail about today, although I will have some sections later about medications.  And then injectables.  So theinjectables in the past used to just be insulin, but in fact now I’ve actually stopped more insulin in my patients than I start because I have other drugs like the GLP-1 receptor agonists.  So the drugs that are, like, say liraglutide or semaglutide.  These are drugs that are injections that sort of make your bodies or your endocrine system in the belly work better.  Which, you know, increase your own insulin production and reduce the glucose formation in your body.  And these drugs really work well, as do other drugs that help us avoid using or even help reduce the amount of insulin the people are on such as the SGLT2 inhibitors etc.  So again, this is for your individual talk with your own physicians, and we'll talk a little bit about certain drugs that might have sort of extra benefit down the road in a few slides.  So again, try keep your blood sugar as low as possible.  This will help with, you know, complications.  Like I said every 1% reduction is a 25% reduction in complications.  That's an important number to remember, because people often say, well, why are you being more aggressive?  7.5 is not that bad.  I’m like well, we can you know you're not on that many meds, I think we can even get better.  Let's work together as a team let's try and figure it out.  And so it's important to do that.  Again following up with your team regularly -  this is something that we talked about a lot with Lori - I’m going to cover that in great detail.  Other than the fact that the most important member of that team is you and your family.  And then all the other people there that you routinely see will be the peripheral people including me.  We have this is a kidney specialist but really there’s all these other people.  And in fact I’m going to give you example.  In my hospital our what's called “Liquid Shelf,” which is on the east side of Toronto, and Liquid Shelf is five hospitals.  Our catchment area is about 800,000 people.  11% of adult Ontarians have diabetes, so that means we have 80,000 or 88,000 people with diabetes in my life, where I work right?  Only 8000 people go to the diabetes education there.  So there's a large number of people that don't have, or haven't taken advantage of, all of the resources that are available in the Community.  and you know they see their family doctor alone, or maybe they see their, you know, nurse practitioner who’ll look after them.  They may or may not have another specialist, but again there's a lot of people in the community that can take advantage.  And if I would have diabetes, I would be like, okay, well what resources are available?  And when you go to the diabetes education program, they'll have access to things like smoking cessation programs, and exercise programs, and other things.  So take advantage of what's available.  You know, lifestyle modification and, you know, diet and sort of weight loss type part of diabetes is something that every single physician knows is something that should be done.  Every one.  So they did a survey, but it's a few years ago now, called the damage strategy kind of a survey, and they surveyed 1000 physicians.  And 95% of physicians said, of course, lifestyle management is important. You know, and that's all of those things: the lifestyle, the weight loss, diet and the exercise.  And they asked those same physicians, “is it your job to do this?”  And 93% said no.  Wait a minute - if I just told you that most people in Ontario, and I’m not sure what's like in other parts of Canada, but if most people in Ontario are ONLY seeing their family doctor, and lifestyle so important, but it's not your job to do it, then whose job is it?  So again as a patient, I would say, well, it is everybody's job.  And I need to talk to my doctor, and then I need to get into the right team, and I need to have them help me with all of the different aspects of care so that I can meet my goals and look after myself.

So again, “You” in red here is the most important.  And again how you can help your team is be prepared for your visits.  Bring your medications with you.  Bring your diabetes logs with you.  Bring your glucometer if it's you know, the One Touch, or whatever you have or your, you know, your Freestyle Libre.  Make sure you’re validating on a regular basis.  Make sure we bring your own blood pressure readings.  And get your labs done before you go to the appointment.  I do that for every one of my patients.  A lot of physicians don't do that, and maybe your team doesn't like this, but I like this because I like to tell my people right now how it's going.  When you send people for blood work after they come to the clinic, and then you've got to pull the chart afterwards and then call them back, to me that doesn't seem sort of sensible.  But every physician the different teams is a bit different. I like to have labs in advance.

Healthy eating and exercise we've talked a bit about.  And again, I’m not going to talk about this because this is what Lori talked about, and it was part of what I just stressed a second ago.   I moved down to the next part.  But I one thing to remember is that if you have diabetes, and I know there was a bit of a backlash, and some people the last time the Diabetes Canada guidelines came out because they started talking about things like, you know, hooking up with weight watchers, etc.  And although we don't want to over focus the weight loss part of diabetes, it's super duper important.  In fact, there are some people that are able to come off insulin, and come off even all of their oral medications with weight loss.  And I’ve had several patients.  I had one patient who was on 500 units of insulin. 500!  Crazy.  Like a ridiculous amount of insulin.  Who was about 450 pounds, who now is less than 200 pounds, and it's on zero diabetes medication.  so I’m sure lots of you, lots of other physicians and Lori's got patients like this, sure.  The weight loss is definitely not the only part of diabetes management.  But it's a big part, and it's very difficult to do.  But thankfully there's a lot more drugs in our toolbox.  But there's a lot more tools in their toolbox in general that we've ever had before to help people get to where they want to go.  But you're not going to get there if somebody says, “Oh, I need to lose 50 pounds.”  It's not going to be there in six months, or even a year.  You got to be realistic.  Set realistic targets and say look, “I'll be happy if I see you in three months - if you've lost three pounds, or you’ve lost a pound a month, if you lose 2 pounds a month I’m even happier.”  Right, so you know it just realistic goals.

