Managing Diabetes. ad# Could My Pet Have Diabetes? Behind the Wheel. A New Class of Medications FEATURE REPORT COPY YOUR FREE

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1 FEATURE REPORT Managing Diabetes Could My Pet Have Diabetes? Protect the health of your furry friend Behind the Wheel Diabetes and driving A New Class of Medications Advancements in diabetes management ad# FALL/WINTER 2015 YOUR FREE COPY

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3 FEATURE REPORT Managing Diabetes The articles published in the Family Health Feature Report: Managing Diabetes are for the general information of the reader. While effort is made to reflect accepted medical knowledge and practice, articles should not be relied upon for the treatment or manage ment of any specific medical problem or concern. Neither Family Health nor Safeway Pharmacy Operations accept liability for reliance on the articles. For proper diagnosis and care, you should always consult your physician promptly. Editorial Contributors to this Feature Report Janet Allsopp, RN, BScN, CDE Melissa Dash, BSc, BSP Michael Fife, DVM Catherine Freeze, M Ed, RD, CDE Audrey McLelland, BSc (Pharm), CDE Michelle Sorensen, M.Ed Medical Advisor Colin MacDonald, MD, FRCP (C) Safeway Health Care Consultants Kelly Gasmen Winnipeg (204) Shauna Nowakowski Saskatoon (306) Rose Marie Boychuk Calgary (403) Donna Hansen Calgary (403) Ana Maria Trotter Calgary (403) Caralee Robinson Edmonton (587) Tanya Zenner Edmonton (587) Jasvir Bhupal Surrey (604) Sarvjit Dhami Vancouver (604) Pharmacy and Diabetes Advisors Stacy Johnson, BSc. (Pharm) Dinah Santos, BSc (Pharm), CDE ISSUE #32 FALL 2015 Magazine Staff Publisher and Executive Editor Robert W. Clarke Editorial Consultant Diane Cruikshank Administration Jan Crouch Layout, Design and Copy Editing Tilt Creative: Joni Millar, Jillian Millar Drysdale Managing Diabetes is a feature report of Family Health, a special publication of Edmonton Journal, a division of Postmedia Network Inc st Street, Edmonton, AB T5J 2S6 Telephone Fax (780) REMEMBER TO RECYCLE 4 ADVANCES IN MANAGING TYPE 2 DIABETES Could new medications help you? 8 IS IT SAFE TO BE BEHIND THE WHEEL? Driving and diabetes 12 THE EMOTIONS OF DIABETES DIAGNOSIS Grieving and acceptance 16 BLOOD GLUCOSE METER COMPARISON CHART Check out what's on the market 19 SYRINGES, PEN NEEDLES AND INSULIN COMPARISON CHART Options available for you 20 HEMP HEARTS A simple way to add fibre to your diet 22 TYPE 1.5 DIABETES Could you have LADA (Latent Autoimmune Diabetes in Adults)? 24 DIABETES AND CELIAC DISEASE Understanding the connection 27 COULD MY PET HAVE DIABETES? Protect the health of your furry friend 30 INSULIN TYPES Choices available at your Safeway pharmacy Dear Customer; contents Diabetes care is always evolving. Though the basics of healthy nutrition, physical activity and self-care are always important, we continue to find better ways to understand and control this condition. In this issue of Managing Diabetes, you will find an update on the latest advances in diabetes care. Learn about latent autoimmune (type 1.5) diabetes, and the connection between diabetes and celiac disease. Consider the emotions that might arise from a diabetes diagnosis, and what signs might warn that it is not safe for someone with diabetes to drive. You'll also discover recipes for hemp hearts that will help you enjoy them. Finally, learn about how diabetes could affect your pet cat or dog and how veterinarians treat it. It s good to know new ways to effectively manage diabetes are continually being discovered. As always, we at Safeway Pharmacy are here to help. Yours in great health, Angie Wierzbicki letter to our customers Angie Wierzbicki, BSc(Pharm), MBA Vice President Safeway Pharmacy Operations Printed by Mitchell Press, Burnaby B.C. ISSN READ PAST ARTICLES FROM MANAGING DIABETES ON THE 'WELLNESS CENTRE' AT M A N A G I N G D I A B E T E S F A L L / W I N T E R

