October 15, 2021 Type 2 Diabetes and Virtual Care

so welcome all uh thank you for being

here my name is brooks roach i am a

diabetes education specialist with

diabetes canada uh and i'd like to begin

by acknowledging that i'm joining from

the traditional and unseated territory

of the migmat people and i invite you as

a viewer to take a moment to reflect on

the land on which we live

and acknowledge the past inhabitants of

what we now call canada

we are here today for a really exciting

conversation to talk about virtual care

what it means why it's important and

specifically how it impacts people

living with type 2 diabetes

so we are joined today of the great

privilege of having some wonderful

guests uh dr elena halperin who is an

endocrinologist an assistant professor

at sunnybrook health sciences center and

the university of toronto department of

medicine's division of endocrinology and

metabolism welcome elena

thank you

i never know how to do that either the

the intro it's all good um

dr tara kiran who is a family physician

at st michael's hospital and the fidani

chair of improvement and innovation at

the university of toronto welcome tara

hi

and uh we also have maria smith williams

who is a healthy lifestyle advocate and

certified personal trainer who lives

with type 2 diabetes welcome maria

hi everyone

hi so thank you so much uh the three of

you for being here i'm super excited to

have you all here and have this

wonderful diverse range of perspectives

that you're all going to bring to this

discussion

so today uh our experts will be

answering some key questions that they

have been hearing from patients and

other folks who live with type 2

diabetes

and they're also going to be taking some

questions from you our viewers so

some have been already submitted and you

can ask your questions interviewing on

facebook live by just posting in the

comments section uh and you can do this

at any point through the webinar if the

question strikes you and we'll answer it

during a q a section uh toward the end

so with that uh let's dive right into

what's sure to be a great conversation

and we're going to start with dr

halperin

with a question as follows so i'm

wondering if you can walk us through the

impact that the covet 19 pandemics has

had on individuals with type 2 diabetes

and their quality of care

um yeah it's a fantastic question and

obviously we're 18 months in almost of

living with uh coven 19 in our midst and

i think we have to start by recognizing

that people with diabetes are people

like all other canadians and so a lot of

the same stressors that have been

happening for everyone else have been

happening for them and diabetes canada

actually did two surveys once in may and

june of 2020 and then again in 2021 and

the themes were similar

so many people living with diabetes you

know we're worried about the fear of

contracting copin 19 struggling with the

mental health uh burden of being

isolated from friends and family

feelings of loneliness

um and a substantial minority of the

survey respondents did have financial

difficulties during the pandemic

possible loss of job and inability to

pay for medications and diabetes

monitoring devices

which made them

made managing their diabetes more

difficult but we also know that as

virtual care goes diabetes actually

lends itself pretty well and that a lot

of people had virtual visits primarily

by phone a little bit by video

across canada the majority of the

respondents to the surveys we're very

happy with their virtual care and hope

that virtual care continues to be an

option for people living with diabetes

well after the need for physical

distancing is behind us which we all

hope is sooner rather than later

and um and then we can get more into

some of the details around different

ways that you can share your data with

your healthcare professional and all of

that but i'll i'll stop there for now

and see what else comes up in the q a

thank you elena um the next question i'd

like to direct to both maria and dr

kieran and it's i wonder if you can each

share sort of each side of the story uh

and that the this is around what has it

been like at the individual level to

both treat and live with diabetes over

the course of this pandemic

maybe we can start with maria

well we all know that living with

diabetes at the best of times is

challenging much less during a pandemic

i've been living now with diabetes for

eight years i was diagnosed in my early

40s

and i found that during this pandemic

i've had to become creative

in the way that i stay active and i

manage my my blood sugars

especially since the gyms are closed

we're all working from home and all the

mental stress that is happening around

you know the fear of of contracting

covid and not seeing your family um

at one point i reached the point where i

was exercising with my neighbors on my

driveway just to

stay motivated and keep active

um so it's it's been pretty good though

i've kind of stayed to a regiment that i

established for myself long time ago and

it's worked out pretty well for me

it's great to hear about that maria and

how your own life has changed i mean i

think from us my perspective as a family

doctor um of course we're seeing just a

snippet of people's lives when they come

in and check in with us and

during that time we really are focused

on trying to make sure that

we're helping them to do everything

possible to keep them themselves healthy

um so mentally and physically well and

then also get all kind of the the

testing that helps us to monitor

whether the diabetes has started to

affect other organs um

in their body whether that be the heart

um or uh and how we can continue ensure

that they have uh keep a healthy heart

or the the feed or the eyes etc

um and so you know really early on in

cobid i worked with a group of

colleagues to try and figure out how can

we

support family doctors and provide

guidance to family doctors about this

switch to virtual care to ensure that um

diabetes care doesn't just fall off the

radar because now we're not seeing as

many people in person and and in person

care of course

uh carries risk um because at that time

we even early on knew that if you had

diabetes you were at higher risk of

getting coveted complications and so we

wanted to avoid exposing people to

in-person visits and potential like um

copic exposure that goes along with uh

coming in person whether that be through

the transportation taking the you know

public transport or seeing people in the

waiting room

um or seeing ourselves and so we wanted

to avoid people having to come in but

still ensure that they were getting the

care they needed um and i think this was

actually a really good opportunity for

us to take a new lens a fresh lens on

you know what it is that the provider

really needed to do what could now be

done by the patient effectively with

some coaching

um

and and and really kind of put together

a new

uh

a new schedule because you know i we

kind of had this process of trying to

see people every three months and going

through a checklist of things with with

them um so now you know what we said is

if people have well control diabetes you

know uh probably a lot of those three

monthly visits could happen on the phone

