Diabetes newsletter by St. Michael's Hospital

DIABETES NEWSLETTER

Diabetes Care in Ethiopia By Maria Wolfs, MD, FRCPC

JUNE 2018

Editors’ Note As we welcome the warmth of spring and start to enjoy longer days of sunshine, we are happy to bring you another issue of the Diabetes Newsletter. Like always, we hope you will find the information here informative, inspiring and interesting. In this edition, you can read about Dr. Maria Wolfs’ experience teaching at a diabetes clinic in Ethiopia. Ethiopia is one of the poorer countries in sub-Saharan Africa, which means people living with diabetes there often cannot access the care and resources they need. Despite this, people strive to do their best for their health despite the many challenges they face.

Scenery of the Ethiopian countryside

Last November, I had the opportunity to travel to Addis Ababa, Ethiopia as part of the Toronto Addis Ababa Academic Collaboration (TAAAC). The vision of TAAAC is to form a strong, enduring, and broad educational collaboration between the University of Toronto and Addis Ababa University.

Here at home in Toronto, patients like Chris Miller and Carol Allain-Pierre also do their best to manage diabetes by staying active, making diet changes and creating healthy lifestyle changes. You can read their stories on pages 4-6.

For a month, I taught at the Black Lion Hospital, which is a tertiary care academic centre in Addis Ababa. The Black Lion Hospital sees over 500 diabetes visits per month. There are 4 weekly diabetes clinics and 2 weekly endocrine clinics with 5 physicians and 5 nurses. Other diabetes related services offered include weekly educational sessions for patients, and access to retinopathy screening and foot care services.

One important way to be an active participant in your own diabetes management is to stay up to date with the latest health information. On page 3, you will find tips from Danielle Goudge, one of the nurses at the diabetes clinic, on how to be “in the know” and find reliable information when you search the Internet. With the recent publication of Diabetes Canada’s 2018 clinical practice guidelines, up-to-date accurate health information is more accessible than ever before. You can read more about this exciting new publication on page 8.

Ethiopia is the second most populous country in Africa with a population of 110 million people. The majority of the country’s population (83.6 %) live in rural settings and agriculture employs up to 80% of all people. It is also one of the poorest countries in Sub-Sahara Africa, with a gross domestic product (GDP) per capita of $706 USD. Life expectancy at birth is 58.37 years of age, with women living on average 61.12 years while men only live 55.69 years. The exact prevalence of diabetes in Ethiopia is difficult to estimate due to small and poor-quality research studies.

Our contact information is available on the back cover. If you have any questions, comments, suggestions or contributions for this newsletter, please reach out to one of us! Annabell Hall RN, MN, CDE and Lucy Chen, PharmD

Continued on page 2 Printed on 100 per cent recycled paper

JUNE 2018 | DIABETES | 1

Diabetes Care in Ethiopia continued from page 1

Dr Wolfs, first from the left, attending rounds in Addis Ababa

A survey done by the World Health Organization (WHO), in 2015 with 10 260 participants aged 15-69 years old, showed that 6.3% of the population was overweight (BMI ≥ 25 kg/ m2) and 1.2% were obese (BMI ≥ 30 kg/m2). The prevalence of diabetes mellitus was 3.3% and the prevalence of impaired fasting glucose (prediabetes) was 3.8%. While these rates are lower than the prevalence rates seen in Canada, the Ethiopian health care system is limited in dealing with the burden of diabetes in the country. Type 1 diabetes is often not correctly diagnosed. This leads to high numbers of patients dying from the condition. Compared to North America and Europe, where type 1 diabetes usually onsets in early childhood, it appears that there is a later age of onset with a peak around 15–25 years in Africa. Other types of diabetes seen more commonly in Africa include malnutrition-related diabetes. There is also a strong presence of diabetes related to infectious disease, like tuberculosis, and HIV. In an Ethiopian national health provision survey, only 59% of health facilities offer services for diabetes. Of these, only 12 % had guidelines for diagnosis and management of diabetes

