Welcome to this special issue dedicated to Live Well with Diabetes. Live Well with Diabetes is an educational initiative of the B.C. Endocrine Research Foundation that is intended to provide clear up-to-date information on all aspects of diabetes self-management. It is our belief that the better informed an individual with diabetes is then the more likely they are to make the right decisions and be proactive with respect to optimal management of their diabetes.

Live Well with Diabetes is a multimedia educational tool that serves as a comprehensive guide to the understanding and management of Type 2 Diabetes, a condition that affects 7-10% of the adult Canadian population, is associated with a doubling of the risk for heart disease and stroke and is the commonest cause of blindness, amputation and kidney failure in our society. Live Well with Diabetes is available on DVD, CD-ROM, videotape and online at livewellwithdiabetes.com. It is soon to be released through public libraries and drug stores.

Live Well with Diabetes covers type 2 diabetes definition and diagnosis, management guides, lifestyle change recommendations, medical therapy explanations, information on complications associated with diabetes, blood sugar testing instructions, information links and much more. This complete information source should always be at your fingertips.

	Live Well with Diabetes was developed by the B.C. Endocrine Research Foundation with the assistance of volunteers, donors and its sponsors LifeScan Canada, GSK, and Merck Frosst Canada.
Call 604-875-5934 or email dvd@livewellwithdiabetes.com to order the DVD or CD-ROM

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The Causes of Diabetes

The fundamental aspects of the cause of diabetes appear to be increasing insulin resistance combined with a pancreas that eventually fails to produce sufficient insulin. When insulin supply can no longer overcome insulin resistance then blood glucose homeostasis is compromised and diabetes results. There appears to be a number of genes involved in the tendency to acquire diabetes yet typically this represents only the potential to acquire diabetes since environmental conditions must be such that the genetic potential is expressed and diabetes results. Therefore insulin resistance and pancreatic insulin production are both areas of interest.

Insulin Resistance. Research suggests that obesity is a key element in the development of insulin resistance yet obesity is complex as well and also has a genetic component. Researchers continue to try and determine the mechanisms whereby obesity leads to insulin resistance since this may provide insight into therapeutic options and possibly the prevention of diabetes. Even the subtleties of how fat is distributed on the body appears to play a role in the progression of insulin resistance.

Beta Cell Function. The cells in the pancreas that produce insulin are called beta cells. The mechanism behind the failure of the beta cells to produce sufficient insulin is one key area of research. While the function of beta cells is reasonably well understood it is not clear why these cells eventually fail to produce sufficient insulin in some people.

Diabetes Treatment

The Canadian Diabetes Association recently announced its updated guidelines for the treatment of diabetes. This of course means the treatment of blood pressure and blood cholesterol as well. Periodically these guidelines undergo revision based on research being done all over the world. The research is geared towards answering numerous questions that still exist regarding how diabetes is best managed and as answers are found the guidelines are adjusted to reflect the new information. Often these studies will focus on blood sugar management, blood pressure management and blood cholesterol management. One very important long-term study being conducted right now is looking at all three of these risk factors and trying to determine the optimal therapeutic approach for each. This North America wide study is called ACCORD, which stands for Action to Control Cardiovascular Risk in Diabetes (www.accordtrial.org) and is in the process of recruiting 10,000 volunteers in 70 centres throughout Canada and the United States. Key aspects of the study will involve an assessment of the benefits/risks associated with aggressive lowering of blood sugars, blood pressure and blood cholesterol in people with type 2 diabetes. This study will finish in 2009 and the results will be very exciting indeed.

Another interesting study is looking at heart disease in type 2 diabetes. In people who have major progression of heart disease and who are potential candidates for heart by-pass surgery it is not clear whether early intervention is beneficial. A major North America wide study is trying to answer this question. Bari 2D (www.diabetesheartstudy.org¹) is investigating the outcomes in diabetes patients who receive by-pass surgery versus those who receive medical therapy as the first line of treatment. Patients are randomized to one group or the other and then followed for a number of years while treating their diabetes as effectively as possible.

There are many other areas of diabetes research so keep tuned into our website for more information and more updates.

¹Note — www.diabetesheartstudy.org is no longer operational

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• Your doctor. It is important to have a good trusting relationship with your doctor. Your doctor is responsible for gathering all your health information making sure your are well taken care of.
• A specialist, an endocrinologist or an internist. A diabetes specialist can make certain all aspects of your diabetes are addressed.
• A diabetes nurse educator. Nurse educators are very gifted at helping you to understand all aspects of your diabetes care and taking the time to explain things clearly.
• A dietitian. A good diet is critical to an effective diabetes management strategy. Dieticians can make the appropriate recommendations and keep you on track.

