2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S2
population will increase the burden of diabetes over the next
10 years. Researchers project an increase of diagnosed diabetes
in Canada to 2.4 million by the year 2016 (5).
The rate of diagnosed diabetes contributes significantly to
comorbidity and diabetes complication rates. Diabetes is the
leading cause of blindness, end-stage renal failure and nontraumatic
amputation in Canadian adults. Cardiovascular disease,
the leading cause of death in individuals with diabetes,
occurs 2- to 4-fold more often compared to people without
diabetes.Approximately one-quarter of Canadians living with
diabetes are also diagnosed with depression, and the combination
of diabetes and depression is associated with poor
compliance with treatment and increased healthcare costs
(6,7). Eleven percent of Canadians living with diabetes also
have 3 or more chronic health conditions, and compared to
the general population, they are 4 times more likely to be
admitted to a hospital or a nursing home, 7 times more likely
to need home care and 3 to 5 times more likely to see a
healthcare provider (8).
Diabetes and its complications increase costs and service
pressures on Canada’s publicly funded healthcare system.
Because of poor compliance to evidence-based recommended
management regimens, diabetes and its complications
significantly contribute to the cost of primary healthcare,
and add to waiting times for treatment in emergency departments
and surgeries. Research indicates that 280 330 admissions
into Canadian acute care hospitals in 2006 – or 10% of
all such admissions – were related to diabetes or its complications
(9,10).
Caution is required when identifying direct, indirect and
induced costs for treating diabetes, given the differing estimates
by different researchers (11-15). Nonetheless, in 2005,
federal, provincial and territorial governments spent an estimated
$5.6 billion to treat people with diabetes and its complications
within the acute healthcare system (5).This amount,
equal to 10% of the annual cost of Canada’s healthcare system,
includes the cost of hospitalization for surgical and emergency
care, in-hospital medications, devices and supplies, as well as
physician and specialist visits. It does not include the costs of
rehabilitation after major surgery or amputation, or the personal
costs to the individual and family (e.g. a parent’s inability
to pay for a child’s higher education).
Moreover, the trend of increased hospitalization has gone
unchecked in the last 5 years. In Ontario, for example,
research shows that little has changed in the rate of complications
due to diabetes. Data analysis shows that approximately
4% of newly diagnosed diabetes patients end up in an emergency
department or hospital for acute complications of their
condition (16).The lack of change in the rate of complications
suggests that despite the increasing evidence about the importance
of managing diabetes effectively, little progress has been
made in ensuring that people living with diabetes get the recommended
care, education and management required to
lower their risk of developing complications.
PREVENTION OF TYPE 2 DIABETES
Prevention of type 1 diabetes has not yet been successful;
however, the evidence indicates that preventing or delaying
the onset of type 2 diabetes results in significant health benefits,
including lower rates of cardiovascular disease and renal
failure; ~30 to 60% of type 2 diabetes may be prevented
through early lifestyle or medication intervention (3).
The modifiable risk factors for type 2 diabetes are well
known. By 2011, more than 50% of Canadians will be over
40 years of age and at risk for type 2 diabetes. Our lifestyles
today contribute to unhealthy eating and physical inactivity.
In 2005, 2 of 3 Canadian adults and nearly 1 of 3 children
aged 12 to 17 years were overweight or obese (17), and are
therefore at high risk of developing type 2 diabetes.
The Diabetes Prevention Program found that people at
risk of developing type 2 diabetes were able to cut their risk
by 58% with moderate physical activity (30 minutes a day)
and weight loss (5 to 7% of body weight, or about 15 lb). For
people over age 60, the risk was cut by almost 71% (18).
There remains an urgent and increasing need for governments
to invest in research to define effective strategies and
programs to prevent and treat obesity and to encourage
physical activity. Health promotion and disease prevention
strategies should be tailored to specific populations, and
should include policies aimed at addressing poverty and
other systemic barriers to health.
ADVOCACY AND OPTIMAL CARE
Effective diabetes care is supported by evidence-based clinical
practice guidelines; regular monitoring of blood glucose,
blood pressure and cholesterol levels; and ongoing feedback
among all members of the diabetes health team to lower the
risk and potential impact of serious complications for individuals
with diabetes. Government investments in chronic
disease management approaches offer an interdisciplinary
approach recommended for effective diabetes care. A team
of healthcare professionals – including physicians, nurses,
diabetes educators, pharmacists and other healthcare experts
who work together with the individual living with diabetes –
is the recommended approach to achieve optimal care.
One of the key challenges of the chronic disease management
approach for individuals living with diabetes is the
greater level of self-management required in order for this
approach to be effective. People with diabetes are asked to
have the skills and abilities to reduce the physical and emotional
impact of their disease, with or without the collaboration
of their healthcare team. There is no question that
self-management skills complement the expertise and care
provided by members of the diabetes health team; however,
the chronic disease management model is a paradigm shift
from the traditional primary or acute care model. People
with diabetes require training in goal setting, problem solving
and planning skills, all of which are critical components
of self-management. They also need access to a broad range