Attending a diabetes conference in Ethiopia; Dr. Wolfs, third from left

and only about half were able to provide tests for blood glucose, urine protein or urine glucose. Another cross-sectional survey showed that among patients with diabetes, none had a follow-up A1c test, only 31% had bimonthly fasting glucose test, and only rare individuals had access to eye tests and foot examinations. Patients had to travel on average 2 hours each way to their appointment, with some travelling for days which posed a significant cost burden for them. The cost of diabetes medications was very high compared to people’s wages. For example, a monthly course of glyburide may cost the equivalent of 4 days’ wages (of a low level government employee) while a monthly course of metformin would cost close to 15 days wages! Most other oral diabetes medications are either not available or are prohibitively expensive. Insulin is also expensive, with the only widely available formulations being Regular Insulin and Lente (N) – insulins not commonly used in Canada since the late 1990s. An additional challenge is that insulin must been cool or refrigerated and most homes in Ethiopia do not have refrigerators, especially in the rural areas. I was fascinated to learn about effective alternative cooling strategies for insulin storage such as the use of clay pots, goat skins, and buckets filled with wet sand. Reflecting back on my experience, I continue to be struck by the generosity and kindness of the medical staff and patients that I met in Ethiopia. People strived to do the best they could in the face of significant personal, economic and political challenges. Trying to practice medicine in such a resource-poor environment highlighted how grateful we should be in Canada with all of the blessings we have available here.

A rural primary care health clinic in Ethiopia

2 | DIABETES | JUNE 2018

How to be “in the know”: making sense of health information By Danielle Goudge RN, BScN, CDE

When we have so much information available at our fingertips, through our smart phones or tablets, how are we supposed to navigate or make sense of what we read? When it comes to our health or health information, it can be even more confusing! We only hope that the few keywords we type into a search engine or browser lead us to information that is not only helpful but reliable and valid. Unfortunately, nowadays the world wide web is home to many self-claimed “experts”. If you are searching for health information, here are a few strategies you can use to help you feel more confident in the information you come across: 1) Who: Who are the authors? Who is contributing to the page? When you are accessing a webpage, think about whether there is an “about page” that helps indicate who is contributing and writing the material. Are there registered or licensed practitioners that are contributing to the content? Are there any references to studies or other material? Knowing who is writing the information is just as important as knowing what they are writing about. 2) What: What is the information available on the webpage? We are told not to judge a book by its cover. However when it comes to a webpage, you may want to consider how it looks. Is it professional? Are there any spelling mistakes? A useful high-quality webpage should be easy to navigate to find the information you are looking for. 3) Where: Where is the information coming from? Many sites are not Canadian and different countries may identify units of measure or medications, for instance, using a different name. 4) When: When was the page last updated? Health information is changing constantly, so you want to make sure that you are accessing a site that is changing based on the most current research! There is usually a “last updated” indication at the

Remember: If you have questions about something you have read, our diabetes team is here to support you!

bottom of a webpage that should help to give you a better sense of how often the site is maintained and edited. You also want to ensure the website is certified and validated through the search engine. An easy way to assess the security of a website is to check to see if there is a valid certificate. On the web browser, look for a green arrow or lock symbol. 5) Why: Why was the site created? Is it trying to sell you something or are there many ads? Sites that flash, blink or have many pop-ups may be more focused on selling product than trying to provide helpful health information! So what are some of the sites that you can access if you are looking for more information related to diabetes? These are some of the suggestions we have. Diabetes Canada: http://www.diabetes.ca Diabetes Canada (DC) is the national organization that aims to be the voice of those living with diabetes and prediabetes. Information available on the DC website is based on the Clinical Practice Guidelines also published by DC. These guidelines represent recommendations to practice based on a comprehensive review of current clinical research and data by an expert committee of reviewers which is made up of nurses, dieticians, physicians, nurse practitioners, pharmacists, and patients. St. Michael’s Diabetes Clinic: http://stmichaelshospital. com/programs/diabetes-clinic/ Hospital websites and program specific pages are also great sources of information as the content is written by registered and licensed health care professionals. The St. Michael’s page contains specific information and resources/ tools/videos that can help you navigate questions related to diabetes like how to manage hypoglycemia and what to do if your pump fails. These resources can be downloaded and saved or accessed when you need them on-the-go! DiaTribe: http://diatribe.org/ DiaTribe is a free online publication that markets itself as providing “insight and actionable tips to those living with diabetes”. The contributing authors are professionals or individuals living with diabetes who try and make diabetes information easier to understand and more about the person and less about being a “patient”. You can sign up and have their newsletter sent to your inbox every week. If you are looking for information about new medications, tips or tricks about managing diabetes, and a community of individuals living with diabetes, this is the site for you!

