Your body with uncontrolled diabetes

Dr. Tobe says he often describes high blood sugar in the blood vessels as icing sugar that is being sprayed in a room, coating everything in sight and sticking to it.

“The net result is that everything becomes brittle and more worn out and the net effect over years of having high blood sugar in the blood vessels is that everything the blood vessels touch — which is everything in our body — is more likely to become damaged.”

Potential complications from uncontrolled high blood sugar are wide-ranging. Dr. Jain, who is the primary-care representative on the project advisory committee for the Canadian Diabetes Prevention Program (C-DPP), says patients could experience eye disease, foot and leg problems, heart attack, stroke, kidney disease or nerve damage.

“It’s important to properly manage blood sugars early on to reduce the risk of developing these complications, which can be very serious or even life-threatening,” he says.

The importance of screening

“A lot of people don’t have symptoms with diabetes,” says Dr. Jain. “The goal of screening is to catch people early before damage begins.”

For the general population, Dr. Jain says screening should begin at age 40 with a blood test. He says the recommended interval for screening is every three years, although he and Dr. Tobe say patients should speak with their family doctor to determine if and when screening is appropriate.

For those with a family history of diabetes, pregnant people who had gestational diabetes, people with prediabetes or certain cardiovascular risk factors can speak with their doctor about whether earlier and more frequent screening is right for them.

And certainly reach out to your doctor if you’re experiencing increased thirst, frequent urination, blurry vision or increased fatigue because these can be symptoms of diabetes.

Managing diabetes 

A diabetes diagnosis can be overwhelming, but Dr. Tobe says patients can start with changing exercise and eating habits.

“We try to help people build up their muscle and try to keep their calories under control,” he says.

Dr. Jain says to combat that feeling of being overwhelmed, patients can take a step-by-step approach, working with their family doctor and other health-care professionals.

“It’s a journey, it’s a process, and you don’t have to fix everything overnight,” he says. “And education is key.”

Sunnybrook has a diabetes education program, SUNDEC, providing participants with individual and group education sessions and resources to help understand and manage their diabetes.

It’s not your fault

Dr. Tobe says management with nutrition and exercise may not always be enough for patients because diabetes is a progressive disease.

This means doctors may eventually recommend medication to help manage blood sugar levels, or a patient may find themselves crossing the threshold from prediabetes to diabetes. And while it might feel like a failure, Dr. Tobe cautions against that mindset.

“We don’t want [patients] to feel like a failure,” he says. “Some people are just more genetically predisposed. If, unfortunately, despite all your best efforts you’ve crossed that threshold, it’s not your fault. But you must help yourself from progressing further and prevent the downstream complications.”

*Statistic from Diabetes Canada

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Along with these dietary changes, many also wonder if they should choose lower fat milk, avoid fried foods or opt for margarine over butter. While choosing foods containing lower levels of fats won’t directly improve blood sugar levels, this can help protect and improve heart health. That’s important because people living with diabetes may be at risk of developing heart disease up to 15 years earlier compared to people who don’t have this condition. Here are some of the reasons why:

Gender
In Canada, women with diabetes are 4 times more likely to develop heart disease due to its connection with hormonal levels during menopause, as diabetes cancels out the protective effect that estrogen provided.

Insulin resistance
Insulin resistance plays a role in the development of diabetes and prediabetes. Insulin is the hormone in our bodies that regulates energy or glucose, and resistance happens when the cells in your muscles, fat and liver don’t respond properly. Over time, your blood sugar levels go up because your body isn’t able to use glucose from your body for energy. Insulin resistance plays a role in the development of plaque in the arteries. If plaque builds up too much, it can lead to blocking the blood vessel, significantly increasing the risk of heart attack or stroke.

Unhealthy cholesterol levels
Diabetes can increase the risk of “bad” cholesterol in the body, and lower the “good” cholesterol, which in turn can increase the risk of stroke and heart disease.

High blood pressure
Many people with type 2 diabetes also have high blood pressure, also known as hypertension. There are likely many factors contributing to both conditions including obesity, a diet rich in fat and salt as well as inactivity.

Inactivity
Physical activity is important for overall general health, and may be especially important if you have diabetes. It can help maintain a healthy weight, keep the heart strong and reduce insulin resistance.