um and you know probably at minimum you

need a once a year in-person check-in

now of course if someone's diabetes is

not as well controlled or they're having

a harder time engaging on the phone

because of language issues hearing

issues

tasks to technology

those are reasons to have them come in

so that they you know don't miss care

but for the vast majority of people a

lot can be done virtually and one of the

things that i really shifted to in the

pandemic was supporting people to do

more self-assessment at home

and so in particular two areas one was

high blood pressure

so

we always try and screen for that in the

office using our own high blood pressure

machine um but in you know instead

many patients felt that they were able

to afford to go out and buy one others

who weren't able to afford it sometimes

their plans would cover it um including

the public plan uh people who you know

are in social assistance uh in ontario

that plan started to cover it as well so

getting people the tools to do their

blood pressure monitoring at home

instead of having to bring them in for

that um the other piece was foot exams

so we're really accustomed to doing a

very specific kind of foot exam in the

office to

ensure that people don't have um uh

damage to their nerves and that they're

uh you know that their

skin and

blood flow is is healthy um and we

realized that actually there are tools

out there that teach people how to do

those things at home

and so we put together you know a tool

for people

physicians to say these are kind of

handouts that you can use for patients

to help them measure their own blood

pressure to help them

um check their own feet and then of

course you know we're always trying to

encourage and empower people around

self-management and the reason and you

know the the

there was even more reason um to do that

now so that's it and then i guess the

last thing i'd say is like we rethought

what the intervals really needed to be

for some forms of testing so do people

really need to go and get their blood

work every three months

who or can it be deferred for six months

or nine months and then when we do it

let's be like more strategic let's take

a little bit more time to make sure

we're getting all the things we need

during that one time so that we don't

have to like have them go back and

repeat that blood work because every

trip to the lab has some risk does

everyone really need to have that eye

exam at one year now some people

absolutely do need to have a bad exam

every year but perhaps there's some

people who are really well controlled um

who don't need to have that eye exam

every year um so i think those are the

other that's the other piece is really

thinking about what needs to be done so

empowering patients and thinking

differently about what needs to be done

now i'll just add

i'll just add two things to that that i

think are interesting is that you know i

really spoke even before the pandemic

about this idea of a three to one ratio

where you know three visits over the

phone or video to one in person

uh one thing that i think we've been

challenged with now is that the pandemic

has gone on for more than a year and

there are some people who are still

somewhat

frightened to come and see their health

care providers or will tell us that

their health care providers are still

not open to see them and that's

obviously something that i think we

really are struggling with because now

it's like if you didn't have that home

blood pressure monitor you haven't been

to the lab in more than a year or you

haven't had your feet checked by a

professional in more than a year and you

have some symptoms or concerns it really

is important not to delay that care

anymore that the risk of delaying that

care probably is worse than the risk of

contracting covid given the high rates

of vaccination and our good access to

personal protective equipment

everybody's masks in the encounter etc

etc so i do think you know i've had a

few of those experiences where someone

didn't go to the lab for more than a

year and their kidney function declined

really significantly over that time and

so obviously there's that balance and

i'm definitely a fan of choosing wisely

when we send people but a year is too

long so if you're watching this and you

haven't seen your doctor in a year or

had blood work in more than a year i'd

really urge you to do that

well i have to say that i was one of

those people that had not been to the

doctor for a year

but

in my defense i would like to say

that my blood sugars are pretty good

so even though it had been that year and

i was too afraid to go to the lab i had

a really good gp

and um

he kept on me about the numbers and

yeah i but when i went everything was

good

you know and that's a really good point

maria that i think dr dr kieran

specifically didn't bring up which is

the blood glucose monitoring which i'll

probably get into

and brooke's next question but it is

true that when it comes to the glucose

monitoring that was the thing i was

actually less concerned about people

going to uh to the lab for i didn't

really care about that a1c test if they

were monitoring their glucose regularly

um but it's one of those things we're

monitoring for as well like kidney

function etc

right

root discussion

thanks folks and i i really appreciate

the the

theme there which is a little bit about

how do we keep a routine or regimen

recognizing how important that is and

injecting that those creative solutions

whether that is accessing one's own uh

blood pressure monitor or as maria you

mentioned we have a comment on facebook

actually saying uh thanking you for

sharing uh your creative solution to

staying active by just going in your

driveway and collaborating with your

your neighbors um because a lot of folks

are looking for some of those creative

solutions to

uh people have been i suppose forced to

innovate to stay where they were before

the onset of the pandemic

and i think that that leads into the

next question which is around

trying to access really the same

standard or form of care

but in a very different medium or very

different sort of rhythm over the course

of let's say a given year so the next

question is

we've many of us you know i lived with

diabetes myself and have had a pretty

shocking

shift of how care is delivered and a lot

of us have experience with this and it's

is moving to a virtual format and

virtual doesn't necessarily mean going

onto a laptop it could mean as mentioned

having an appointment over the phone it

could mean having a blood pressure

monitor in the home it's it's a it's a

means of

taking these these metrics and

mechanisms into a new

form of delivery

so i think we can all relate to that and

you know the transition to virtual care

for type 2 diabetes is certainly no

exception so i'm wondering uh dr kieran

if you can explore sort of basically

what this means what is what is

underlying virtual care and what are the

different ways that we can really look

to provide or receive care virtually

yeah so when i think about virtual care

i think about three different modes

so we can think about care on the phone

um care by video

or care by email or secure messaging

by secure messaging i mean often it's

like in a platform um where you know