Okay, managing your blood pressure.  Now, I’m going to get into some of the more medical things.  So it  turns out that blood pressure control is important not just in diabetes.  This is a meta-analysis, which is a grouping of all the studies that have been done in blood pressure control until 2005.  There's been some done since then, but there's 27 trials and in these trials there's more than 100,000 patients.  And if you control blood pressure, on average in these trials they only brought blood pressure down by seven millimeters of mercury.  So not a lot.  But, on average, by seven mmHg.  And just by doing that, we reduced strokes by 36%.  We reduce mortality by 27%.  And we reduce cardiovascular events by 25%.  This is in everyone.  If we focus in people with diabetes and you aim for a blood pressure of about 130 over 80, you can have a 50 – five zero - percent reduction in cardiovascular and stroke events by controlling blood pressure in people with diabetes.  And for that reason, Diabetes Canada has for a long time maintained that the blood pressure target in people with diabetes should be 130 over 80.  If you have high blood pressure and diabetes, then high blood pressure and diabetes together accelerate the risk of complications.  Particularly the kidney complications.  But the vascular complications of diabetes are mainly driven by the blood pressure part of the story.  In fact, in that UKPDS study that I showed you before, the reduction of 1% of your A1c that led to a 25% reduction in the complications. In that study, they did a nested sub-study of blood pressure control.  And it turned out, and I don't want to say that blood pressure is more important than blood sugar control, it's not, you do both things together, but the blood pressure control part of that study was massively more reduced cardiovascular events than the blood sugar control.  So, in fact, the blood pressure part was very, very, very clear that we have to be much more aggressive with controlling blood pressure in diabetes than we thought we used to in the past.  The other thing is when I see somebody with diabetes who has high blood pressure, and I start them on a medication, the thing I have to remember to tell him is like okay I’m starting on this first medication and it’s usually an ACE inhibitor, or an ARB, and I'll talk about that in a bit certain types of medications that we should be using this first line for our patients with diabetes, because they have extra benefit, over and above reducing blood pressure, these drugs also reduce cardiovascular events.  And, if needed, kidney events and patients with kidney disease.  But I say to the patient's, look, I’m starting you on maybe one or two medications at the beginning, depending on their blood pressure is.  But the average person with diabetes needs about three and a half medications to control their blood pressure.  So you're going to need to be on, you know, three or maybe four medications to get your blood pressure, down to target in most people.  So it's not a failure if I see you now and I start one medication, then see you in three months and your blood pressure is still high and I need to add another, that's not a failure.  That's just sort of where we are.  So I think we've got to understand that in order to get there, particularly in diabetes, because A) it's more difficult, to control blood pressure in diabetes and B) we have a lower target blood pressure than we do in the general population.  In the general population is 140 over 90 but in diabetes it’s 130 over 80.  And for those two reasons, you need to be on more medications.  So have your blood pressure checked every time you see your doctor, or NP or a nurse.  Anytime you go to a health clinic with somebody is testing you, check your blood pressure.  If you already know what your blood pressures are because you're checking at home, even better.  So I asked all of my patients, if they can, to get a blood pressure monitor at home.  If you go to Costco or WalMart or one of the larger stores, or even to the Shoppers or, you know, your favourite pharmacy, most places have blood pressure cuffs around about $50 to $60.  Sometimes there are very expensive ones, but you don't need to buy expensive ones.  If you want one that, you know, is going to be a good one, look for a little heart with a check mark on it.  If it's got a heart with a check mark on it, that blood pressure cuff has been validated by Hypertension Canada.  And Hypertension Canada does validate the blood pressure cuffs.  Make sure that it's done.  And also it's really important when you're going to the pharmacy to pick this up, ask your pharmacist, “is this the right size cuff for me?”  Because a lot of people have bigger arms or smaller arms, and if you have miss-cuffing, which is a cuff that is either too small or too big, then that can make an error of your blood pressure reading by I’d say 10 or 15 points.  And that's a big difference.  So if it's fit properly, and you know how to do it properly, and there's lots of videos on how to do this on Hypertension Canada’s website www.hypertension.ca.  If you go on there, you can actually watch videos of how to do it and keep a log, it's actually more accurate than what your doctor or your nurse tracks in the office.