Increased body weight
Insulin therapy can lead to weight gain, as insulin promotes fat storage in the body. In turn, being overweight or obese means your heart has to work harder to do its job, increasing the risk of heart disease and other cardiac complications.

Ways to protect your heart

When it comes to diabetes there are many ways to protect your heart, such as having regular check ups with your doctor or endocrinologist to monitor your blood pressure, cholesterol and blood sugar A1C to get these levels into health ranges. The target ranges for blood pressure and cholesterol are much lower for people with diabetes, and similar to targets for someone who has already has had a heart attack or stroke. It’s also important to not smoke, and to take any medications as directed.

Coming back to diet, it plays a critical role. Worldwide, diets low in fruits and vegetable are major contributors to the risk of developing diabetes and heart disease, and nutrition therapy is an integral part of managing both conditions together. Generally, avoid processed foods as they are normally high in salt, sugar and saturated fat. Opt for fresh fruits, vegetables, legumes, beans, lentils, nuts, whole grains and lean proteins, while limiting alcohol intake. Be sure to reach out to your diabetes care team for more information and direction.

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Chris Mueller – nurse practitioner in the Outpatient Leukemia Clinic

Chris Mueller.

As a nurse practitioner in Sunnybrook’s Outpatient Leukemia Clinic, Chris Mueller works with patients and families at very difficult times in their lives.

“I get to know patients very well,” says Chris, who notes that close surveillance is critical as patients with acute leukemia and lymphoma can become ill very quickly. “We are always assessing for complications of chemotherapy, particularly infectious signs and symptoms. If a patient who is immunocompromised develops a fever, we provide rapid assessment and start them on antibiotics to help avert serious complications.”

The clinic is nurse practitioner-led, providing chemotherapy and transfusions, as well as diagnosis and care for any complications that may arise from a patient’s illness. Patients range from young adults to seniors and experience a range of outcomes from cure to palliative care.

The model of care places an emphasis on team collaboration and communication. If a patient heads to the Emergency Department and is clinically stable, prompt communication between the two areas allows the patient to move quickly to the clinic. Chris notes the improved access to care helps boost patient satisfaction as well as clinical outcomes.

Chris and her nurse practitioner colleague work closely with the registered nurses on the unit to understand each patient’s personal health journey. For Chris, one of the most impactful parts of her role is seeing the interactions between patients and their families.

“I am so grateful to see incredible acts of love between people that I would not ordinarily get to experience in my everyday life. Patients and their families can be incredibly resilient in the face of great stress,” says Chris. “I aspire to have as much strength, resolve, and courage as our patients and families do.”

Carolyn Lawton – diabetes nurse practitioner

Carolyn Lawton.

Ask Carolyn Lawton what she loves about her role as a nurse practitioner and she struggles to narrow it down.

Carolyn admits she finds it gratifying using her specialized knowledge to educate patients and families about their diabetes care plan. She also gets very excited about the explosion of technology and medication in the area of diabetes.

“I’ve seen the leaps and bounds that diabetes care has recently made with treatment and technology,” says Carolyn, who has worked in her role as nurse practitioner since 1996. “There’s an ever-expanding toolkit of diabetes medications. It’s exciting but also comes with the responsibility of ensuring you’re providing the right drug and the right technology to the right person.”

One out of every five patients admitted to Sunnybrook has diabetes. People living with diabetes have longer hospital stays and are more likely to be readmitted than those without the condition. On top of this, surgical site infections are linked to blood glucose results that are above the 5-10 mmol/L guidelines.

The role of Diabetes Nurse Practitioner was created to improve outcomes and address these realities. Research has shown that a nurse practitioner with specialized training is associated with patients’ greater use of insulin therapy, meaning lower mean blood glucose levels.

Carolyn spends her days between inpatient units and outpatient diabetes clinics, helping identify and limit factors which may interfere with safe, high quality diabetes care. She’s an active member of the Diabetes Champion Group which drives best practice at the unit level and also works with the Sunnybrook Diabetes Education Program (SUNDEC) and the Rapid Assessment Diabetes and Referral Program (RADAR), which follows highly complex patients in an outpatient setting.