that it's you you're when you're

communicating with your doctor that's

not going to be hacked and uh you know

it's separate from usually your other

kind of personal email and some people

have access to that but some people um

it's just sort of regular email

which does have some

i guess security challenges with it

um but you know when we think about

virtual care during covid

i describe these three different ways in

which we can think about virtual care

but the vast majority of it actually

occur you know from surveys and data we

see has really been phone care

phone phone is is how most of the

appointments have occurred in canada

um and then second would probably be

video a video and actually video and

email and some of the surveys i've seen

have been pretty close to each other um

it does depend though on your doctor so

it's very doctor dependent whether the

doctor um has adopted either of those

things

um and and so with phone

obviously you know

we can talk about uh

you know how you're doing from an

exercise perspective what's your blood

sugar readings been like what is your

blood pressure monitoring like um but

there are limitations because i will say

even from a mental health perspective

although we can talk about what your

anxiety is i often find it's actually

harder to make that connection and

really understand where a person is

coming from without

seeing them face to face and so the face

to face can be by video or it can be in

person

um

and then so the things that we also have

to look at then that you know you can't

get through the phone often are i can

think about it times when i was in

urgent on in our urgent care clinic and

someone with diabetes thought they had a

new foot lesion and so that was when i

would then convert and look to video so

i started off as a phone call

hearing about what it is that they you

know were worried about and i was like i

can't really assess this unless i see it

and so the two options for seeing it are

either

looking at it via video virtually

um so the two virtual options i should

say are looking at it by video and then

the other is actually them sending a

picture by email or secure messaging

so depending on a patient's comfort we

would use one of those two modes

um

uh i would so so video is really helpful

for and i often would convert a phone

appointment to a video appointment if

there's something that i need to see

um

email as i said it can be useful if

somebody you know doesn't can't figure

out the video technology because

sometimes that can be a little bit

tricky like in some cases for us to use

the video technology uh i know you can

just facetime but in our own my own

institution they discourage face timing

i will say that i i if if a patient has

you know the ability to do that i'm i'm

very open to doing that um but i know

some doctors are more reluctant so there

are some some more secure kind of ways

in in ontario where we can deliver it

for example called the ontario

telemedicine network but often patients

have to download an app and that can be

confusing and so just the whole process

of setting up the video is not

straightforward for everyone

um sometimes it just works and then

sometimes actually in the video you

can't see the resolution quite as well

as you want to so let's say there is a

lesion on the foot and you're looking

you're looking and the person can't

really like adjust their camera properly

um so you maybe don't see the right part

and then maybe you know it's too blurry

for you to really understand is this

like spreading redness or is it like

really defined

so an alternative then like as i said

was the email or secure messaging and

sending a photo and so

um that's really useful but i think the

other

useful piece about email or secure

messaging is being able to just dialogue

in the absence of a visit and so what we

call asynchronous or and not at the same

time communication so i could email you

at one time and you can respond at a

different time

and that's really useful for things like

sending blood test requisitions which is

probably the most common thing but also

handouts and links to some really great

educational videos um and then i think

on the reverse side patients sending me

their blood pressure readings or their

blood sugar monitor readings

so in my practice you know as i said i

was trying to educate folks about how to

do your own foot exam and so we started

to share this handout from the diabetes

organization in the uk

for something called the ipswich touch

test or how to keep your feet healthy so

that would be an example of something

that i would send by email i'd often

also commonly send the website for

hypertension canada which has some

really great resources of where to

budget

get a blood pressure machine or

how to do your blood pressure

so all of these three modalities fit in

the vast majority phone but video and

emails certainly have their use

unfortunately not all doctors and all

healthcare providers are comfortable

with video and email and not all

patients are comfortable or have as much

access to those two modalities either

which limits their their use on a wider

scale

i'll just add to that when it comes to

the glucose monitoring piece so there

are a growing number of technologies

both sort of sensor-based technologies

um where somebody's wearing a monitor on

a regular basis like a freestyle library

or a dexcom but even more traditional

finger poking blood sugar meters that

have a bluetooth to an app on a

smartphone and so when you get that data

on the smartphone you can connect it

through

to a clinic account

and the data can be shared sort of um

once and securely and then it's just

shared which is really nice because i

mean in my practice i see a lot of

patients with insulin and it's almost

impossible to adjust insulin medication

without good glucose data and so when

when those devices became a little bit

more readily available at the onset of

pandemic and the sharing

platform became more readily available

we've got a lot of our patients on those

sharing platforms and so that's almost a

fourth modality if you can think about

it where it's sort of

sharing or remote monitoring sharing

data with your practitioner and

sometimes we would talk about the data

synchronously meaning over the phone or

video sometimes we'd even share a screen

and i would show them what i was looking

at and show them well i see that you

tend to sort of dip overnight and then

rise and then when you wake up and we

can talk about what the habits are and

what adjustments to medications and

activity we need to do for that um and

sometimes it could be asynchronously

because they could say for the last two

weeks my glucoses have been running high

and they can email me or another member

of the team like nursing dietitian and

ask for some advice on how to fund how

to manage that and so again i think

that's an innovation that became more

more prevalent during the pandemic that

i do hope will stay to help

people feel supported in their

self-management of diabetes

i was actually using one of those

monitors before the pandemic occurred so

my

endo was an elderly

gentleman and he was surprised with that

tech when i came in with the graph and

everything and he was like what is this

[Laughter]

