Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada

Transcription

1 Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada Kathleen Gibson, RD CDE SLICK Dietitian September

2 Outline Facts about Diabetes What are Clinical Practice Guidelines? What are the key areas for community practice? What is diabetes? Putting it into Practice How does SLICK fit in? 2

3 Facts: Diabetes in the 21 st century One of the most challenging health problems facing the world 246 million people worldwide diagnosed in th leading cause of death in developed countries Complications heart attacks, stroke, kidney failure, amputations and blindness 380 million people worldwide projected to be diagnosed by 2025

4 Facts: Diabetes in Canada 2.4 million Canadians living with diabetes 1.9 million formally diagnosed in ,000 Canadians have undiagnosed type 2 diabetes More than 150,000 Albertans living with diabetes 6 million Canadians with pre-diabetes or at high risk of type 2 diabetes Fastest growing population segments at highest risk! Aboriginal Asian, Southeast Asian, Latin American and African Boomers

5 Facts: Economic Burden Worldwide Over $1,500 billion est. cost USA $174 billion est. direct and indirect cost Canada $17.4 billion est. economic cost

6 Facts: Direct Acute Care Costs Canada $5.6 billion est. direct costs in 2005 Estimated at $8.14 billion in in 10 hospital admissions 10% of 2,803,300 admissions in 2006 were for diabetes or diabetes-related complications This represents 10% of the annual cost of Canada s entire health care system. Includes things like: hospitalization for surgery or emergency, in-hospital medications, devices and supplies, physician and specialist visits Does not include: rehab after major surgery or amputation, personal costs to the individual or family A key finding shows that the rate of complications related to diabetes has not changed, despite increased information about the importance of management.

7 What is to be done?

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9 What are Clinical Practice Guidelines? Comprehensive, evidence-based recommendations for health care professionals to consider in the management of their clients living with diabetes. First presented in 1998, and again in 2003 and 2008 Every update includes the latest evidence related to the prevention and management of diabetes A reference tool to help translate the best available evidence into practice. Comprehensive means all-inclusive. There are 44 chapters under the following headings. Definition/Classification/Diagnoses, Screening for Type 1 and Type 2 Diabetes, Prevention of Diabetes, Management, Macrovascular and Microvascular Complications, Diabetees in Children, Diabetes in Special Populations and Appendices. The majority of the chapters fall under Management and Complications Evidence-based means based on peer-reviewed research Developed by a team of 76 expert volunteers including specialists, family physicians, nurses, dietitians, pharmacists and other health care professionals.

10 What are Clinical Practice Guidelines? Meant to help in the decision-making process But the actual treatment decisions are supposed to be individualized Client values and preferences need to be part of the decision-making process Hope that the use of these guidelines leads to better lives for people living with diabetes in Canada

11 Key Areas for our Practice Definition, Classification and Diagnosis of Diabetes (S10) Screening for Diabetes (S14) Prevention of Diabetes (S17) Management Self Management (S25) Targets (S29) Lifestyle (Physical Activity, Nutrition Therapy) (S37, S40) Pharmacological Treatments (S46, S53) Hypoglycemia (S62) Complementary and Alternative Medicine (S91) The S numbers refer to the pages in the Clinical Practice Guidelines.

12 Key Areas for our Practice - continued Complications Heart Disease (S95, S99, S102, S119, S123) Cholesterol (S107) High Blood Pressure (S115) Kidney Disease (S126) Retinopathy (or eye damage) (S134) Neuropathy (or nerve damage) (S140) Foot Care (S143) Sexual Health (S147)

13 Key Areas for our Practice - continued Diabetes in Children Type 1 (S150) Type 2 (S162) Diabetes in Special Populations Diabetes and Pregnancy (S168) Diabetes in the Elderly (S181) Type 2 Diabetes in Aboriginal People (S187) There is plenty of other information in the CPG. The CDA has developed a powerpoint that goes through each section of the guidelines and it is 261 slides long. That would be a four+ hour presentation! We are going to try to focus on the key points. Other information includes in-hospital management of diabetes, physchological aspects of diabetes, pancreas and islet transplant

14 Basic Diabetes Information When someone has diabetes, it means their body has difficulty making insulin, or has trouble using the insulin their body makes. Insulin is required to get the glucose from our blood into the body to be burned as fuel. The glucose in our blood comes from the food we eat. If the glucose stays in the blood and gets too high it can cause immediate problems. Slightly higher blood glucose levels over the long term can cause damage to the body (eyes, heart, kidneys, limbs)