These are the most important people. There is often a need for a number of special helpers. These include:

• Your pharmacist can help clarify the pills you are taking and help you understand the roles of the different medications.
• A foot care specialist. To avoid foot and lower limb complications you should see a foot care specialist regularly as well as checking your own feet yourself everyday.
• An ophthalmologist or an eye doctor. The problems that occur with the eyes associated with diabetes don’ always appear as an immediate impairment of vision. Therefore it is important to have regular eye check-ups. If there is evidence of eye damage, laser therapy can be used to halt the progression of the damage and preserve your vision.
• A social worker to help you cope with some of the social problems and perhaps even a psychologist because it is often difficult for you and your family to cope with this disease. Sometimes it can actually become somewhat depressing. Therefore, depression sometimes needs professional help.

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What have I done to cause diabetes? You might ask yourself why do I have diabetes. Have I done something wrong? Well almost always the answer is no. We know that the vast majority of the tendency to diabetes is genetically transmitted. If you are obese, your chances of developing diabetes are much higher than if you are not obese. But by the same token we know that obesity has many genetic causes as well. So, rather than blame yourself for where you are at, I think it is better to think of what I can do about it, to control your diabetes and to make your health better.

Why do I have to test my blood sugars? Testing blood sugars provides you with valuable information that lets you know whether the diet, exercise and possibly medical therapy are working for you. Ask your diabetes doctor what your blood sugar targets are and do your best to achieve those targets. If changes in diet and physical activity for a period of 8 to 12 weeks doesn’t help then it may be time to start some form of medical therapy. Good blood sugar control is essential to good diabetes management and therefore you need to test your blood sugars and take medications as prescribed by your doctor.

I feel okay so why should I bother with medications and making changes in my diet and exercise? Diabetes is a very deceptive disease because most people diagnosed with diabetes have probably had it for a number of years but didn’t know it. The symptoms are not always obvious. The average blood sugar tends to rise gradually and as it rises there is damage occurring throughout the body; to the heart, the eyes, the kidneys, the nerves. This can occur even though you feel okay. That is why it is so important to take action as soon as you are diagnosed with diabetes. Make the changes suggested by your doctor and see a dietician immediately. Take the medications if needed and focus on taking care of yourself. Managing your diabetes is like managing a long-term investment. You must be thinking years ahead and the quality of your future life depends on decisions and actions in the present.

Once I start taking these medications will I have to take them for the rest of my life? It is very possible that you may be taking many of these medications for the rest of your life but this should not be your focus. These medications are helping you to manage your diabetes and the associated risk factors. Think of these medications as a way to help you manage your wellness and avoid the long-term complications associated with diabetes. What really matters is the quality of life and these medications are often essential to helping you manage your blood sugars, blood pressure and blood fats, the risk factors associated with diabetes.

Once I start insulin am I going to gain weight like friends say? When diabetes is poorly controlled there is a large amount of glucose being excreted in the urine. When insulin is started and blood sugar control improves much of the blood sugar (calories) that was previously being excreted in the urine is now being effectively absorbed into the body tissues and as a result some people may gain weight. This only happens when excess calories are consumed so when taking insulin you should pay very close attention to your food intake, carbohydrates in particular, as well physical activity.

I’m getting plenty of physical activity but I can’t seem lose any weight and don’t know what to do? Weight loss can be very difficult and is a complex issue. Sometimes the best efforts at balancing energy output with caloric intake result in little or no success with respect to weight loss. Please keep these two important messages in mind. First of all increased muscle tone and mass can mask a reduction in fat tissue and the focus should be on how you feel with respect to energy levels. Always remember that the physical activity is helping you to lower your insulin resistance and improve blood sugar management. Secondly, there are numerous research studies that indicate ‘fat and fit’ represents a far lower risk for heart disease and stroke than someone who is thinner but is less fit. Although some weight loss is desirable and beneficial the primary emphasis of a physical activity program should be on improved fitness and a sense of well-being.

My vision is fine so I don’t understand why I need to keep going to an eye doctor? The problems that occur with the eyes associated with diabetes don’t always appear as an immediate impairment of vision. With diabetes the small blood vessels in the back of the eye can become damaged, especially when blood sugars and blood pressure are poorly controlled. This can occur before you notice any change in vision. Therefore it is important to have regular eye check-ups. If there is evidence of eye damage, laser therapy can be used to halt the progression of the damage and preserve your vision.