but it really helped because he was able

to identify when i was dipping or when i

was going a little bit too high

and adjusting my meds that way

and i've tried the freestyle libra

um my only problem with that is

it doesn't last the 14 days i don't know

if it's because of going to the gym it

gets knocked off or whatever i never get

it to last 14 days even with those

little sticky strips

yeah every you know everyone has to find

the devices that work for them for sure

but i love that you brought it in and

you sort of took control and educated

your physician because i think that's a

really important part of diabetes that i

often say and and dr kieran mentioned

this already like we spend such a tiny

amount of time with our patients and

they have to limit the disease day in

and day out and make those decisions

about activity and food and medications

and how to manage all of that in the

context of a pandemic and so where you

learn something and you bring and you

share it with us and then we can then

share it with another patient and that's

just a

a great way to manage as a team

absolutely i really agree that it's

really wonderful to see the sort of

tables turn a little bit where maria you

said you know check out this technology

and look at all that it can do and look

what it's doing for me i really like

that uh you know changing the direction

of how how information often flows

um

the the next question that i'd like to

pose is to the three of you and and it's

regarding um

we've touched on what your experience

has been like and a little bit on sort

of the opportunities so i i suppose i'd

like to hear more and a lot of folks are

are discussing this more frequently as

it becomes more common but what are the

real opportunities and challenges posed

by virtual care for type 2 diabetes

i guess one opportunity

is to get care closer to home

not necessarily you know some people

have more complex diabetes and need

access to subspecialty care like you

know endocrinologists with expertise and

certain influence management etc and and

that used to be a really big challenge

you know those like at least in ontario

we have like northern travel grants and

so you know just to come in to see the

doctor for 15 minutes but it was like a

two-day trip to come down from somewhere

in northern ontario

so i i think that um while we were doing

some virtual medicine for remote rural

communities before it's because we can

now just do it on the phone it's just a

lot more accessible um

than it used to be so that's a

definitely an opportunity that i think

um myself and some of my patients have

i've gotten more referrals for more

rural and remote communities to help

support their care because of the

pandemic

yeah just i think a couple that i'll

highlight one is um i think that

uh

as a just building on atlanta's point i

think if we take an equity lens they're

both opportunities and challenges

i think

virtual care is helpful for for some

folks because it means they don't have

to take a half day off work to see the

doctor they don't have to pay for

parking or transportation or child care

and so for some people it actually helps

from an equity lens um and uh and helps

level the playing field for them but for

other people virtual care really doesn't

meet their needs um and so we've been

doing some patient experience surveys

and our family health teams that work

with the university of toronto and

and what we found in the results is that

you know

most people are very comfortable with

the privacy and security of phone and

video and in email or secure messaging

but um some groups are less comfortable

and so it turns out you know if you are

living with a lower income or

um you are new to canada or have poor

fair health you're generally less

comfortable with the private insecurity

of virtual care and it turns out that

those same people also you know

many people want virtual care to

continue afterwards but people who fit

those three descriptors if they're new

to canada live with the lower income or

at poor fair health they're actually

less likely to say that they want those

virtual modalities to continue and so

that suggests to me that you know the

virtual care is not meeting some

people's needs and of course you know

one of the reasons i often uh you know

would bring people in is is people who

for example have hearing difficulties or

who have actually difficulties around

access to technology and so their phone

wouldn't be working well

um and so it was really hard to actually

just have a conversation uh and

um people who have uh speak a different

language although i could get a

translator on the phone

there are many people who for whom they

speak enough english

um that if you meet them in person the

conversation is fine but somehow when

you get on the phone it's actually a lot

harder for both parties to understand

each other

um so i think that there are both

opportunities and challenges with

virtual care so we have to be conscious

to still offer the in-person appointment

for those people who need it at the same

time recognizing that virtual care helps

other people

so i think that's like one piece and i

guess the second opportunity challenge

we'll just put out there relates to

to um what songs that we've just talked

about which is you know the opportunity

for people to have take even more

control of their conditions so

and that means that you know some people

can you know now feel much more

comfortable with self-assessment than

they did before um and and i think this

really works for people who are you know

ready to take

take that that role for themselves

unfortunately there are some people who

um i think still look to their doctor a

lot for that kind of thing or for whom

like their their life is just so chaotic

it's hard to focus on the diabetes and

so those people might get left behind

more from a virtual care perspective and

i think elena kind of alluded to that

with some of her her cases that she

brought out that some people have kind

of um

just not gone in for their diabetes

check in a long time and i know maria

you kind of mentioned you didn't have

lever but you were still connecting with

your doctor and you were conscious and

doing your blood sugar levels at home

and stuff like that so

so i i would say it's more just like

people who who um there's like a almost

be a divergence some people who have

even more skills and self-management

self-assessment and then others who've

just kind of stayed where they're at

for myself i am so happy with virtual

care

that um

i i can go see my doctor my endo maybe

once a year

because i think i go

i used to go twice a year to go see him

now i'm good with just once or you know

just continue this whole virtual care

business

and um the i think i think what what

tara talks about that's so important is

choice is that what we're hearing from

as you know in the first and second wave

of the pandemic it was really about

keeping everyone safe including the

healthcare practitioners right but it

really shouldn't be about that part

anymore

and that people who are comfortable

coming in should be able to come in and

people who would like to continue to get

their care virtually should but like i

said there are some patients where i ask

them to come in and they still turn it

back to phone i sort of say i really was

hoping to see you this time because i

really want to look at those feet

but have you looked at your feet and are

you concerned and better that we could

connect and at least do um uh you know

maybe probably 80 of what i would do i

could do over the phone forever and it's

that 20 of in person

that i would like to be able to do and

that's that will work in that sort of

post-pandemic environment sort of a

once-a-year in-person visit um but um

yeah i agree i think i think we need to

put choice at the forefront and equity

at the forefront in terms of the way we

we offer different different access

phone video in person secure messaging

it really has to be what's going to work

for the patient to feel confident in

managing their diabetes

i think one other point i'll just raise

as well which builds on other parts

we've discussed is

i think i'm often conscious that people

are having different experiences based

on their position and their physician's

comfort level with things and i think

that's something that as a system we

need to do more to address i think

every physician is comfortable using the

phone but certainly not video or email

secure messaging and some of their there

are some systems barriers so

you know um

the

if we want to like sometimes if we want

to integrate video within our own

electronic medical record in a very

seamless way we actually actually have

to pay more

uh fees to the vendor for that feature

if we want to integrate secure messaging

into our you know to make it seamless

within our workflow again that is

another feed that the office kind of has

to put up and and i think you know we

need to move to a model where those are

standard features of our electronic

medical records that there are standard

ways that we're getting trained on that

you know as when we get trained as a

doctor we're getting trained in how to

conduct an in-person visit not on like

email etiquette and like how to build

your practice in a way that um

email can be part of it yet we know that