Okay, so home readings, are very, very vital and I ask all my patients to get your own blood pressure cuff.  And in fact sometimes I’m able to help them with that by getting some support through our assistance programs.

A word on SALT.  We all eat too much salt.  95% of Canadians eat too much salt in their diet. If you want to lower your blood pressure, sodium restriction is an important part of this.  We should be eating less than 2000 milligrams of sodium in a day, which is one level teaspoon of salt.  In order to do so, you have to check labels.  If you're eating any canned foods or boxed foods, things that come those middle aisles of the grocery store rather than the outside aisles, then you're for sure eating too much salt.  But I already know you're eating too much salt because I told you in 95% of Canadians eat too much salt.  So even people that tell me they don't need too much salt, unless they tell me they're checking labels and know that they're eating 1400 milligrams a day which nobody does unless they’re regularly seeing us or  or your dietitians, then for the most part, everybody eats too much salt.  So how are we going to eat less salt?  Well, the first thing is check labels.  Okay, and if you have a sort of a stoplight approach, here we have red = too much, orange = watch out, green = go ahead.  And then the milligram component is how many milligrams in each of those.  You know packages or cans, or whatever we have, which is another way to look at it, as percent of your daily serving, you want to look for things that are in the green. Limit the things are in the orange and watch out for the things or don't even take the things that are in red.  But the best way to eat or make sure you're eating a little salt is use things that don't have labels on it.  If you get your own fruits and vegetables, and you make your own food from scratch, then it's got low salt.  Whereas if you buy a box ore a can of Campbell's tomato soup, and you have a bowl of Campbell's tomato soup, one bowl of Campbell's tomato soup is 800 milligrams of sodium.  That's almost half of the sodium in one little bowl.  And if you had a couple of pieces of bread with it, then you're about 1000 milligrams of salt.   So unless you're checking your salt labels, unless you cook from scratch, unless you're avoiding restaurants on a regular basis, we're all eating too much salt.  And that's very important for both kidney protection, vascular protection and blood pressure control.  Okay.  Only about 10% of the salt in our food is what we add with salt shaker about 80% of it comes from processing.

Okay.  Managing your cholesterol.  Again, cholesterol, we always um, it's probably the most studied thing in medicine.  So it IS the most studied thing in medicine.  So we know with more certainty than anything else we do in medicine that reducing your cholesterol or adding cholesterol reducing medications in people with high risk, reduces cardiovascular events.  And we know also with more certainty than with anything else we do in medicine that statins are the safest drugs that you have in your arsenal of anything we do for cardiovascular risk reduction.  Safer than aspirin/a baby aspirin.  Safer than a vitamin E, for example.  I can say it’s safer than a vitamin – hard to imagine that.  There's a lot of negative propaganda about some of the cholesterol drugs.  It's completely negative propaganda.  Cholesterol drugs save lives, full stop.  And, in fact, if you look at these trials, and this is a curve or a graph showing your cholesterol level on the on the X axis, and the reduction in your cardiovascular events on your y axis, it's a linear line.  The trials that have had the lowest cholesterols have had the best outcomes.  So now we aim for a lower cholesterol than we ever have before.  And in fact we are able to get there because we have more tools in our toolbox.  So again most patients - starting with a statin as these trials state, and statins have shown that if you reduce your cholesterol by 1% - so that was your LDL was 4%, and you bring up to 3% - then you can have a 30 to 50% reduction in heart attacks, strokes and vascular death.  And if you go from 4% down to 2%, which is our target for most people, then that's now a 60 to 80% reduction in cardiovascular events.  So we have a very large group of trials that have proven this beyond a shadow of a doubt.  So anytime that people quibble about cholesterol, I actually have a lot of slides in the handouts that I gave to them to read.  After that are very helpful to try and hopefully educate people in the right way.  So most people with diabetes are at increased risk for cardiovascular disease, and we can reduce that cardiovascular disease by putting those patients at risk on cholesterol meds.  Even if your cholesterol is normal.  So a large study called the CARDS study was a study of diabetes patients - people living with diabetes – who had no history of heart disease, who had cholesterols that were pretty good even normal cholesterols, and they were put on statin, atorvastatin 10 milligrams, and they in fact had to stop the study early because of overwhelming benefit.  It no longer became ethical to have a patient like this not on a statin. And there was about a 40% reduction in cardiovascular events, and almost a 50% reduction in stroke in that trial, and there's been several other trials that have shown the same thing.  So even if your cholesterol is in quotation marks “normal,” you still need to be on a cholesterol drug because we want to reduce that cholesterol by 50%, or get you down to an LDL of less than 2.0.  And we should be checking that regularly at least yearly for screening and maybe more regularly if we've got you on therapy.