Carolyn recently read hockey player Max Domi’s autobiography; Max lives with diabetes.

“He speaks about “no days off,” the pressure of always making the right choices. I think as health care professionals we understand, and know this is a heavy burden to carry,” says Carolyn, who adds there’s a need to study new diabetes technology to see how it impacts patients’ quality of life.

Aimee Santoro – high risk obstetrics nurse practitioner

Aimee Santoro.

Having a high risk pregnancy can be incredibly stressful for women and their families. At Sunnybrook, a nurse practitioner role is helping to reduce emergency department visits by providing personalized care and patient advocacy.

Aimee Santoro spends her days with women who are pregnant and may have kidney disease, a history of preterm birth, a pregnancy complicated by genetic or chromosomal problems, high blood pressure, preterm delivery or be carrying multiples.

Each year, Sunnybrook’s high risk obstetrics clinics have roughly 15,000 patient visits. Aimee’s days are often dotted with difficult conversations.

“I’m at ease spending time with women who have difficult news to process and supporting their decision-making,” says Aimee. “I take the time to help women and their families understand, in layperson’s terms, what they’re facing.”

Aimee has spent 17 years in the field of high risk obstetrics. A critical part of her role is early intervention, before a woman makes the decision to visit an emergency department when concerned about a complication.

“Patients call me with questions and concerns. Many are on the verge of heading to an emergency department; they’re experiencing high blood pressure or having spotting or symptoms of urinary tract infections,” explains Aimee.

She acts quickly by ordering labs and arranging an ultrasound for these women, so women avoid an emergency visit and instead receive care from a clinical team familiar with their health journey. Aimee is also co-leading a research project into early screening for preeclampsia, with the goal of improving detection and subsequent treatment for women.

Aimee is quick to add how much she enjoys working with the entire team, including the maternal fetal medicine specialists, to problem solve.

“My work is incredibly satisfying,” says Aimee. “Not only do I really enjoy caring for women and their families to ensure they have the best outcomes, but I am always learning something new in an exciting field.”

Photography by Kevin Van Paassen

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Nicholas Durand, D.Pod.M., foot specialist at the Sunnybrook Centre for Independent Living (SCIL), says that people with circulation issues from stroke, heart disease, and diabetes to name a few, are especially at risk of issues including infections, if their feet are neglected.

Self-treatment with corn removal plasters and blades can often make simple problems much worse!

So what to do?

Use a reputable service

If you choose to get a pedicure, use a service that you have had a positive experience with before, or one that comes recommended from a trusted source.

Use a service with good hygiene practices

Use a pedicure service that practices good hygiene (frequent hand-washing, wiping down of surfaces, disinfecting of instruments).

Pack your bag

Take along your own dedicated, cleaned instruments.

Say no to sharp tools

Make sure the pedicure service does not use sharp instruments or dig at your nails or feet.

Time to see a medical professional?

If you experience foot or leg pain, pain in the calf when walking, swelling in the leg and foot, or see sudden colour changes in the foot, or have a sensation of coldness, it may be best to see a registered chiropodist or podiatrist. These medically trained practitioners identify, treat and manage safely and cleanly, simple to complex foot conditions.

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From drowsiness to muscle aches, all medications have side effects. But researchers suggest searching the web could be the culprit for triggering these side effects, not the medication itself, according to a new study from Sunnybrook Health Sciences Centre.

In the study published online in the International Journal of Cardiology, researchers reviewed patient intolerance to statins – a common cholesterol-lowering drug – in 13 countries across five continents. They then compared the recorded intolerance rate to the availability of websites that discuss the adverse effects of statins through the country’s Google search engine.

“English-speaking countries – United States, United Kingdom, Canada and Australia – had the largest number of websites about side effects and the highest rate of statin intolerance,” says Dr. Baiju Shah, senior investigator of the study and an endocrinologist at Sunnybrook Health Sciences Centre; compared to countries like Poland, Brazil, Japan and Germany that had a much lower prevalence.

The results could be an indicator of the nocebo effect at work, the study reports.

Considered to be the evil twin of the more familiar “placebo effect,” the “nocebo effect” is where negative expectations of a treatment lead to negative effects from that treatment.