when you know studies have been done and

we and we offer people things like video

and email actually the asynchronous

messaging or um that means like being

able to message with your family doctor

uh

at different so you're messaging a

different time than your family doctor

messaging that kind of

communication is what people really like

because it's super convenient and often

can prevent a visit but that kind of

thing has not been integrated into our

workflows and we haven't really helped

all our profession um come up to the

same level to use those so i do think

that's an opportunity that we have to

build on it's kind of funny when we talk

i find when we talk about virtual care

that we're just like talking about the

phone basically which is a technology

we've had for decades yeah

but that's a really good point the uh

how ubiquitous the phone is it's really

not that unusual to be accessing care

this way it's you know alexander graham

bell would recognize what we're up to so

uh you know i think that's a really

excellent point

um so folks thank you for for that those

perspectives um and i now will we'll

open the floor to some questions that

we've been receiving uh and like to say

thanks to everyone who has been in

questions over the facebook chat and if

you have anything else you'd like here

please feel free to add it now

uh the first is sort of a trio that i'll

package together and it's specifically

around

a change in basically blood sugar trends

blood glucose trends that folks are have

been undergoing and they're wondering

what the connection might be between

stress and lifestyle changes and this

happening so uh first person is is

stating that they're

they're uh over the course of a year

they've gone from an average of around

six to seven point five

uh and and all else being consistent

food and exercise they're saying food is

the same thinking if this is stress uh

another person was essentially the same

question they were running consistently

from seven to eight and they're suddenly

up in the nine percent range

and then another yet again the the

triplet in this trio of questions is

before covid their their hemoglobin a1c

blood work results were very very good

between seven and eight uh but in july

this year it went back up to nine so

again just wondering all else being

fairly consistent what do you think is

the culprit here recognizing you folks

don't have access to the the in-depth

data but maybe it's a chance to speak to

the impact stress has had

in what you've seen

um so yeah i mean i have two two initial

thoughts one is that

stress definitely impacts blood sugars

and sometimes just being able to have

people understand that in real life is

like helps to alleviate that stress

because it's a bit of a chicken and egg

and if you're doing self-monitoring but

even if you're not and then you just go

and you see that your a1c is way higher

than it has been in the past and you get

more stress about it and so we know that

um physiologic stress whether it's

because you're fighting an infection or

because there's a lot of you know

external stressors in the world today

will raise a lot of your stress hormones

like cortisol and adrenaline and those

things actually cause your blood sugars

to go up another thing that is very

closely linked to sleep quality so if

you're not sleeping well then you tend

to wake up with higher blood sugars and

that will impact the whole day but the

other thing that i think is always

important to mention is this pandemic

has been going on for a while and

diabetes is a progressive disease

so it may have nothing to do with the

pandemic and it's just that over time

despite the same amount of activity and

diet

and

similar all lifestyle things being equal

the pancreas

poops out your pancreas is already sort

of pooped out when you get diabetes in

the first place and then you there's a

lot you can do to support it but

sometimes you just need to look at other

new levels medications different ways of

treating things so and i like to tell

people that so that they don't feel like

they've done something wrong

this is who you are your genetics and

whatever other environmental factors

gave you diabetes in the first place and

it is common that over time people need

to add on medications those are my two

thoughts when i hear that kind of

recurrency yes stress plays a role but

also 18 months has passed so

i can uh relate to that because i

noticed that my blood sugar spiked to

numbers i hadn't seen since the time i

the beginning of my diabetes journey

um and my doctor was like i called

saying

my numbers are crazy

i think i need insulin

and he was like ah

ray are you sure about this oh my god i

think i need insulin like the numbers

were 22 i reached 22 at one point um

but i knew it was stress i was doing

everything else the same i intermittent

fast everything else was the same except

the stress factor was on because i was i

kept my family like prisoners in the

home they couldn't go anywhere we were

like it was crazy um and once he got me

on the insulin and then this the stress

left like this year with the vaccine

whatever i start noticing the numbers

start coming down and now like the

insulin is unless i'm eating something

really high carb or something like you

know

that's the only reason i would have to

use that

so i could totally use mine that's a

very common story marianne we have other

reasons why people might need insulin

temporarily because they get added

another medication gets added that

spikes up their blood sugars etc

really important message because a lot

of times when people hear the word

insulin they think it's forever and

always and they get very frightened but

for people living with type 2 diabetes

that's not necessarily the case but it

can be a very helpful tool when things

feel like it's spiraling out of control

yeah

i think the other thing that i just like

to build on too is just like how

exercise and diet has changed for many

people over the pandemic and i think

many of us might think that we haven't

changed our hat our like exerciser

diabetes that we're doing like sorry

exercise and diet but um actually they

have changed because of some of the

nature of our habits so

you know if you're doing a lot more

working from home for example um that

means that you're not taking those steps

to like commute to work um that you

might have and you're spending a lot

more time being more sedentary in one

place you're not even walking to

different offices to have meetings with

people and so um you know maybe you're

still doing like the one workout the one

workout a day of 30 minutes like on your

on a treadmill or whatever um but and i

know exercise in general has been hard

for people with gyms closed and all of

their restrictions but let's say even if

you were able to do that same kind of

workout a day all of those other pieces

in your day are different and so it may

overall be like you're doing for example

less steps and you're you're more

sedentary than you have been in the past

without even totally realizing it and

then i think the other piece um relates

to also the diet like similarly if

you're working from home i know for me

it's like

it's like really tempting to go down to

the kitchen and like just take a snack

whatever

you know just because it's there the

food is there whereas when you're

working in the office um often those

types of things are a lot um

they're more structured and a little

harder to get to

so

and then i think also when you know many

of us are stressed we're sometimes

stress eating so uh i think i think

those factors even sometimes you don't

necessarily think that your breakfast

lunch and dinner are different obviously

there can be these sort of small changes

that can have bigger impacts as well

thank you folks um we have another

question that is uh from someone who's

fairly recently diagnosed and they say

they're still in the learning curve the

question they have is

when they check their blood sugar and

the reader says for example 6.9 after a

meal they're wondering is that a good

number is that too low does that mean

they have if they have something that's

uh worth four would that become a ten

how do they figure out wondering how

they figure out how much room they have

to eat something else

i also want to hear what maria has to

say

so i i mean i think that um you know

there's a lot i don't know about this

person in terms of medications etc right

so i think the big one is sometimes

people who are living with diabetes are

worried about something called

hypoglycemia which is a low blood sugar

but you don't really need to be worried

about worrisome or dangerous

hypoglycemia unless you take insulin or

a medication that makes your pancreas

make more insulin like glyburide or

glycosides you're not taking those

medications you don't have to be too

worried that a number is too low because

it may be normal for you that day and um

you may feel a little low if you go from

over 10 to four very quickly let's say

you went for a run and you you know

burned out a lot of that glucose you may

clo but you're not going to get to like

sort of a hypoglycemic seizure or coma

or anything like that it's really only

when we introduce medications like

insulin and glycogen glycoside that we

have to be worried about that we

generally talk about the target glucoses

after a meal being up to 10.