What about Smoking?  Well again, you heard Lori has said - there's no question - if you are smoking, stop.  As a physician, I have to think about the 5 A’s this is from the Canadian Cancer Society. 

1.Ask my patients about smoking use. 

2.Advise them to quit.

3.Assess their readiness to quit and interest in support – when they are ready, when they go from pre-contemplation which is, “yeah I should quit one day,” to “OK – I want to quit now.  How can you help me?”  Then I will allow a system on quitting, I’ll make a referral, and I’ll follow up with them afterwards. 

4.Assist with providing information and referrals

5.Arrange for follow up or additional support.  There’s lot’s of resources.  And if you want resources, is fantastic.  In every single region no matter where you live, there are excellent smoking cessation resources and tools.  More than we’ve ever had before.   

8. Screening process.  We talked a bit about it, and Lori talked about it.  I’m not talking about it in great detail.  It was in that sheet that she showed you earlier on your patient flow sheet checklist.  But make sure you screen for you know at diagnosis every three months.  Certain things should be checked every year certain things should be checked.  Every one to two years are certain things should be checked regularly.  And again, Lori showed you this before - these tools are available on the Diabetes Canada website.

9.  What has become clear is that in people with diabetes, particularly higher risk people with diabetes, certain medications do more than what they're just supposed to do.  So ACE inhibitors, which are drugs like pirindopril or ramipril are angiotensin receptor drugs, which will be like the “sartan” drugs: valsartan,  or losartan or irbesartan.  Those drugs don't just lower their blood pressure, but they also protect the kidneys and they also reduce cardiovascular events.  So for most people with diabetes, even if your blood pressure is normal, you should be on an ACE inhibitor or an ARB.  And that's fairly clear from several large trials.  When we're looking at glucose lowering medications in previous , we used to say, well, if your sugars are high start with lifestyle and add in metformin.  And then if they are still above target, here are the drugs in alphabetical order, choose the one that you think is best.  That is no longer the case.  We now look for compelling indications.  And if people have either an underlying cardiovascular disease, underlying heart failure, underlying kidney disease, or they have multiple risk factors, then two classes of drugs jump up as the ones that we should be using.  Either SGLT2 inhibitors which lower your risk of heart attack, stroke, cardiovascular disease, heart failure, or progression of kidney disease.  Or the GLP-1 receptor agonists which are the injection drugs like liraglutide, semaglutide.  These drugs lower your risk of MACE or Major Adverse Cardiovascular Events (heart attack, stroke and CV Death).  Statins, and we talked about under the cholesterol part.  And anti-platelet drugs like aspirin are also indicated in higher respects.  It's not for everybody with diabetes, but if you're older or you have long standing diabetes, or you're already had a cardiovascular event, or you've got other high risk factors like kidney disease, then you should be on all of these types of drugs.  So it's very important that your doctor thinks about this because, in fact, many doctors and Canada haven't maybe read the most recent.  Guidelines in the 2020 update, which is exactly what I showed you here.  For the diabetes drugs, if you have atherosclerotic cardiovascular disease, or heart disease, you know, vascular disease in your neck, previous stroke or mini stroke, circulation problems on your legs, chronic kidney disease, heart failure or you've got multiple risk factors, then you should be using drugs with what we call “Grade A, Level One Evidence” here in dark blue, you should be either using the GLP-one receptor agonists, those injections either daily or weekly, or the SGLT-2 inhibitors to reduce those events.  So this is really a bit of a complicated table, but I’m just showing you that this is right from diabetes Canada Guidelines.  This is something your doctors will understand and your medical team will understand how to read.  And you should be asking well, by the way doctor, yeah I’m a high risk patient because remember I’ve had this kidney trouble or I had this heart trouble.  Am I on the best drugs to protect my heart and kidney and organs?  Because I know there's some changes in the guidelines.  And they'll say oh yeah you're on this drug, this is the one that, you know, your doctor was talking about this, it’s the one you've heard about.  So this is very important.

And it really shouldn't be up to the patient to remember this.  It should be up to the teams to remember this and some of this is new, so it takes a little while.  So you guys hopefully can be a bit of ahead of the curve here on getting on the right medications.