JUNE 2018 | DIABETES | 3

Staying Active and Having Fun By Chris Miller, nonagenarian and person living with type 2 diabetes

This year I celebrate my 92nd birthday, which I suppose makes me a nonagenarian (someone in their 90’s). My diabetes journey began when I was in my 70s. My doctor put me on a “diabetes watch list” based on blood tests and I was told that I needed to be careful. I really didn’t know what to expect so I carried on as usual. When Chris Miller I entered my 80s I was told I needed medication but I wanted to try a vegan diet before starting. I did this under the supervision of my doctor to see if that would help the diabetes. Unfortunately I got very ill. I then started taking the diabetes medication and started monitoring my blood sugar levels frequently. In March 2016, I started insulin injections. I’ve learned to take diabetes seriously and do as much as I can to slow it down. I make sure I follow instructions from Dr. Advani and take the prescribed medicines. I grew up enjoying the outdoors and having diabetes did not slow me down at all. I was a paratrooper in World War II.

Chris and wife Mary Anne

I have always had outstanding support from my wife Mary Anne. I met her in 1958 and she taught me to ski and play tennis. She is great company and we share excellent and wholesome meals together. We eat lots of vegetables and enjoy the outdoors together. We went on many wonderful canoe and car camping trips with our four children. In my 80s, I gave up tennis and skiing. But, I find I haven’t had to sacrifice much in my lifestyle from having diabetes. I have recently found a very congenial walking group. We meet once a month on a Thursday. Everyone walks according to their own ability. I usually do 2 to 2 ½ miles each time. My favorite is when we visit cemeteries – the routes are usually well paved and it isn’t too hilly. In addition I have just started a weekly exercise class as well. It is made just for elderly people like me. This week, we did chair exercises. It felt great to use my muscles! I also enjoy birding with my wife and youngest daughter. We like to go to Leamington and Point Pelee. We walk around and look at different birds in the trees; this is a wonderful way to spend the day. It’s wonderful to see that research is being done on diabetes and the advances that are being made. My advice for others is to learn about your own body and find ways to stay active while having fun.

“My advice…is to learn about your own body and find ways to stay active while having fun.” Chris ready for WWII

4 | DIABETES | JUNE 2018

Making Changes By Carol Allain-Pierre, person living with diabetes

I was diagnosed with type 2 diabetes in the spring of 1994. I had seen my family doctor 2 weeks earlier for a physical. He checked my fasting blood glucose and A1C as a precaution due to risk factors of family medical history, race and BMI. I developed symptoms of unquenchable thirst, extreme tiredness, blurry vision, cravings for sweet foods and drinks, upset stomach, muscle pains, mood swings and tingling and numbness of my tongue. One of my most vivid memories of that time was waking up at 3am one early morning, craving sugar so much that I drank almost a liter of coke! Coincidentally, my mother had been diagnosed with type 2 diabetes the year before. She was the one who recognized my symptoms and encouraged me to see my family doctor immediately, which I did. I was referred to an endocrinologist right away and was admitted into the hospital for a week so that my blood sugar levels could be normalized and get the right medications prescribed. I met with the dietitian and nurse educator and learned all about diabetes and its complications. I have always had a complicated relationship with food. Being told that I would now have to change all my eating habits and do away with foods I found comforting made me very upset and angry. Also, I found it difficult to accept that I would now have to self-inject insulin and prick my fingers a number of times per day for glucose testing. This sent me into a deep depression. I felt like I was grieving the loss of a good friend due to the fact that many of the foods I liked to eat were now not on the menu and if it was, only in very limited quantities!