4 Advances in Managing TYPE 2 DIABETES Diabetes is on the rise in Canada. Close to two million Canadians are thought to have type 2 diabetes. More than 60,000 new cases are diagnosed each year. Type 2 diabetes affects the way the body processes and uses glucose (sugar). Glucose is an important source of energy. Insulin helps glucose move into the body s cells, where it can be used. In type 2 diabetes, the body does not make enough insulin or the body cannot effectively use the insulin that it does make. When the body does not use insulin effectively this is called insulin resistance. If glucose cannot move into the cells, it builds up in the blood stream. This leads to hyperglycemia (high blood glucose). Health risks related to type 2 diabetes Having high levels of glucose in the blood over a long period of time can lead to complications. These include: blindness heart disease reduced blood supply to the limbs nerve damage stroke and problems with erections (erectile dysfunction). Reducing the risk Your actions play a role in preventing and managing diabetes. Risk factors for type 2 diabetes are divided into those that can and cannot be changed. Those that can be managed include: obesity high blood pressure (hypertension) high cholesterol physical inactivity and smoking. Risk factors that cannot be changed include: being over age 40 M A N A G I N G D I A B E T E S 4 F A L L / W I N T E R

5 SGLT2 inhibitors Forxiga Jardiance Invokana dapagliflozin Canagliflozin empagliflozin Could new medications help you? a family history of diabetes a history of gestational diabetes (a type that appears only during pregnancy) schizophrenia being a member of a high-risk group (Aboriginal, Hispanic, South Asian or African descent). Symptoms and diagnosis Some symptoms of type 2 diabetes are: fatigue frequent passing of urine and unusual thirst. However, many people with type 2 diabetes may not have any symptoms. They are often diagnosed when seeing a doctor for an unrelated concern. The A1C blood test is commonly used to diagnose and monitor diabetes. This test measures the percentage of hemoglobin (a protein in red blood cells) that is coated with sugar. It gives an average of your blood glucose levels over the past three to four months. Goals of therapy A1C is an important measure. It shows how well your diabetes treatment plan is working, and whether changes are needed. The A1C test can gauge how well blood glucose control goals are being met and maintained, and is recommended every three months. The Canadian Diabetes Association has set recommended A1C targets for blood glucose control. For most people who have type 1 or 2 diabetes, therapy aims to achieve an A1C of less than or equal to seven per cent. Medications Standard therapy combines lifestyle changes with insulin and oral medications (called anti-hyperglycemic agents) to lower blood glucose. Metformin (Glucophage) is usually the first medication prescribed, unless there are reasons it should not be used. Newly diagnosed people who have elevated glucose or A1C levels may also use insulin with or without other medications. If A1C goals are not achieved within three to six months, other oral medications may be added. A new option - SGLT2 inhibitors The kidneys play an important role in reabsorbing glucose so it can be used in the body. In people without diabetes, the kidneys filter about 180 grams of glucose each day. Before glucose can be absorbed into the circulation, it must move from the kidney back into the blood stream. Two transporters help glucose to be reabsorbed in the kidney. These are facilitated glucose transporters (GLUTs), and sodium glucose co-transporters (SGLTs). SGLT2, one of these transporters, is responsible for about 90 per cent of the glucose that is reabsorbed. Recently, three medications have been approved in Canada. Canagliflozin (Invokana), dapagliflozin (Forxiga) and empagliflozin (Jardiance, available in October 2015) belong to a new class of oral diabetes medications known as SGLT2 inhibitors. They work to block the action of SGLT2, lowering the amount of glucose reabsorbed by the kidneys. More glucose then leaves the body in the urine. These medications work along with diet and exercise for adults who have type 2 diabetes. How well do these medications work? Studies have been done to test how well canagliflozin and dapagliflozin work in adults who have type 2 diabetes. Many results have been positive, as they show: lowered fasting blood glucose levels lowered post-prandial (after a meal) glucose levels M A N A G I N G D I A B E T E S 5 F A L L / W I N T E R

