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Managing Diabetes Magazine - diabetes

Guidelines for the Prevention and
Management of Diabetes in Canada
Help for setting and achieving target goals

Every five years the Canadian Diabetes Association (CDA) updates the Clinical Practice Guidelines used by health care professionals to help you manage your diabetes. The guideline updates published in December 2003 reinforce that good diabetes control (striving for values as close to normal as safely possible) can prevent, delay and/or improve the complications of diabetes.

These new guidelines recommend tighter blood glucose control and earlier intervention in order to reach target goals within six to twelve months. The new guidelines are available at the CDA website www.diabetes.ca. A searchable format helps users find the information needed quickly and easily.

A diagnosis of IFG and/or IGT (prediabetes) confirms a person is at risk of developing diabetes. Studies have shown that lifestyle intervention (healthy diet, moderate weight loss and a minimum of 150 minutes of aerobic activity each week) is very effective in delaying or preventing the development of diabetes.

As much as 2.7 per cent of the population may have undiagnosed Type 2 diabetes. Screening for Type 2 diabetes should be done every three years in people over the age of 40 who have no other risk factors. Earlier or more frequent screening is recommended for those with risk factors for developing Type 2 diabetes.

Another important part of the new guidelines discusses Self-Monitoring of Blood Glucose (SMBG), essential for all people with diabetes. Benefits include improved A1C (glucose control), avoiding hypoglycemia (low blood glucose reactions) and increased lifestyle flexibility. Benefits are enhanced when dietary choices, physical activity and medications are adjusted in response to blood glucose (BG) values. Ask your diabetes educator for more information on learning to interpret SMBG results and how to make appropriate changes. For best management, people with Type 1 diabetes should test a minimum of three times per day while those with Type 2 diabetes should test at least once daily. More frequent testing is often needed to get the information necessary to make behavioural or treatment adjustments and help meet optimal blood glucose values. SMBG should include pre-meal (pre-prandial) and two-hour post meal (post-prandial) testing times.

Recommended Treatment of Diabetes

Nutritional therapy is an integral part of diabetes treatment for all people with diabetes. With nutrition therapy, the goal is to improve or maintain quality of life, nutritional status and health while preventing and treating complications of diabetes. Use the healthy diet recommended for everyone in Canada’s Guidelines for Healthy Eating. In general, these guidelines suggest eating a variety of foods from all four food groups and choosing whole grain products, fruits and vegetables more often.

Benefits of physical activity include better fitness, improved blood glucose control and lipid (blood fats) profiles, lowered insulin resistance and maintenance of a healthy weight. The new guidelines suggest people with Type 2 diabetes should accumulate at least 150 minutes of aerobic activity (such as brisk walking, biking, continuous swimming, dancing, raking leaves, or water aerobics) each week spread over three non-consecutive days. If possible, accumulate 4 or more hours of exercise per week. Those with diabetes (including elderly people) should also do resistance exercise (weight lifting) three times per week. In resistance exercises, start with one set of 10 to 15 repetitions, progressing to two sets of 10 to 15, then three sets of 8 repetitions, three times per week. Before beginning any physical activity program, check with your doctor.

If lifestyle interventions do not allow a person with Type 2 diabetes to achieve target blood glucose values within two to three months, or if that person has an A1C equal to or more than 9.0 per cent at the time of diagnosis, medications to lower the blood glucose (oral antihyperglycemic medications) or insulin should be started. For overweight people with an A1C of less than 9.0 per cent, the drug metformin either alone or in combination with another oral medication is recommended. People who are not overweight can begin with one or two oral medications from different classes. People with an A1C equal to or more than 9 at diagnosis should begin immediately on either two oral medications from different classes or insulin therapy along with lifestyle interventions. The lag time between adjustments or additions of other oral antihyperglycemic medications or insulin should be kept to a minimum. Aim for reaching target values within six to twelve months of diagnosis.

Women with pre-existing diabetes who want to become pregnant should optimize their blood glucose control prior to conception. Women are recommended to carefully plan their pregnancy by working closely with their diabetes health care team. The goal for A1C pre-pregnancy is equal to or less than 7 (equal to or less than 6 if possible).

Those with Type 1 diabetes are advised to use multiple daily injections (MDI) of insulin (three to four per day) or insulin pump therapy (continuous subcutaneous insulin infusion or CSII). Multiple daily injection insulin regimens consist of basal insulin injections once or twice daily, along with a bolus injection of fast or rapid-acting insulin to cover food intake at each meal. Fast or rapid-acting insulin (lispro or aspart) combined with basal insulin is preferred over regular insulin in achieving post-prandial (after meal) targets. The injections help improve A1C while reducing hypoglycaemia (low blood glucose) reactions.

All pregnant women should be screened for gestational diabetes (GDM) between 24 to 28 weeks. Two of the three defining values in the previous chart must be present for a diagnosis of GDM. Recommended blood glucose target values for GDM are less than 5.3 before meals, less than 7.8 one hour after a meal and less than 6.7 two hours after a meal. If GDM cannot be managed with nutrition therapy alone, insulin therapy should be used. While insulin is known to be safe, most oral medications have not been proven safe for use during pregnancy. Since having GDM increases a women’s future risk of developing diabetes, lifestyle intervention should be an important consideration after pregnancy.

Having diabetes is associated with a high risk of vascular (heart and blood vessel) problems. Aggressive management of blood pressure and lipids is generally needed to lower the risk of heart attack or stroke. The target goal for blood pressure control is 130/80 mmHg. Unless a person is not able to take Aspirin™ diseases. It also contributes to high blood pressure. All people with diabetes are urged to stop smoking.

Guidelines recommend checking your A1C level every three months. People should check their feet regularly and health professionals should also perform regular foot exams for them. Blood pressure should be monitored at each appointment. A lipid profile (the blood test that reveals cholesterol and triglyceride levels), should be done at diagnosis, then every one to three years as indicated. See Guidelines at www.diabetes.ca for more information on the screening and treatment of complications.

Most people can use the target values in the new guidelines. Professional judgement is necessary to determine who can reasonably and safely achieve these targets. When setting individual goals and treatment strategies, consider individual risk factors including age, prognosis, existing complications and other diseases, along with the risk of and ability to recognize symptoms of hypoglycemia. Work with your doctor and the other members of your diabetes health care team to decide which target goals are appropriate to the treatment and management of your diabetes.

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While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2019, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1    [DI_MDab15]