My cholesterol lab results are in the normal range so I don’t understand why I should take a cholesterol lowering medication? There is strong evidence that lowering the bad cholesterol, the LDL cholesterol, to levels well below the normal range can reduce heart attacks and strokes in people who have a high risk for these events, and that includes people with diabetes. In other words the LDL target is lower for people with diabetes. The family of medications that is used to lower cholesterol most effectively is the statins, and along with a heart-healthy diet and exercise, you should take your cholesterol-lowering medication if your doctor prescribes it.

My blood pressure is the same as my wife’s but she isn’t being told to take blood pressure medication? One of the reasons for this would be that blood pressure needs to be managed more aggressively in people with diabetes. There is clear evidence that lowering blood pressure below normal targets helps to reduce damage to the eyes and the kidneys, two major long-term complications associated with diabetes. Lower blood pressure can also reduce heart attacks and strokes in people with diabetes so blood pressure lowering medications are often essential as part of the treatment of diabetes.

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The Complications

Heart Disease and Stroke. The risk of developing coronary heart disease, which is the kind of heart disease that is commonest in western society and the kind that people with diabetes are particularly prone to, is very high. The risk is roughly double in diabetics when compared to the general population without diabetes. A large proportion of diabetics will present some form of arteriosclerosis, either in their heart in the form of angina, heart attack or congestive heart failure or in the circulation to the brain leading to stroke or in the circulation to the periphery leading to abnormalities of blood flow to the legs, the development of aneurisms in the abdomen and abnormalities of the blood flow to the kidneys.

The Eyes (Retinopathy). We know that about one in twenty Canadians have diabetes and even more than twice this number have it and just don’t know it. Years ago, a lot of patients used to lose eyesight from diabetes. It still happens but it happens a great deal less than it used to. The primary reason that it does not happen as much is because we are able to save a lot of patient’s eyesight by using laser treatment. Diabetes affects the blood circulation throughout the body including the small blood vessels everywhere and the eye is no exception. The eye is very much like a camera with lenses upfront and film in the back. The film that lines the back of the eye and takes pictures of what we see is called the retina. In the retina there are tiny blood vessels, arteries and veins that bring the blood to and from the back of the eye. In diabetes, the blood circulation is not as good as it ought to be and those blood vessels can close off and what can happen is new blood vessels can grow. They can cause bleeding and scarring and blood vessels can leak fluid into the center of vision, which is called the macula. The two problems that we see in diabetic eye disease are new blood vessels growing and bleeding and the blood vessels leaking fluid into the center. Both of those problems can be treated with laser, which can often cut vision loss in half. We find that if we catch patients early, while they still have pretty good vision, the laser treatment is much more effective. Therefore we really need to screen patients in advance before they have trouble with their eyesight on a routine basis, usually once a year. If they are doing well, we will see them back the next year. If they have problems, then we can do some tests to see whether laser treatment will be helpful in keeping their vision. Some of the people who take really good care of themselves can have wonderful sight for their whole lives and other people who are not as careful often lose significant eyesight.

The Kidneys (Nephopathy). In diabetes there is a very high risk for damage to the kidneys. As a result of high blood sugars and high blood pressure the small blood vessels in the kidney can become damaged and leaky. When this happens the filtering ability of the kidney is impaired and it is no longer as good at getting rid of the bad and keeping the good. One of the best ways to avoid kidney damage is to manage your blood sugars and blood pressure as best as you can. Your kidney function should also be checked by your diabetes doctor at least once a year.

The test is one that measures very small amounts of protein in your urine, and is called microalbumin. The test can be done on a urine specimen taken at any time of the day, or on one taken in the early morning. The results should be less than 2.8 mmols/mg of Creatinine in the female, and less than 2.0 in the male. Microalbumin, if present can be successfully treated by both good blood sugar control and good blood pressure control. The goal level of your blood pressure is less than 130 and less than 80 (130/80 mm Hg).

Nerve Damage (Neuropathy). In diabetes there can be progressive damage to the peripheral nerves, especially the feet and fingertips as well as the sexual organs. This can occur gradually so that many people are often unaware of the progression. One of best ways to avoid this is with good blood sugar and blood pressure management as well as regular physical activity. Nerve damage to the feet means that lesions or sores on the feet may go unnoticed and thereby become infected. The healing process is also not as rapid as it used to be. This is why you should check your feet everyday, the soles and in between the toes. Make sure any issues are dealt with.

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