“If, for example, someone reads online about adverse muscle effects related to statins, they may be more likely to notice and attribute any muscle pain they’re feeling to their prescribed statin and stop taking them,” says Dr. Shah. “This could be dangerous.”

Through his clinic, Dr. Shah treats patients with Type 2 diabetes, many of whom take statins to reduce their risk of heart disease and stroke.

“Muscle pain is one of the most common complaints from people taking statins,” he says. “But most randomized controlled studies of statins indicate that muscle pain develops only slightly more often in people taking statins as it does in those taking a harmless sugar pill.

“The benefits of statins in people at risk for heart disease are proven, so patients may be missing out on these life-saving benefits simply because of perceived side effects.”

This doesn’t mean side effects should be ignored.

Karen Lam, a pharmacist at Sunnybrook, suggests ruling out other causes of these side effects, including potential interactions with other medication, food, or supplements, before assuming the medication itself is to blame.

“Grapefruit, for example, can interfere with the body’s ability to break down certain medication,” says Lam. “This can cause medication to build up and lead to toxic side effects.”

Taken with some types of statins, grapefruit can increase the risk of side effects such as muscle damage.

“When choosing to take or not take any prescribed medication, you should always speak with your health-care professional and weigh the risks with the benefits,” says Lam. “Especially when those benefits can save your life.”

If you are taking medication, speak with your pharmacist about what medications, foods or herbal remedies may interact with the ones you are taking.

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Who is at higher risk?

“Individuals with diabetes, and unfortunately more often, older individuals who are newly diagnosed with Type 2 have a higher risk of foot problems that can result in serious complications,” says Nicholas Durand, D.Pod.M., foot specialist, at Sunnybrook’s Centre for Independent Living (SCIL).

‘Tingling’ in the foot

Neuropathy or damage to the nerves causes numbness or reduced nerve stimulation to the muscles often in the lower extremities. Add to this, vascular issues or reduced circulation within large blood vessels, or smaller, perfusion vessels that carry blood to the skin. This slows healing and can contribute to lower immunity.

“Some patients describe the numbness, as a tingling or electric shock sensation, or a feeling that their socks are constantly bunched up under their toes,” says Durand, who collaborates with pedorthists and prosthetists at SCIL, and with diabetes care areas of the hospital including SUNDEC (Sunnybrook Diabetes Education Centre), Endocrinology, Vascular, Infectious Diseases, and Dialysis.

Individuals with Type 2 diabetes are also more prone to foot issues, because they may have other medical conditions, and unlike patients with Type 1 diabetes diagnosed at an earlier age, they have less experience monitoring the condition.

Prevention is crucial

“Preventive steps are crucial,” says Kevin Fraser, certified pedorthist, SCIL. “We educate patients about the risk factors and about the importance of frequent and thorough inspection of their feet – what to look for when examining their feet.”

“Areas of concern might be a developing callous, or an area where the skin has hardened or become red because of pressure or rubbing from their shoes or seams in their socks,” Due to reduced circulation and lost sensation, a simple blister can quickly worsen, and give rise to serious infection,” says Kevin. “We work with patients to address and help reduce pressure points on their feet by creating custom-made foot orthotics or fitting orthopedic footwear.”

“Life is busy,” adds Durand. “Sometimes it feels like it gets in the way and you may inadvertently step on glass or injure your foot in some way and not feel it. As an individual with diabetes, it is best to be aware, and be informed. Seek help and advice when you need it. Keep moving as much as possible, maintain a healthy diet, and strive to be at a moderate weight.”

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Diabetes can limit life choices when it’s not managed well, says Caplan, and good management includes many things. Staying active is important, and current guidelines call for 150 minutes of physical activity per week, or about 30 minutes per day. Healthy eating, good sleep and regular check ups are also key pillars. Caplan says improved outcomes are linked to those people who are most engaged in their own care, so don’t underestimate the power of good choices and planning ahead.