and it's normal if you check your

numbers a couple hours after the meal

for it to go up that is a normal

response even if somebody who doesn't

have diabetes there's going to be a

slight increase it's just that when the

pancreas is working totally properly

it's more it's like stays in that kind

of four to eight range uh most of the

time um and so a six point nine after

meal is a fantastic number um and can

you eat more um sure do you need to eat

more maybe not so i wouldn't eat to your

numbers i would eat to your hunger to

your fullness learn a bit more about

intuitive eating

and

one of the nice things about checking

numbers after meals which people don't

always do is you get to learn what the

difference is between you know

having if you think about the plate

method and you have a quarter of your

plate b carbohydrates versus if the

whole plate is carbohydrates you're

going to see a different number and if

you eat that whole plate of

carbohydrates but then you go for a nice

20 minute walk after the meal you'll

also see the impact on your blood sugars

um so that's great that you're checking

a lot of people think that people who

are early diagnosed don't necessarily

need to check and you definitely don't

need to wake up every morning and check

every morning and you always have a

blood sugar of six to seven like that's

not a useful tool for yourself or the

doctor if you're consistently always

have a good fasting trigger but learning

to check

as a teaching a self-feedback tool to

say what does this type of exercise

which are these types of foods and as i

adjust my medications what are my

numbers gives you a lot more of an

understanding of how your body's

responding to these different factors um

so that's i think a helpful

uh helpful tool to use

well when she said the 6.9 i was like

that's a good number

i would necessarily continue to eat like

or if you have to have something with a

protein in it and a salad sometimes

that's my trick thing if i think i need

to eat some more i have a vegetable of

some kind or a fruit

like a low glycemic fruit and that

usually helps

me you know or i fill up on water

that's also very helpful

we have uh someone else that's that's

curious about um you know to the mention

earlier of uh seeing checking one's eye

health they're the curious if that has

to go through an ophthalmologist

so actually it doesn't uh you can you

can see an optometrist and if you have

diabetes you um that should be covered

by ohip

um or i know this is a national webinar

but i think i think that uh in other

provinces that would be the case too so

at least in ontario

if you have diabetes you're able to see

an optometrist and that's covered under

the health insurance plan

what's tricky is that in ontario right

now the optometrists are kind of working

to roll

and so since september they

um

are kind of protesting uh the

um the government's sort of uh not

increasing the

amount that they get paid for uh certain

types of exams by um refusing to see

people who are p who o hip would pay for

which is unfortunate because it is

really some of the most the people who

wouldn't be able to afford to see the

optometrist otherwise so

um so right now unfortunately people

with diabetes are like caught in limbo

in ontario when it comes to seeing an

optometrist

um

but i'm hopeful that that's not going to

last for very long an unusual

circumstance an optometrist is

a wonderful choice for screening and in

fact it's not a good use of an

ophthalmologist time just for a

screening routine eye exam

if something is identified that needs to

be addressed that's when either the

optometrist or the family doctor can

refer you to an ophthalmologist

and i have found it's a bit hit or miss

the work to real thing i certainly still

had patients being seen by their

optometrist so it's uh you know this is

the

um the reality of healthcare in general

you don't know until you try

um but i would completely agree with

what tara said is that the optometrists

are trained to do that screening um and

um it's much easier usually to get an

appointment with an optometrist than it

is with an ophthalmologist and so let

the optometrist be your first line of

defense and if they see anything that

they're worried about they are able to

pass you forward to an ophthalmologist

who could potentially do something about

it

thank you folks we have a similar sort

of vein of question which is someone

that was told at a diabetic workshop

that an annual visit

to the podiatrist is free and they're

wondering because they went and were

charged 150

so i will add sort of the caveat that

this will vary depending on

what province or territory you're in

what your provincial plan looks like um

i know we have some some resident ohip

experts but i would check into what your

your province is actually all about

yeah

yeah in ontario unfortunately it's not

covered and i suspect it's the case in

most provinces where the health

insurance plan won't cover um

foot care from a sharopodist or

podiatrist

obviously family doctor care is is

covered and so some family doctors work

with nurses like we have a nurse

in our team who does support foot care

um so if you're lucky to be in a family

doctor's office where they provide that

kind of service that's one way to access

it um at a lower for free um and then

there are also some training centers um

that offer low cost or free foot care to

folks as well um so if you're looking

for

if you if you don't have an insurance

plan that covers it

and you don't feel like you can pay for

it out of pocket those are are a couple

of options

yeah that was what i was going to

recommend as i know when i have patients

who can't afford it i usually send them

to at least here in the gta the michener

institute is the one that's doing most

of the training for the for profits and

podiatrists and so obviously depending

on where you're living you may be able

to access some care that way

and diabetes canada has local chapters

where they try to help people um sort of

navigate and know what resources are

available to them um um and there's

always that phone number you can call

and brooks can tell you more about

to help you navigate some of that stuff