15 Four terms related to diabetes (S10): Prediabetes Type 1 diabetes Type 2 diabetes Gestational diabetes Prediabetes is a new term and refers to two specific conditions that place a person at increased risk of developing full-blown diabetes. The first is call Impaired Fasting Glucose which means your blood glucose first thing in the morning is higher than it should be, but not high enough to give you diabetes. The second is called Impaired Glucose Tolerance which means that after you eat food, your body is not able to get all the glucose out of your blood and your blood glucose stays higher than it should. But again, not high enough to be called diabetes. Not everyone with prediabetes will go on to get diabetes. With some lifestyle changes it is possible to stop or reverse the pathway. Type 1 diabetes refers to people who make virtually no insulin of their own. For an unknown reason, the pancreas is unable to produce insulin and the blood glucose rises very quickly and dangerously. Type 1 represents only 5-10% of the people with diabetes. Type 2 diabetes may range from your body not being able to use the insulin you produce (insulin resistance) to your body not being able to make enough insulin. Insulin is the key in both type 1 and type 2. The difference is the pathway that happens in the body, and the speed with which it happens. Gestational diabetes refers to diabetes that happens only during pregnancy and often disappears immediately after the birth of the child. It is a form of insulin resistance, and often insulin is needed to help control blood glucose.

16 Diagnosis of diabetes (S10) FPG 7.0 mmol/l OR Casual PG 11.1 mmo/l + symptoms of diabetes OR 2hPG in a 75-g OGTT 11.1 mmol/l Fasting means no caloric intake for at least 8 hours Casual means any time of day without regard to the interval since the last meal Classic symptoms of diabetes: poydipsia (increased thirst), polyuria (increased peeing) and unexplained weight loss Oral Glucose Tolerance Test: a client is given a known amount of glucose (75 g) to eat and/or drink and their blood glucose is measured 2 hours later. Note: A confirmatory lab glucose test must be done in all cases on another day in the absence of unequivocal hyperglycemia accompanied by acute metabolic decompensation.

17 Risk factors for Type 2 Diabetes (S14) Older than 40 years old Family History Member of a high-risk population Female Gestational diabetes History of delivery of baby 9 lbs We are going to focus mostly on Type 2 diabetes, but will touch on prediabetes and gestational. This first set are things we have no control over (unless we lie about our age!). Family History refers to first degree relatives: parents, brothers, sisters and children. Does not include grandparents, cousins, aunties and uncles Gestational diabetes increases a women s risk of developing diabetes, and uncontrolled gestational increases the child s risk of getting diabetes. By 2011, 50% of Canadians will be over 40 years of age and at risk for type 2 diabetes.

18 Preventable Risk Factors (S14) Prediabetes High blood pressure High cholesterol Overweight Carrying your weight on your stomach Low physical activity levels Unhealthy eating habits These are things we have some control over. Recall that prediabetes can be controlled and perhaps reversed. And the other factors are things we can change and improve.

19 Screening for Diabetes (S14, S187) For adults with 1 additional risk factor: A FPG every 1-2 years For children 10 years old with 1 additional risk factor: A FPG every 2 years For very obese children (BMI 99.5 %ile): An OGTT every year We are going to refer to Aboriginal Clients for the rest of the presentation. Some of the targets are different for this population since it is a high-risk population. The prevalence of diabetes in Alberta is 5.3%. The prevalence of diabetes in Aboriginal people in Alberta is 11.9%. This 2006 data is from the Alberta Diabetes Surveillance System. In addition to screening, routine medical care should include identification of the preventable risk factors (overweight/obesity, elevated waist circumference/bmi, lack of physical activity, unhealthy eating habits, prediabetes) to identify higher-risk people who would benefit from diabetes prevention and individualized counselling. Individuals with normal results but with risk factor (besides Aboriginal heritage) should receive post-test counselling on promotion of healthy lifestyles to prevent diabetes. People with diagnosed prediabetes and/or polycystic ovary syndrome (PCOS) should be encouraged to have an annual OGTT. These recommendations are all at a level D, which means a consensus by the panel evaluating this information.