“Being diagnosed forced me to begin to work on my unhealthy relationship with food and how it has and still does affect my life.” I was fortunate to be able to take a short leave from my job so that I could attend the many appointments and tests required by my specialist and to institute a change in lifestyle so that I could maintain my health. I was fortunate to be surrounded by a supportive group of friends who were always ready to support me in accepting that my life had to change, if I wanted to make sure I did not develop any complications. They provided me with love, strength, a shoulder to cry on as well as having the difficult discussions in regards to my eating habits. They actually read up on the issue of diabetes so as to have a better understanding of what I was going through and what they could do as friends to make sure the changes made were successful.

Carol Allain-Pierre

“I was fortunate to be surrounded by a supportive group of friends… They actually read up on diabetes so as to have a better understanding of what I was going through and what they could do as friends…” Having diabetes meant that I now had to make sure I had regular meal times, checked my blood sugars daily and took several types of insulin and other medications. My meals needed to be balanced and not just consist of carbohydrates, as was my habit. It felt like I now had a second full time job! I could no longer just book a ticket and travel. I had to make sure I had enough medications to last during my time away and also make sure that wherever I visited I was able to get my medications if any emergency were to occur. Apart from the change in dietary habit and having to be more active, I very much resented the fact that now my life was controlled by diabetes. With the help of therapy, my nurse educator, my friends and family, I was finally able to mostly accept the reality that I was now living with diabetes and would have to do so for the foreseeable future. Being diagnosed forced me to begin to work on my unhealthy relationship with food and how it has and still does affect my life. The fact that one has to think about every morsel of food eaten and how it will affect your body is not an easy thing to deal with, though I have, for the most part, been able to do so. Continued on page 6 JUNE 2018 | DIABETES | 5

Making Changes story continued from page 5

Chunky Vegetable Lentil Soup Makes: 6 servings / serving size: 1 1/2 cup Prep: 25 mins / cook: 30 mins / start to finish: 55 mins INGREDIENTS 1 tablespoon olive oil 1 medium onion, cut into thin rings 1 clove garlic, minced 1 cup dry green (French) lentils, rinsed and drained 1 pound whole small mushrooms (halve or quarter any larger mushrooms) 4 medium carrots, thinly sliced (2 cups) 2 stalks celery, chopped 4 cups water 1 can (14 oz) vegetable broth 1/4 teaspoon salt 1/4 teaspoon ground black pepper 1/4 of a head napa or red cabbage, sliced DIRECTIONS 1. In a 4-quart saucepan or Dutch oven heat oil over medium heat. 2. Add onion and garlic; cook for 4 to 5 minutes or until onion is tender, stirring occasionally. 3. Stir in lentils; cook and stir 1 minute. 4. Add mushrooms, carrots, celery, water, vegetable broth, salt and pepper. Bring to boiling. Reduce heat and simmer, covered, about 25 minutes or until lentils are tender. 5. Divide among soup bowls; top with cabbage.

6 | DIABETES | JUNE 2018

Right to left, Carol, her mother, niece and sister

One of the changes which was difficult for me was changing to being less sedentary and more active. I do my best to keep active by walking, and my favourite, aqua fit class! I have always loved the water and find it easier to go to the pool rather than the gym. Since I know this about myself, I do it so as much as possible. At times, I have to push myself to go to class but do not regret it as I always feel better. I firmly believe that physical activity is extremely important in managing one’s type 2 diabetes. This has been a truth for me – when I am not active, I feel worse which then takes me down a road where I do not eat right, which then affects my mood. All in all, it ends up being an unhealthy cycle which is difficult to break away from. I keep the credo “everything in moderation” always in mind as a constant reminder that I must do my best to eat well, exercise and follow the directions given to me by my medical team. I have been fortunate to have been in the care of an excellent endocrinologist who expected that I would be an active partner in my health care and understands that making sudden and drastic changes in health and lifestyle does not always come easy. He lends me all the support I need to make me successful in managing my diabetes and takes a holistic approach to the management and care of my diabetes and health. I am fortunate that I am able to travel, work at a job that I am very committed to in providing supports and services to those marginalized by society and spend time with my family and family of friends, look at the stars and look into the sparkling eyes of my grand nephews. I struggle at times but I understand the importance of not remaining in a space where I neglect my health, as it is mine to lose.