because it is a real problem i mean we

could talk a lot about the fact that we

live in a universal health care system

but medications are not universally

covered devices are not universally

covered and a lot of this preventative

care is not universally covered and so

we know that that's an ongoing challenge

for people living with diabetes and

that's why if there's um uh resources

like diabetes canada to do their best

they can't necessarily fix all the

problems but help you navigate this

complex system that we live in in canada

yeah that's uh really quite well taken

uh atlanta point will make well taken

and i think i'll i'll add the plug that

if you would like to get put in touch

with resources you can call one eight

hundred dancing or visit

uh diabetes or email info diabetes.ta

and uh it's a a big part of a lot of our

advocacy initiatives is making sure that

as many people as possible have access

to the treatments that they need

but also in the meantime to direct

people the right way within the system

so um thanks for that

uh

another question is regarding um

a person that's that's their their

doctor hasn't been available for

in-person consultations they've had

blood tests periodically and have a

glucose monitor at home but they're

wondering about self-monitoring for

symptoms of

kidneys feet other complications that

they should keep an eye out for

so one thing that i would just jump in

to say is that i i think it's worthwhile

just checking in again with the doctor

because things are changing

and sometimes some doctors are still

working on what's called a virtual first

model where they want to talk to you on

the phone first

and then if there's a reason to bring

you in they will bring you in

i've been encouraging all of my

colleagues to move away from that kind

of model now given that we have very

high vaccination rates

and generally good access to personal

protective equipment as physicians

so uh my hope is that most physicians

now and many much of the data shows this

is that the vast majority are seeing

some people in person

um but i think sometimes the way their

message machine conveys it

uh or maybe that the way the

receptionist conveys it might be

different than that

so grab a phone appointment with the

physician though then and tell him tell

him or her why you might want to come in

person so that's just

maybe i'll turn it to you or maria to

answer that other piece but i just

wanted to to flag that part

yeah i know i i completely agree with

what tara's saying and i think that

there's a lot of and generally know

access to primary care is challenging

and so people will call and they won't

get an actual person on the other line

and the voicemail still says we're not

seeing people in person but like if you

actually talk to your doctor they will

bring you in it's we know it's not

always so easy and that's certainly the

approach i've been taking in my in my

undercover practice for at least the

last six months

um in terms of symptoms kidneys is a

really tough one you don't tend to have

symptoms of kidney dysfunction until

it's quite advanced

but if you start to get swelling in your

ankles difficulty breathing some

shortness of breath

um just like a really bad sort of

fatigue and unwellness then like you

know so it's really not specific that

could be a sign that your kidneys are

not clearing in general people say oh my

kidneys are at my back if they if i have

a low back pain is that my kidneys

almost never unless you have a kidney

infection or a kidney stone your kidneys

are not going to cause you pain from a

sort of what we call diabetic kidney

disease

um steve you know i mean tara already

spoke about there's a lot of great

things you can call this like touch the

toes test is the other term for the if

switch test and you can find it on the

diabetes uk

um website and it's a great you know you

need a partner at home to do it for you

because they have to be touching your

toes and seeing if you feel it

you're having like nerve pain which

feels more almost like your foot's

asleep or you're having um

like pins and needles in your toes that

could be a sign that maybe you're

experiencing some neuropathy related to

diabetes and of course the big stuff

that you hopefully have seen the heart

and stroke types of commercials and

things like that

it's um

any sort of chest pain shortness of

breath stroke symptoms or having

difficulty breathing sudden loss of

vision anything like that

that's a straight to the emergency

department type of symptom that really

in the first wave we saw people staying

at home with those types of symptoms for

too long and my colleagues who work on

the inpatient side of medicine we're

seeing a lot of people presenting with

disease later because they were afraid

to go to the emergency department so

um i hope that answers the question

about what sort of symptoms to monitor

for um while you're at home but i think

the most important message is if you're

worried about your health your doctor

wants to look after you and you should

seek care

because i added a couple of things to

our chat and i don't know if you're able

to to add it to the facebook live

yeah we can thank you

that might be thank you tara

we'll get those in the facebook chat as

well

um

folks recognizing we we do unfortunately

have a hard stop this is such a great

conversation and really great people's

questions being answered in real time i

know we have a hard stop at 5 00 pm

eastern and i want to just field two

questions that

are pretty

personally tailored and i think could

could really benefit from having a

tailored answer so these questions are

from a viewer who is on a maximum amount

of oral meds plus ausum thick and i

think next step is insulin their a1c is

consistently eight to nine they can't

see their endocrinologist until december

and they're wondering what they can do

to get this a1c down

so that's that's question one and the

second one is someone who's calling from

or watching from victoria bc where there

is a critical shortage of g fees

their own doctor is on medical leave so

they don't have a doctor and they're

feeling very much on their own with type

1 and it's getting worse their a1c is