20 Prevention of Diabetes (S17, S188) Programs need to be culturally appropriate Focus on: Increasing awareness of diabetes Increasing physical activity Improving eating habits Achieving healthy body weights (loss of 5% of initial body weight) Creating an environment supportive of a healthy lifestyle People with prediabetes may benefit from medication to help prevent type 2 diabetes. This would be part of a community-based Diabetes Program. Prediabetes medication could include Metformin or an alpha-glucosidase inhibitor (Acarbose). So someone on metformin may not have diabetes, but is on the medication to prevent getting diabetes.

21 Management of Diabetes Diabetes care depends on the daily commitment of the person with diabetes to self-management practices (S20) This daily commitment is supported by a multidisciplinary Diabetes Healthcare Team Can include any or all of the following: Family physician, specialist, nurse, dietitian, CHR, pharmacist, social worker, SLICK team This idea of self-management is key to diabetes care. This section of the CPGs refers to Organization of Diabetes Care Involves the client, and the health care workers who help the person with diabetes and their support people manage their care. Family support is helpful to the person with diabetes. The Team should facilitate the transfer of information among all members of the team as appropriate to ensure continuity of care.

22 Self management Education (S25) Increase the client s involvement in, confidence with and motivation for control of their diabetes. A key part is self-monitoring of blood glucose, SMBG (using a glucometer, and knowing what the numbers mean) Healthy self-management behaviours include: Healthy Eating Checking blood glucose Using medications Physical Activity Smoking Cessation People with diabetes should be offered timely diabetes education that is tailored to encourage and enhance self-care practices and behaviours Places to get this education for clients: Aboriginal diabetes Wellness Program, Diabetes Education Centres as part of a hospital, Community health care workers, Empowerment is a key idea. Clients need to play an active role in their diabetes care for the best health outcomes. Places to get additional information about diabetes: Canadian Diabetes Association, Aboriginal Diabetes Wellness Program, PRIADE

23 Targets for Control (S29) Good control of blood glucose is key to managing diabetes. Good control of blood glucose can reduce the risks of complications such as heart disease. Both fasting and post-meal glucose levels can play a role in complications. When setting treatment goals, individual risk factors need to be considered: age, presence of complications, awareness of low blood glucose There have been many clinical trials related to diabetes control and its role with complications. Fasting refers to at least 8 hours without caloric intake. Post-meal refers to 2 hours after a meal. Fasting gives an indication of how your body is doing without the influence of food. Post-meal allows the Diabetes Team to know how well the body is handling food.

24 Targets for Control - continued A1C Before Meals After Meals After Meals if A1C target not met 7.0 % mmol/l mmol/l mmol/l A1C is the glycated hemoglobin and is it is a measure of how well the blood glucose has been controlled in the previous 3 months. It is related to both the fasting and the post-meal blood glucose levels. A level of < 7.0% is related to reduced complications in all people with diabetes. A1C can be measured at a lab, or by the SLICK team Before meals includes first thing in the morning (fasting). After meals is 2 hours after a meal. If you ate supper at 6pm, you would check at 8pm. Blood glucose can be measured in the lab, or with a glucometer by the client or a health care provider. But recall, these are guidelines. Individual client targets are made with the diabetes healthcare team and take into consideration the needs of the client.

25 Monitoring Blood Glucose Control (S32) A1C Every 3 months if targets are not met, and when treatment is being changed. Every 6 months if targets are regularly met and treatment is stable SMBG Needs to be individual and depends on medications used We ve talked about what to measure and what number we are looking for. Now we need to talk about when to measure. Recall that A1C is a measure of how the blood glucose has been over the previous 3 months (how long a red blood cell lives). Meeting the target helps reduce the risk of complications for all people with diabetes. Insulin alone: at least 3 times per day and include before meal and after meal measurements Diabetes pills or lifestyle alone: individualized and should include both before and after meal measurements Insulin and diabetes pills: at least once per day, at different times of the day

26 Physical Activity (S37) 1. At least 150 minutes of moderate aerobic physical activity each week. Spread over at least 3 days per week, with no more than 2 consecutive days without exercise. 2. All people with diabetes, including the elderly, should perform resistance exercise 3 times per week. 3. An exercise ECG stress test should be considered for activity more vigorous than brisk walking. One of the cornerstones of diabetes management. Moderate activity means: biking, brisk walking, continuous swimming, dancing, raking leaves, water aerobics Vigorous activity means: brisk walking up a hill, jogging, aerobics, hockey, basketball, fast swimming, fast dancing The activity should happen for at least 10 minutes at a time. Resistance exercise means activities that use muscle strength to move a weight or work against a resistant load. Often refers to weight lifting or using resistance bands. This area requires initial instruction and periodic supervision from someone with expert skills. This could be an exercise specialist, physiotherapist, occupational therapist. The stress test is important in people who were previously sedentary (didn t move much) and who are at high-risk for heart disease. If the plan is for walking, a stress test is not required.