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7 reduced A1C weight loss heightened HDL cholesterol and reduced triglycerides. One negative result is that LDL cholesterol levels became higher. After meal glucose level A1C Weight loss Canagliflozin 0.7% Less than or equal to 4 kg Dapagliflozin 0.5% 2 to 3 kg After four weeks of taking the medication, people usually see A1C levels drop. The greatest reduction occurs at three to six months. Who should use these medications? SGLT2 inhibitors are suitable for adults with type 2 diabetes who have tried metformin or insulin, but continue to have high blood glucose levels. Currently, they are not recommended for those who have problems with their kidneys, including end-stage kidney disease or being on dialysis. Dosage details The recommended starting dose of canagliflozin is 100 mg taken once a day, at any time of the day with or without food. People who need more blood glucose control can increase the daily dose to 300 mg, if their doctors agree. The recommended starting dose of dapagliflozin is 5 mg taken once a day, in the morning. If more control is needed, a doctor may consider increasing the daily dose to 10 mg. Safety information The negative side effects found in the studies for SGLT2 inhibitors include the following: Increased passing of urine this relates to more glucose leaving the body in the urine. The glucose draws more fluid with it as it passes out of the kidneys. Low blood pressure when some people first begin the medication, their blood pressure can become low enough to cause symptoms. Their bodies lose extra fluid in the urine along with the glucose. Those who are elderly, take diuretics (water pills), or have low systolic blood pressure are more at risk. (Systolic blood pressure is the first number in a blood pressure reading the 120 in 120/80.) Effect on kidney function the kidneys may not work as well with a SGLT2 inhibitor. Frequent monitoring is recommended for people who have chronic kidney disease. Increased potassium levels SGLT2 inhibitors can interfere with the release of potassium from the body in the urine. People who take other medications that increase potassium are at a greater risk. Risk of infection urinary tract (urine system) infections and fungal infections of the genital area become more likely. Those who have a history of these infections, women, and uncircumcised men are at higher risk. Increase in LDL cholesterol increases in LDL cholesterol have been reported, and relate to the amount of medication taken. Monitoring is required. The U.S. Food and Drug Administration (FDA) is warning that the type 2 diabetes medicines canagliflozin, dapagliflozin, and empagliflozin may lead to ketoacidosis, a serious condition where the body produces high levels of blood acids called ketones that may require hospitalization. Investigation is continuing on this safety issue and will determine whether changes are needed in the prescribing information for this class of drugs, called sodium-glucose cotransporter-2 (SGLT2) inhibitors. For more information, visit tinyurl.com/type2fda. In the pipeline Lifestyle choices will always be a key part of managing diabetes. The new class of medication is an important advance, allowing better blood glucose control. Discuss these possibilities with your health team to gain better control and prevent longterm complications of diabetes. WRITTEN BY: Melissa Dash, BSc, BSP, a pharmacist practising in Saskatoon, SK. M A N A G I N G D I A B E T E S 7 F A L L / W I N T E R

8 Is it safe to be BEHIND the WHEEL? It may seem to you that as long as you can keep your diabetes under control, it is your own business. However, once you get behind the wheel of a vehicle, your condition has the potential to affect others. Traffic safety laws require you to notify the registrar of your provincial motor vehicle licensing authority about any disease that could interfere with your safe driving. Diabetes is one condition that must be reported. Licensing authorities can request a medical assessment of any licensed driver s fitness to drive. If safety is a concern, the driver s license can be issued with conditions, such as a periodic medical, or restrictions. As well, a licence can be suspended until certain conditions are met, or cancelled. The Canadian Diabetes Association (CDA) believes that everyone with diabetes has a right to be individually assessed for a license to drive. Check out ca for more information on diabetes and driving (search driving ). Maintaining your fitness to drive safely To keep your driver s license, you must meet certain requirements. You must manage your diabetes properly, and make sure your blood glucose levels are high enough to operate your vehicle safely. Poor blood glucose control can affect your judgment while driving. If you cannot recognize and treat early warning signs of low blood glucose, you risk your safety and the safety of others. Driving and Diabetes Poor management of diabetes heightens your chance of developing complications that affect your eyes, blood vessels, heart, kidneys and nerves. Such complications can also interfere with your ability to drive safely. Your doctor also has responsibilities in regard to your diabetes. You must be taught to prevent situations that can affect your ability to drive safely, and how to recognize a severe low blood glucose reaction. Your doctor will also monitor your condition. In most provinces and territories, your doctor must report to the licencing authority if you become unfit to drive. Type of diabetes treatment and driving The way your diabetes is treated can affect the class of driver s license you are allowed to hold. Treatment with diet -Those whose diabetes is well controlled by diet alone can hold any class of license. They must not have any other medical problems that could affect their ability to drive safely. Treatment with oral medications - Those whose diabetes is well controlled with medications taken by mouth can also hold any class of license. Again, they must not have other medical problems that could affect driving ability. They cannot be at risk of having low blood glucose reactions while driving. Treatment with insulin - Those whose diabetes is well controlled with insulin can hold a class 5 license (G in Ontario). They may be eligible for a commercial class of license if they meet specific conditions. They must not have any other medical problems that affect their ability M A N A G I N G D I A B E T E S 8 F A L L / W I N T E R