10. And then putting it all together.  And Lori already talked about this, is really just the multi-faceted, multi-professional, multi-disciplinary, multi-intervention strategy to reduce these events.  Does this work?  Does it matter?  And I wanted to show you one two more slides and then we're going to stop for questions.  This is a trial that was published not just once but three times in the New England Journal of Medicine.  It’s really hard - it's the hardest journal to ever get published in.  And this is what a trial of people with diabetes who are spilling a little bit of protein in the urine – microalbuniurea.  They only had 160 patients.  And they publish an eight year, 15 year and 21 year follow up of putting people on intensive therapy which was, you know, we are going to be a little more aggressive with lowering your blood pressure, a little bit more aggressive at lowering your blood sugar, a little more aggressive at putting you on an ACE inhibitor or an Anti platelet drug like aspirin versus usual therapy, which is just the way that the patients used to be treated in those clinics.  And what they showed was that after four years, there was a 50% (five zero) percent reduction in kidney and eye complications.  After eight years there was a 50% (five zero) percent reduction in cardiovascular complications.  That was you know, heart attacks, strokes and amputations.  And by 13 years, there was a 50% reduction in death.  So just by being a little bit more aggressive in all of the things that I’ve just talked to you about, even in such a small trial, we have now proof that all of these things matter when we do them more aggressively.

So when you have a patient with diabetes, even though we know diabetes blood sugar disease, you as a patient and your team should not be or will not be gluco-centric, but you need to remember your ABCDEs.  We will call these the lifesavers.  And that, again, is what Lori showed you before is the A for A1c blood glucose - A1c of less than 7%.  B for blood pressure.  C for cholesterol - mainly a statin.  Aim for an LDL less than 2.0 mmol/L. If your LDL is already less than 2.0 at the start, it doesn't matter, you should still be on a statin because we know that even in people with normal cholesterol, they still have a benefit by being on statin.  The D for the drugs to protect your heart and your kidneys.  These are the ACE inhibitors, the statins, and then these now SGLT2 and GLP-1 receptors agonists which we do have several trials for.  In the last few years we've really had a plethora of cardiovascular, and kidney and heart protecting trials with these agents, and it really has changed the way we manage people with diabetes.  And again the E for the exercise and eating.  And the S for the smoking, screening for complications and stress reduction.

So that was my final slide along with a reminder to go to Diabetes Canada’s website.  There are so many tools there.  It's unbelievable how much they've done here.  There's a lot of tools on your handheld devices.  There's tools for physicians, and you know, diabetes professionals to help you decide which drugs the patient should be on, how we can manage.  It just they've done a great job with knowledge translation and support for people living with diabetes, and really, kudos to Diabetes Canada and everybody who’s been involved.  So I think that's me done there.  Will be happy to answer some questions or.

Dr. Lionel Noronha: Thanks so much Dr. Steele.  We appreciate your passion and commitment.  We're going to go through a few questions.  I apologize we're a little bit over time, but I couldn't stop such a great talk.  First question: does type two diabetes affect congestive heart failure?  Is there something we can do about it?

Dr. Andrew Steele: Right, so heart failure is we typically talk about heart failure with preserved ejection fraction, and heart failure with reduced ejection fraction.  That means reduced ejection fraction means you've had some damage to your heart.  To most people with heart failure, who got reduced ejection faction have already had a heart attack, either the one that they knew about or one they maybe didn't know about, and the treatment then is to treat the cardiovascular disease, make sure that we have a cardiologist involved and see if maybe you need to revascularization.  Go on all the right therapies, you know, statins and anti-platelet drugs, and drugs to control your blood pressure (ace inhibitors), all the things that the cardiologist would want to use.

 But the heart failure with preserved ejection fraction is as a sort of a more interesting group.  And those are people that might have a good heart pumping well, but it's a little stiff.  It's not working or acting as well.  And people with diabetes have a lot of heart failure with preserved ejection fraction.  It turns out that in people with diabetes there's a lot of undiagnosed heart failure.  And if you look at the diabetes trials with a class of drugs called SGLT2 inhibitors, we actually had a very large reduction in heart failure, heart failure hospitalizations, heart failure diagnoses, or heart failure admission to the hospital, and complications and death from heart failure when we use SGLT2 inhibitors.  So that was unexpected.  We were doing these trials to say, “are these drugs safe?, are they safe in general for heart attacks and other vascular…?”  And we saw this amazing reduction in heart failure.  So the people that are in the know who are smart said “well let's design heart failure trials!”  And we've now had two published heart failure trials that show that SGLT2 inhibitors in people with a diagnosis of heart failure who've got this reduced ejection fraction, it makes you live longer and have less cardiovascular events.  So the heart failure story within diabetes is this: it's very common.  It's becoming one of the leading causes for admissions to the hospital.  And we have new tools in our toolbox, these SGLT2 inhibitors, along with the other classes of drugs that we use for heart failure, the what we call ACE inhibitors and ARB drugs, the beta blocker drugs, and drugs called mineralocorticoid receptor agonists, as we know how four pillars of heart failure protection in Canada and throughout the world.  And one of those pillars is a diabetes drug the SGLT2 inhibitor.  So diabetes and heart failure intertwine.  And so much so that one of the pillars for managing heart failure, even in people without diabetes, is this diabetes drug called the SGLT2 inhibitor.  So again, if you have heart failure or your risk for heart failure, make sure your doctors are screening, and you’re on appropriate therapy.