27 Nutrition Therapy (S40) Nutrition counselling by a registered dietitian, in either small group or one-on-one setting. Follow Eating Well with Canada s Food Guide. Maintain regular timing and spacing of meals. Consistency with starchy foods is helpful Choose foods with a low glycemic index. Caution is needed when taking insulin and using alcohol. Another cornerstone of diabetes management. Following a healthy eating plan can drop A1C by 1-2%. Eating Well with Canada s Food Guide is the key piece for health eating for all Canadians, including those with diabetes. There is no diabetes diet. Low glycemic foods tend to be higher in fibre. Teaching about glycemic index depends on the individual s interest and ability.

28 Medications in type 2 diabetes (S53) If targets are not met using lifestyle within 2-3 months, medication should be started. If the A1C >9.0% at diagnosis, medication(s) should be started along with lifestyle changes. Often more than one medication is needed to reach target A1C. This target should be achieved in 6 to 12 months. Metformin is often the first medication started. Basal insulin can be used along with oral medications. The earlier targets can be met, the better it is for the long term success of the client. Recall that nutrition can decrease an A1C by 1-2% The medications drop the A1C at different rates. Metformin can also drop A1C by 1-2%. Any client using insulin or insulin secretagogues should be informed about hypoglycemia.

29 Hypoglycemia (S62) Means a blood glucose < 4.0 mmol/l Can be caused by medications for clients with type 2 diabetes Treat a low blood glucose with 15g of carbohydrate (3 glucose tabs, 4 dextrose tabs, 3 tsp of sugar mixed with water, 175 ml regular pop), wait 15 minutes and check blood glucose again. Retreat if necessary. If the next meal is > 1 hr away, a snack can prevent a repeat low blood sugar. Important not to over treat a low blood sugar. Prevents a rebound swing to a blood glucose that is too high. The symptoms can include trembling, sweating, anxiety, hunger, nausea, confusion, weakness, vision changes, difficulty speaking, headaches, sizziness

30 Influenza and Pneumococcal Immunization (S86) People with diabetes should receive an annual influenza vaccine. People with diabetes should be considered for vaccination against penumococcus. People with diabetes, especially with kidney or heart complications are at high risk for complications from influenza and pneumococcal disease. The vaccination can reduce hospitalizations by up to 40%.

31 Complementary and Alternative Medicine (S91) Up to 30% of people with diabetes use complementary and alternative medicine for various issues. Potentially serious problems Not enough evidence regarding safety and efficacy. Clients with diabetes should be routinely asked if they are using complementary and alternative medications. Includes herbal medications, dietary supplements, minerals, vitamins and other micronutrients Issues with potential side effects with physician prescribed medications. Possible harm from some herbal remedies. Studies on complementary and alternative medicines are often small, and of short duration. If a client chooses complementary medicine over Western medicine, it is important to still check all the targets for diabetes management to know if it is working and not harming the client. Remember that diabetes management is focused on the client, and the client has the right to choose. It is our job to make sure they have all the information to make the best choice.

32 Heart Disease Complications of Diabetes Kidney Disease Eye Disease Amputations These are the main complications of diabetes. Because Type 2 diabetes can be slow progressing, people may already have some complications when they are diagnosed. First Nations people in Canada have both high rates of diabetes and its complications.

33 Complications Prevention (S102) Step 1. Vascular protection Step 2. Treat high blood pressure Step 3. Protect the kidneys Protect the heart is the top priority. Can protect against both macrovascular and microvascular events. Macrovascular refers to large blood vessels and an event would be cardiovascular disease, heart attack, stroke Microvascular refers to small blood vessels and is related to kidney disease, eye disease and issues with the feet.

34 Heart Disease People with diabetes develop heart disease years earlier than someone without diabetes. The following individuals should be considered high risk: Men 45 years and Women 50 years Men < 45 years and Women < 50 years with more than 1 of: Exisiting heart disease, kidney disease, eye disease, family hx, extreme single risk factor, diabetes > 15 years with age >30 years Assessment for heart disease risk should include: Smoking, physical activity, nutrition, duration of diabetes, sexual function history, waist circumference, lipid profile, blood pressure, glycemic control, kidney function, periodic ECGs E.g., LDL > 5.0 mmol/l, SBP > 180 mm Hg

35 Heart Disease - continued Baseline resting ECG should be performed in: All people > 40 years All people with duration > 15 years All people with high blood pressure, kidney disease and/or reduced pulse A repeat resting ECG should be done every 2 years in people considered at high risk for heart disease.