The Tip Tank Annabell Hall, RN, MN, CDE

Your blood sugar level should be 5.0 mmol or more before you drive. If your blood sugar level is between 4.0 to 5.0 mmol/L, eat some carbohydrate containing food before you begin to drive. If you suspect or feel that you have a low blood sugar (hypoglycemia), you should treat the low blood sugar and wait for least 45 to 60 minutes before you start driving. Measure your blood sugar level immediately before and at least every four hours during long drives.

Adapted from: https://www.diabetes.ca/diabetes-and-you/healthyliving-resources/general-tips/guidelines-for-diabetes-and-private-and-commercial

Diabetes Word Search c c c c c c c c c c c c c c c c c c c c c c c c

Food Pump Carbohydrates Sugar Fats Glucose Hypoglycemia Hyperglycemia Insulin Medication Needles Protein Selfmanagement Target Sweet Meter Inject Basal Cup Measure Scale Blood Pills PancreasÂ

JUNE 2018 | DIABETES | 7

Diabetes Canada Publishes New Clinical Practice Guidelines 2018

Adapted with permission from Diabetes Canada press release by Sherry Calder, senior manager, Communications and Marketing”

By Dana Whitham, MSc, Clinical Leader/Manager and Lucy Chen, PharmD, Case Manager

In April of this year, Diabetes Canada released their latest set of clinical practice guidelines. Published every five years, these guidelines are meant to improve the quality of diabetes care across the country. Clinical practice guidelines are recommendations written for health care providers, based on looking at the scientific evidence and weighing the benefits and harms of different options. This latest version brings a few notable changes, best of which is that each chapter now has key messages targeted directly for people living with diabetes. If you've never read through the guidelines before, I would encourage you at a minimum to read through these key messages. Ask your diabetes team about any questions you may have about the content of the guidelines. Rest assured, you are in good hands at St. Michael's Centre for Diabetes and Endocrinology. The majority of our staff were either authors this year or in previous years and volunteered countless hours with the aim of sharing information and empowering individuals just like you.

Guideline recommendations are developed by following a very rigorous process. “This ensures that each recommendation is based on the strongest evidence available,” says Dr. Hux. To write the 2018 Diabetes Canada clinical practice guidelines, 135 diabetes care experts across Canada participated in the development process. This included people living with diabetes who provided input into the development of resources and tools.

In recent years, scientific and clinical evidence in diabetes care have evolved rapidly. As Dr. Jan Hux, the president of Diabetes Canada, says, “There is a vast amount of information for health-care providers to stay up-to-date with, and our goal is to provide them with the guidance and tools to help inform and engage patients in their care so they can live well through all stages of their life.” For busy clinicians, practice guidelines are very valuable for distilling the vast amount of information so patients can benefit.

The latest 2018 Diabetes Canada Guidelines focuses on: 1) Reduce the Risk of Complications

• Using the right medications to protect your body (feet, eyes, kidneys, etc.)

2) Keep People with Diabetes Safe

• Using medications safely

• Safe driving

• Taking care when sick

3) Support Self-Management

• Starting and staying on track – setting goals for healthy lifestyle habits (eating, physical activity, etc.)

To check out the updated guidelines, visit guidelines.diabetes. ca. You can also download the free app available at the App Store or Google Play store.

Are you interested in contributing to this newsletter? You can share your story of living with diabetes, a favourite healthy recipe, or helpful tips for other patients. You can also sign up to receive email notices when a new issue of the newsletter comes out. Contact one of the editors by email: Annabell Hall HallA@smh.ca

Lucy Chen ChenLu@smh.ca

DIABETES NEWSLETTER

JUNE 2018

Design by Marcelo Silles, Medical Media Centre

Become a Patient and Family Advisor at St. Michael’s You sometimes notice things we don’t. Things like how your care is provided, and how we could be doing better. Play a valuable role in helping to ensure the best possible patient experience at St. Michael’s. Become a Patient and Family Advisor. Visit stmichaelshospital.com/patientandfamilyadvisors for more information.

For more information, please contact PatientandFamilyAdvisor@smh.ca