Dr. Lionel Noronha: Great Thank you.  Does metformin help older men with enlarged prostate?

Dr. Andrew Steele: Ah - not necessarily I don't think.   Not that I know of!  If you have an enlarged prostate, then typically I mean the olden days urologists would be lined up like 50 patients and we just core out one after the other of a prostate called a TURP.  Now we don't do that anymore.  We've got great drugs that can, you know, block the androgen effects, and alpha blockers.  And so medically we can treat your prostate very well with medications.  But I don't know.  Is it something that just don't know about, Lori?.

Lori Berard: You know, I think I would say is that there could be a association between less need to have to go to the bathroom at night if your metformin is successfully lowering your glucose.  So no not the actual disease of BPH but, in fact, if you lower glucoses, you may need to urinate less at night.  So it might actually help with the symptoms.  Would be my thought.

Dr. Lionel Noronha: Excellent point.  Really good question: Why do blood sugar numbers rise and drop dramatically through the night, even though your medications and eating are quite stable, including…

Lori Berard: Yeah so there's two things about that.  And the first thing that comes to my mind is that.  We don't necessarily ever appreciate the effect of activity on our glucose levels.  And activity usually appears not at the time that you're doing it, but you see the benefit of activity or the benefit of lowering glucose of activity later four or five six hours.  And it doesn't matter what kind of diabetes you have.  So sometimes if you're having difficulty overnight, it's because maybe you've been unusually active, you know, in the evening.  And if you're on insulin you haven't reduced your insulin dose, or you didn't maybe have an extra snack to think about that.  But one of my favorite top topics around when you don't understand what's happening with your glucose levels is that if you're not using healthy insulin sites that you could do the same thing, two days in a row, but if your insulin is going into an area of lipo hypertrophy so fatty tissue that your insulin may be absorbed differently than if it's in healthy tissue.  So sometimes when people are having trouble with this, which we would call variability, one of the first things to do is check where you give your insulin.  Are you using healthy sites?  If you're using an insulin pump, are you changing your sites regularly?  So sometimes it's how the insulin is being delivered.  So the two things - activity and insulin delivery to me.  Maybe I don't know if Andrew wants to answer that.

Dr. Andrew Steele: Yeah and that's part of it.  And the other thing is, I think everybody thinks that you absorb your glucose like at the same rate every day, and again people have different levels of absorption.  Especially with people who have gastroporesis or some damage to the nerves in your stomach.  And you know the food you eat, you don't necessarily absorb all that glucose immediately.  Sometimes it's a bit of a delayed absorption.  So yeah I think there's a lot of other factors.  And again, it's the overall control rather than any individual variation that we worry about.

Dr. Lionel Noronha: Thank you.  There's a question that a patient was diagnosed with diabetes November.  Their A1c is still high.  What are the complications they should be worried about?  So just for sake of time, it's been dealt with, but really I always think top to toe: your brain, your eyes, your heart, your kidneys, your blood vessels, erectile dysfunction.  Poor control affects all of this over time.

Dr. Lionel Noronha: Also, there was a question: Is A1c different…

Lori Berard: reason I would say so, for that question about high glucoses when diagnosed and you know A1c high.  Just make sure you've been screened for everything.  Because we know that there's often complications at the time of diagnosis.  So if it's type two diabetes, and it's been around for a while, you should have screened for everything that Dr. Steele talked about as well.  So that’s the only thing to do is make sure…

Dr. Andrew Steele: In the UKPDS study, these were new onset diabetes, and 20% of them already had retinopathy, and 20% them already had protein in their urine.  And it takes a while for that to develop, which means that new onset diabetes isn't really new onset diabetes.  It's been there for a while beforehand in many patients.  And family doctors, unfortunately, don't often like to label patients or maybe I don't think we ever lied to our patients, we don't we don't do that, but we insulate them from the truth.  Insulate them from the truth.  And so it's unbelievable how many people come to see me and they've already got maybe Stage 3 kidney disease, and they've got a bit of protein in their urine or a lot of protein in your urine, and I’ll say well, I’m looking back at their charts and I’ll see that they’ve had diabetic kidney disease for the last 3 or 4 years, and they’ll say “no it's new my doctor just told me.”  So I think we have to be open with our patients and make sure look you guys are some you know you have a you have diabetes I’m screening for these things - there's a bit of damage to your kidneys, but don't worry we're going to fix it.  And then down the road, if you need to, we’ll send you to a kidney doctor And unfortunately, I think you know there's not always good communication both ways.  So make sure that you open up to your doctor and ask them these things.  You guys are the most important part of the team, so ask the question!  So they are not telling you the answers - make sure that they do.