36 Heart Disease - continued Vascular protection (S102) for all people with diabetes: Lifestyle modification (healthy body weight, healthy diet, physical activity, smoking cessation) Optimize blood pressure control (< 130/<80) Optimize blood glucose control (A1C 7.0%) For people at high risk: ACE inhibitor or ARB therapy Low dose aspirin Lipid-lowering medication (LDL <2.0 mmol/l, TC:HDL < 4.0) Primary target for blood pressure for people with diabetes is <130/80 Blood Glucose targets A1C <= 7% Dylipidemia targets: LDL-C <2.0 mmol/l, secondary target of TC:HDL ratio < 4.0 Can only determine LDL if person is fasting for at least 9 hours. Smoking and gum chewing is not fasting. Only sips of water can be taken.

37 Heart Disease - continued Lipid (S107) Fasting lipid levels should be measured at diagnosis and then every 1-3 years. More frequent testing is needed if someone is on medication for lipids (at least once per year). Blood Pressure (S115) People with diabetes and high BP should be aggressively treated to reach the target of <130/80 mm Hg. This may require more than one medication.

38 Kidney Disease Chronic kidney disease is one of the most common and devastating complication of diabetes. Fifty percent (50%) of people with diabetes have kidney disease. Kidney disease from diabetes is one of the leading causes of kidney failure in Canada. Screening for kidney disease: at diagnosis of diabetes and once a year afterwards.

39 Kidney Disease - continued What is screening? Urine dipstick for protein: screens for other kidney disease Random Albumin to Creatinine Ratio (ACR): screens for the presence of very small proteins in the urine. Men < 2.0 mmol/l Women <2.8 mmol/l Estimated Glomerular Filtration Rate (egfr): serum creatinine, age, gender If the ACR is elevated beyond the targets, 2 repeat ACRs need to happen within the next three months. ACR can be elevated by other things: recent major exercise, fever, urinary tract infection, congestive heart failure, menstruation, severe high blood pressure, extremely high blood glucose. People with diabetes and chronic kidney disease should have an ACR done every 6 months.

40 Kidney Disease - continued To prevent the onset, and delay the progression: 1. Best possible control of blood glucose 2. Best possible control of blood pressure Using an ACE inhibitor or ARB, has been shown to protect the kidneys. Targets are the same for all people with diabetes! A1C < 7.0%, BP<130/80 mm Hg Even without evidence of elevated blood pressure! You may have a client on an ACE or an ARB who does not have high blood pressure, but may show signs of kidney disease.

41 Eye Disease (S134) Diabetic retinopathy is the most common cause of new cases of legal blindness in people of working age. An estimated 2 million people in Canada have some form of diabetic retinopathy (just about everyone with diabetes!). Vision loss is associated with a 4-fold increase in early death.

42 Eye Disease Screening (S134) When: At diagnosis for all people with type 2 diabetes. If retinopathy is not present, rescreen annually. How: Gold standard is 7-field stereoscopic colour fundus photography with interpretation by a specialist. Direct ophthalmoscopy through dilated pupil Because the burden of diabetes is higher in Aboriginal peoples, it is recommended that the screening happen annually. Gold standard means the best! Direct observation can happen with an ophthalmologist or an optometrist. A few optometrists now have cameras in their offices, but most are not trained to the gold standard method.

43 Eye Disease Prevention (S135) 1. Best possible control of blood glucose 2. Best possible control of blood pressure 3. Best possible control of lipids Seems familiar! In people with Type 1, good control meant a 76% reduction in the onset of eye disease. For people with Type 2, high blood glucose is an independent risk factor in the onset and progressions of retinopathy. Treatment of Retinopathy includes: Laser therapy surgery

44 Nerve Damage (S140) Detectable nerve damage will develop within 10 years of diagnosis in 40 to 50% of people with diabetes. Risk factors for nerve damage and pain are exposure to: high blood glucose high triglycerides overweight/obese, Smoking high blood pressure Under-diagnosis is a fundamental problem in the primary care of people with diabetes.