increasing and they can't see an endo

until december so wondering what they

can do

and feeling desperate

oh i feel so badly for both of you

although i know that many of my patients

can't see me until the new year

so

i guess my answer to that is it is it is

the system is struggling and individuals

are struggling because of that

for the first patient i would say is

your is your primary care practitioner

comfortable starting insulin a lot of

primary care practitioners are

comfortable starting basal insulin

does your endo work with a diabetes team

and even though you can't see your end

though maybe your endo can at least

speak to the nurse and prescribe a

starting dose of insulin so the nurse

could get going on it

so that's those are my thoughts then i

think it's great that you've identified

that you sort of maxed out all the other

options and it's time to start some

insulin december is not that far away in

the grand scheme of things um but if

you're really motivated those would be

two channels that i would recommend

in terms of getting started on the

insulin

i don't have a good answer about not

having access to any sort of primary

care on in victoria um except to say

that i think there's a move afloat

especially as it comes to virtual care

to start thinking about

providing care across provincial

boundaries it's still very complicated

our licenses don't cross provincial

boundaries right now and so it's really

you know the cpso says i'm only supposed

to provide care to people who are in

ontario unless it's a crisis and they

absolutely can't get care somewhere else

and then i could provide virtual care

outside um so i don't have a great

answer to that i wonder what tara say

yeah it's always um it's always so hard

to hear from people who can't find a

family doctor but i'll say i've

encountered the same thing with my own

patients who've moved away from toronto

and i'm continuing sometimes to refill

their meds and and be their doctor

because they haven't been able to find a

new one in their new place

um so i guess i have a a

a few suggestions so the first would be

in some provinces there are centralized

um

uh

pathways to finding a family doctor so

in ontario there's something called

healthcare connect quebec also has a

centralized pathway a few other

provinces do too i don't think british

columbia is one of them but if you're in

a province where that's the case

you can use that

the second is that often connected to a

medical school there are training um

centers and so find out in um at so ubc

has a medical school and they train

family doctors and their family doctors

who are trained on uh in victoria and so

you can

try and figure out which of the clinics

are are is a teaching clinic and

oftentimes the resident physicians of

teaching clinics are growing their

practices or looking for some new

patients and so you could approach um

you could approach a teaching clinic

and then of course the third is

unfortunately not a great one but there

are obviously walk-in clinics they're

both in-person and virtual clinics that

you can use and uh you know i think that

you know it's not optimal because we

know that continuity of care is really

important especially if you have a

chronic condition but it's better than

no care so

so um if you aren't able to find a

provider one of the other two ways then

then that's the case then you can use

that i will say i think there's a move

to more team-based models in the island

of vancouver um and uh so of course also

keep your um keep your hopefully keep

your mind open to think to seeing a

nurse practitioner um if that's an

option because it doesn't necessarily

have to be a family doctor that you have

the only thing i can recognize oh yeah

sorry bro

i think we have like three minutes or

something but what i was gonna say and i

ladies don't jump on me

what has worked for me to bring my a1c

level down

was intermittent fasting i know there's

some controversy about that

but that has actually worked really well

for me to help me manage my

my condition so

you might wanna

yeah i definitely wouldn't jump on you i

think any any any approach lifestyle

approach that works for patients is

great i only caution those who are using

insulin or those other medications i

mentioned and doing intermittent fasting

that you're monitoring your sugars

frequently and you know what a low blood

sugar feels like and have some support

to adjust your medications as needed

right

yeah good point uh great point both of

you um keith i think that that

importance of being a bit creative in

how we solve problems as mentioned

earlier is really important

um so folks i we do have a couple

questions that unfortunately will will

not be able to answer with the time

limit of one hour but those questions

are around uh numbness in feet how how

often a person should be checking

throughout the day and uh specific types

of blood glucose monitors so for those

questions uh i can i can confidently say

they are all uh we're very well equipped

to answer those at the diabetes canada

info line so please feel free to a check

our website or the reach out to uh 1-800

banting as mentioned earlier are our

infoline or to email

infofive.ca and we can our team will be

happy to direct you the right way

so with that i i we do have to come to

an end but i just want to say a sincere

thank you to everyone who viewed and

submitted questions it was a really

really thoughtful discussion and

especially of course to our guests uh it

really meant a lot to have your your

input uh maria elena and tara

it was really fantastic conversation i i

know personally i i gained some

knowledge of this and i hope that

everyone viewing did so as well

so i'd like to say a sincere thank you

and assure everyone as mentioned

diabetes canada is going to keep working

to make sure that these questions are

not only answered but answered with uh

better answers you know with where it's

more satisfactory how how resources are

available to you so uh thank you all and

again please don't hesitate to reach out

to diabetes canada if you have questions

and we'll do our best to steer you in

the right direction so george yes thank

you again and and take care

thank you