Dr. Lionel Noronha: Thank you.

Dr. Andrew Steele: Not everybody's like that, but there's certainly, you know like I said, it's important to know because you know you're the one that's in charge.

Dr. Lionel Noronha: I appreciate that, and you know I’m just trying to be a little bit time sensitive, so if we can just add some super briefly:  is the A1c target different in young children with Type 1 diabetes?

Lori Berard: So it is less.  Typically in the glycemic… sorry for children living with type one diabetes, the clinical practice guidelines states a target of less than 7.5%.  So it is different, but again individualized by who's managing you, what you're using, what kind of glucose monitoring you're doing.

Dr. Lionel Noronha: Excellent.  There's a question here: considering you follow the medication regime prescribed, is weight loss the best way to reverse diabetes?

Dr. Andrew Steele: Probably.  I mean, you know, I don't know if you can reverse it, but if you mean getting off your medications and getting your numbers under control.  And obviously the earlier you do this in your disease, the better, right?  If you start later on, it's going to help control, but you're probably still going to need to take medications.  But you know, like I said before, I’ve had several patients who've had large weight loss, who've never come off all of their insulin and all of their medication.  But like, many, many patients actually.  And there's some people that do that and believe in this in in sort of an unusual way where they do the crazy intermittent fasting and all these other things.  I’m not sure that's the safest way to do it.  But it should be part of anybody's strategy for management of diabetes is weight control.  And if you are able to lose weight, you will find that you need less diabetes medications.

Dr. Lionel Noronha: Thank you.  What we’ll…go ahead…

Lori Berard: So all I would say that we do know that there's lots of work going on in in remitting diabetes, and it's doing something that we're not used to which is yes, intensive lifestyle intervention, try to lose some weight, get your you know get into a lower carbohydrate diet.  And then there's these research studies, looking at “hit ‘em hard hit ‘em early!”  So instead of starting one diabetes med, they're starting three, and they're sort of, you know, getting glucoses down and giving your pancreas a chance to reset and then you can remit it for a while.  So weight loss is huge.  I would say carbohydrate content is another thing that's really important to look at.

Dr. Andrew Steele: In the new trials that are coming – the GLP-1 receptor agonists, some of the newer ones that are coming - these injectable drugs - with these drugs almost 50% of the patients in the newer ones, have A1cs that returned to the normal level of less than (5?) which is unbelievable.  So we are seeing a change in therapy for diabetes under right now like, as we need some of these trials haven't even finished yet.  So the future for diabetes is very strong and bright, I think.

Dr. Lionel Noronha: Excellent.  Couple more questions and I'll wrap up.  What are your thoughts on intermittent fasting as a tool to manage diabetes and, I guess you could put in there, weight?

Dr. Andrew Steele: If you are on an SGLT2 inhibitor, I would caution against prolonged fasting. But I like intermittent fasting in general.  I mean our bodies are meant to have fed states, which means we have metabolisms and physiology built up to store, you know calories and carbohydrates and fats.  And then we also have a physiology built up to burn fats and carbohydrates.  So that's the fasted state.  So we're not, we're supposed to be hunters and gatherers by nature, we're not supposed to supposed to eat like 800 to 1000 calories each meal, three times or four times a day.  We're supposed to be foraging for food and sort of, you know, eating sort of a Mediterranean type diet, or you know, a Paleo diet or whatever.  Which means there are times we were supposed to fast.   And so I like fasting.  But be careful if you're on insulin.  Be careful if you're an SGLT2.  Talk to your team and devise a sort of a healthy way to do so.  But if you're on oral agents and your pre-diabetic or diabetic and you want to try and lose weight, anything that works for you works well.  I like whether it's you know the Atkins diet, or zone diet, or South beach diet, or you know Health Canada diet or weight watchers.  Whatever works, right?  So I don't think you need to spend a lot of money to go to Dr. Bernstein or one of these fancy guys.  Just do it on your own.  But Jason Fung has written a couple of books on intermittent fasting.  I mean he tried to study it.  He didn't get funding for it.  I like his approach, and I’ve got a lot of patients do it.  But I’ve also seen a few patients come into the hospital with diabetic ketoacidosis because of this because they did it in the context of also being on the wrong drug.  So make sure you really are set up with your team if you're going to do this.  And Lori I’m sure you have this question all the time.