45 Nerve Damage Screening (S140) At diagnosis and then annually. Done using a 10-g Semmes-Weinstein monofilament or a 128-Hz tuning fork. (S199) Assessing the loss of sensation on the top and bottom of the foot. May include reflexes and assessment of pedal pulses Decreased sensation can lead to foot damage, ulceration, infection and eventual amputation Best measure of prevention? Best possible control of blood glucose!

46 Foot Care (S143) Foot problems are a major cause of illness and death in people with diabetes. Foot problems contribute to increased healthcare costs. Foot examinations should be done by the individual daily and healthcare providers at least annually. Range of motion, callus pattern, bony deformities, skin temperature and sensation testing. People at high risk for foot ulceration and amputation should receive foot care education, professionally fitted footwear, smoking cessation strategies and early referrals to specialized care. Any infection must be treated aggressively.

47 Sexual Health (S147) Erectile dysfunction affects 34 to 45% of men with diabetes. Risk factors: Increasing age Duration of diabetes Poor control of blood glucose Smoking High blood pressure Poor control of lipids Cardiovascular disease ED can negatively affect quality of life for those affected, regardless of age. Men should be regularly screened. There are validated questionnaires that are sensitive and specific are listed in the CPGs. Women are affected by increased urinary tract infections, yeast infections, vaginal dryness. Best first step: best possible control of blood glucose.

48 Type 2 in Children and Adolescents (S162) Increasing in frequency over the past 20 years, especially in high risk populations. Risk factors: Family history Overweight Impaired glucose tolerance Polycystic ovary syndrome, acanthosis nigricans Exposure to diabetes in utero High blood pressure High blood lipids Family history is a first degree or second-degree relative: mother, father, sister, brother; grandparents, aunts, uncles Impaired glucose tolerance how your body handles the meal Mother had gestational diabetes Recall screening is for age>10 years, FPG every 2 years.

49 Type 2 in children Management: Healthy eating Physical activity Attain a healthy body weight Family counselling Medications (metformin or insulin) Screening targets and frequency are the same as for adults with type 2 diabetes At diagnosis and annually thereafter

50 Diabetes and Pregnancy (S168) Pre-existing diabetes Best possible control of blood glucose before conception Pre-pregnancy: A1C: 7.0% During pregnancy A1C: 6.0% Fasting and before meals: mmol/l 1 hour after a meal: mmol/l 2 hours after a meal: mmol/l Targets are much stricter to prevent harm to the fetus.

51 Gestational Diabetes Onset happens during pregnancy. Screening between 24 and 28 weeks gestation. Initial screen is with a 50-g glucose load and blood glucose check 1 hour later. If positive (between 7.8 and 10.2 mmol/l), then a 75-g OGTT is done. If >10.3 mmol/l, then gestation diabetes

52 Gestational Diabetes - continued Gestational diabetes is diagnosed if 2 of the following values are found on the OGTT. If only one is met, then Impaired Glucose Tolerance of pregnancy is diagnosed. Fasting blood glucose 5.3 mmol/l 1 hour blood glucose 10.6 mmol/l 2 hour blood glucose 8.9 mmol/l Once diagnosed, the targets are the same as for women with pre-pregnancy diabetes.

53 Gestational Diabetes- continued During pregnancy A1C: 6.0% Fasting and before meals: mmol/l 1 hour after a meal: mmol/l 2 hours after a meal: mmol/l Test blood glucose at both before and after meals (4 times a day) If targets are not met within 2 weeks using nutrition alone, then insulin should be started. Targets are much stricter to prevent harm to the fetus.

54 Postpartum All mothers should be encouraged to breastfeed. Gestation Diabetes OGTT 6 weeks and 6 months postpartum. Follow screening for diabetes guidelines. Get screened for diabetes when planning next pregnancy.

55 How can SLICK fit in? Complications Screening Team (mobile and communitybased) Screen for: Blood Glucose Control (A1C, blood glucose) Cardiovascular (blood pressure, lipids, lifestyle counselling) Kidneys (urine dipstick, ACR) Eyes (visual acuity, gold standard photographs) Nerves (sensation testing) We do not screen for diabetes! Our clients are to have a diagnosis of diabetes. We can be a component of a community diabetes program, but we are not THE program. The mobile teams are attempting to visit each community twice a year. But the A1C should be measured q 3 months. So clients need to be followed by their doctors or nurse practitioner or primary care network.

56 Questions? Discussion?