Caplan says she is often asked about how to navigate things like travelling and attending social events, and offers these helpful tips:

Travel

Rather than letting your diabetes become an excuse not to travel, remember that you often have choices when it comes to where you are going and how much you pack. It all comes down to having a plan. Before you leave:

• visit any necessary travel clinics and update your vaccinations
• consult with your diabetes team about meal planning, adjusting your medications around changing time zones, and stocking up with extra doses
• make sure you have travel insurance arranged before crossing the border
• arrange to wear proper identification (ie. MedicAlert)
• keep all medications in original packages and on your person
• stick to your routine as much as possible
• have a copy of your doctor’s note stating you have diabetes and need to travel with your medications
• inform airport security that you have diabetes and are required to carry insulin and supplies
• carry food and snacks

Attending social events

Staying socially engaged is important for overall health and wellbeing, and with some modifications and planning, there are no reasons to miss out on this aspect of your life:

• bring food items you can eat to social gatherings
• remember that it’s OK to indulge a little once in a while
• exercise that day
• eat prior to going out to prevent overeating
• share large restaurant portions with a friend or take half the serving home
• drink lots of water
• scan the buffet or menu carefully before you making your selections
• stop eating when you are full

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It’s well researched and documented that smoking cigarettes can have a bad impact on your health.

Bonnie Bristow, radiation therapist, says smoking can have much more of an affect on the body and its functions than people may realize.

“Patients and their families are sometimes surprised to hear about the ways cigarettes can affect their bodies,” she said.

Here are some of the more surprising facts:

Smoking hurts your eyes.

Smoking cigarettes doubles the risk of changes in the lens of your eye, resulting in cataracts, Bonnie says. It triples the risk of age-related macular degeneration, which is the leading cause of blindness over 65 years old. And it also increases the risk of glaucoma, another leading risk of blindness.

Smoking slows down healing.

“Oxygen is the basis for wound healing and it all begins at the cellular level,” Bonnie says. “Smoking deprives the body of the much-needed oxygen required to repair and build cells.” If you have a surgery coming up, it’s a great time to consider quitting smoking.

Smoking affects your Zzzzzzzs.

Nicotine is a stimulant. That means, while many people think it calms them down, it actually temporarily increases energy, your heart rate and breathing, and your blood pressure. Cigarette smokers can easily develop insomnia (the inability to fall or stay asleep) if they smoke close to bedtime.

“Smokers often feel more restless in the morning after having difficulty falling asleep,” Bonnie says. “The nicotine changes your natural circadian rhythm and increases your risk of sleep apnea.” Sleep apnea is a disorder where your breathing pauses and starts when you are asleep.

Smoking affects your senses, your skin and more.

Smoking dulls the sense of taste and smell. It also is one of the main causes of premature aging of the face because of the biochemical changes in the body that speed the aging process. If you smoke, you may be more susceptible to seasonal flus and colds and you have an increased risk of diabetes.

Smoking harms other peoples’ bodies: your spouse, kids and friends.

Bonnie reminds us that exposure to second-hand smoke causes more frequent and serious asthma attacks, respiratory infections and ear infections in kids. Rates of tooth decay are doubled in kids exposed to second hand smoke. Adults in contact with second-hand smoke have an increased risk of heart disease, stroke and lung cancer.

If you need help to quit smoking, check out sunnybrook.ca/quitsmoking for more resources or talk to your family doctor who can point you in the right direction. Here are some tips from a Sunnybrook social worker.

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While there is no such thing as a “diabetes diet”, healthy food options play an important role in both preventing and managing diabetes. The Glycemic Index (GI) is a way of evaluating the effect a carbohydrate food has on blood sugar levels, and can be useful in determining healthier food choices.

Experts recommend choosing low GI foods as often as possible, as they have been associated with a number of health benefits. Those include a higher fibre content, improved heart health, improvements in weight management and a slower rise in blood sugar levels. Some examples of low GI foods are legumes, low-fat dairy products, oats, wholegrain bread and many fruits and vegetables.

It can also be helpful to pair a high GI food with a low GI food. For example, eat cold cereal with almonds, or fruit and nuts together. Avoiding processed foods as often as possible will avoid the pitfalls of salt, fat and empty calories.

At the Sunnybrook Diabetes Education Centre (SUNDEC), coaches are available to help patients with diabetes reach their nutrition goals. They look at what, when and how much you are eating and help determine an individualized plan that works for each patient. If you are interested, call 416-480-4805.

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