Lori Berard: Yeah, so I like intermittent fasting.  There is evidence that it works.  My only other addition is, is that if you're on gliclizide, so a sulfonylurea, that's another, you have to be very careful.  So insulin, sulfonylurea or SGLT2 inhibitor because you want to avoid issues related to not having enough carbohydrate when those drugs are on board.

Dr. Lionel Noronha: Fantastic.  Just for time, we're gonna have one more question.  Before I asked that, I’d ask all the participants to go to the chat.  There's a link for evaluations.  It's very valuable for us to get your feedback in developing future events which Diabetes Canada has expressed an interest in.  So please do that while we have the last question and wrap up.  So last question will be: The Libre causes me to break out in a rash.  Any recommendations?

Lori Berard: Yeah.  Um.  So Andrew I’ll take that one.  It's a bit of a tough question because you really need to make sure a few things: is that you're preparing your skin properly so it's clean and dry.  A lot of people wipe it with alcohol, and then stick the sensor on and so there's wetness underneath.  Or maybe it's the alcohol that's causing local irritation.  Some people have sensitive skin.  So there's certain things that you can try to do.  One is make sure that you're changing your sites, that you're not going back to the same one.  That your site is clean and dry - dry is huge.  And then you can use a preparation like a skin tack or a liquid bandage, and it actually will cover the skin, which will allow you to have a bit of a barrier between you and the sensor.  Unfortunately, like there seems to be less reporting of it, and I think that that's maybe because there's a little bit of a change in the adhesive, and I don't know that for sure.  But I think its proper skin prep.  You can use something that's a bit of a barrier between you and the sensor.  Go to your healthcare professional, this is something that they probably have a bunch of tools in their toolbox about.  And last but not least, you know, again make sure you change your sites.  Don't go back to the same site over and over again.  But it really is individualized, so I don't have a great answer to it.  It's it's really more about skin prep, and perhaps a barrier.

Dr. Lionel Noronha: Thank you.  One one thing that I could add.  You know clinically a lot of these devices require a glue to stick to your skin, and often it's not the device, it’s the glue.  So with a lot of patches as well, I recommend the patient dries the skin, cleans it.  And then your doctor can prescribe an inhaled steroid puffer that we use an asthma, and you pop it on the skin that reduces the chemical reaction or the contact dermatitis that's occurring.  But fantastic.  You've been very patient with time, we appreciate your commitment.  Just a few final wrap up thoughts if I can, and then I'll thank everyone.  Lori raised a great point about the personal tracking sheet for your diabetes on the Diabetes Canada website.  That's a great tool that helps you oversee your condition.  She repeatedly said these words:
“you monitoring your diabetes.”  So this really resounded for me as a critical thing for a diabetic.  Now a diabetes is a team approach: your family doctor, your endocrinologist, your nephrologist, cardiologist, your diabetes nurse educator, dietitian, pharmacist, personal trainer, your family.  These are all your team.  If there is one sentence, I can leave you with: “You are the captain of your condition - you have to be the driver for your care.”  That's what really changes things.  Both our speakers reinforced that diabetes is a condition that affects a lot more than your blood sugars.  All the organ systems we talked about.  Dr.  Steele went into detail about A1c less than 7%, blood pressure less than 130/80.  Get your cholesterol down at least under 2.0 – maybe under 1.8 for your bad LDL cholesterol. Statin drugs: despite what you hear on the imminent news sources like CBC and the Toronto Star save lives.  You know, quit smoking.  These are some of the take home things.  That last study the STENO 2 study is one of my favorites. I had to read it twice.  I couldn't believe as a clinician that 160 patients followed over this time could have that clinically significant outcomes about a 50% reduction.  So all these boring things that we talked about: blood pressure, cholesterol, A1c, quit smoking.  It cumulatively vastly affects your outcomes, not even getting into medication so much yet.  You know that again the SGLT2s, the GLP-1s, this is what transforms your future.  This is not esoteric, this is real.  So with that in mind, just like to bring it to your awareness, we're doing our best to get recordings of all three sessions on the Diabetes Canada website.  Please do your evaluation.  And I’d like to thank the following people.  First of all, I have a team of wonderful people who helped me get these going.  They’re so modest.  They did not want to be named, but I know you are.  And thank you very much.  Grace Leeder and Diabetes Canada thank you so much for all the technical support in having these.  Most importantly, thank you, you know, Miss Berard.  Thank you Dr. Steele.  Your passion, your commitment, it comes through, in you're talking.  These are free sessions you did, and you'll be here all day answering questions.  I appreciate your commitment to our patients.

And lastly, you the participants.  I’d like to thank you for sending your great questions.  You know I hope you learned something today, and more importantly than just being educated, I hope you're motivated and powered to take on your illness.  You can absolutely change your future outcomes.  Thank you very much.  I hope you enjoy the rest of the weekend.  Have a great day.