9 to drive safely. They also cannot be at risk of having low blood glucose reactions while driving. Low blood glucose warning Low blood glucose is a major concern if you have diabetes and drive. Knowing more about low blood glucose can help keep you safe behind the wheel. Low blood glucose measures as less than 4 mmol/l on a blood glucose meter. Signs and symptoms can vary greatly from person to person. You must be able to recognize symptoms you experience when your blood glucose gets low. These symptoms may include: trembling sweating hunger anxiety nausea weakness tingling confusion difficulty concentrating tiredness or drowsiness vision changes dizziness heart palpitations (rapid, pounding or fluttering heartbeat) headache If you cannot recognize your own warning signs of low blood glucose, your blood glucose could drop so low that you pass out while driving. Medications and risk for low blood glucose Certain types of medication give you a higher chance of having low blood glucose. Insulin and oral medications that cause the pancreas to release insulin can affect you this way. Such medications include: glyburide (Diabeta) gliclazide (Diamicron, Diamicron MR) glimepiride (Amaryl) repaglinide (Gluconorm) nateglinide (Starlix) Some heart pills, called beta blockers, may hide the symptoms of low blood glucose. Talk to your doctor and pharmacist to find out if any of your medications put you at risk of having a low blood glucose reaction. Certain situations also increase your risk of having a low blood glucose reaction. They include: not eating regularly skipping meals eating meals later than usual eating less at a meal than you usually eat Commercial drivers who use insulin to treat their diabetes must meet the following conditions to be considered for a commercial class of license. They must: earn a certificate showing they know how to measure blood glucose. (A specialist in care of diabetes or a doctor can issue this authorization.) have had no episodes of low blood glucose that have caused a loss of consciousness or required others to help treat it in the past six months. have no significant change in insulin therapy. If a significant change does exist, monitoring shows stable and effective blood glucose control. be able to identify the symptoms of a low blood glucose reaction. control their diabetes well, with an A1C less than 12 per cent, and less than 10 per cent of their blood glucose levels below 4 mmol/l. test blood glucose adequately, along with an up-to-date logbook record that can be verified. understand how to care for diabetes, as well as the causes, symptoms, and treatment of low blood glucose. have no other medical problems affecting the ability to drive safely. have an annual or periodic medical review, including an eye (ophthalmologic) exam. keep a blood glucose meter and a source of fast-acting sugar within reach in their vehicle. Equipment used to deliver insulin must also be with them at all times. test their blood glucose within an hour of starting to drive, and about every four hours while driving. In addition: Commercial drivers must not start to drive or must stop the vehicle if their blood glucose falls below 6 mmol/l. They should eat, and not drive again until blood glucose measures above 6 mmol/l. The family doctor must approve the work schedule, and consider it to be compatible with insulin treatment. Criteria for the initial application and annual recertification of a commercial license must be met. Other criteria can exclude a driver from maintaining the license. M A N A G I N G D I A B E T E S 9 F A L L / W I N T E R

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11 doing more activity than you normally do drinking alcohol on an empty stomach having certain gastrointestinal (digestive system) problems having liver or kidney function problems having a history of severe low blood glucose reactions. How can I continue to drive safely? Learn all you can about diabetes. If you have not been to a diabetes education class lately, go for an update. The way diabetes is managed changes as new research findings become available. Test your blood glucose regularly, at different times of the day. Readings taken immediately before you eat, two hours after you begin eating, and before your bedtime snack can tell you how well your blood glucose is being managed. Know what your glucose level should be at these times. Know how your diabetes medications work. Balance your food, medications, and activity to keep blood glucose in the target range. Measure your blood glucose level immediately before driving, and at least every four hours while driving (more often if needed). Always carry your blood glucose meter. An accurate reading is your best indication of a blood glucose problem. Keep a logbook of your readings. If you take medication to manage your diabetes, make sure you always have a treatment for low blood glucose and a snack on hand. You may be stuck in traffic or delayed on your way home. Prepare for the unexpected! If you suspect your blood glucose is low, park in a safe and legal place and test. Do not drive if your blood glucose is less than 4 mmol/l. If your blood glucose measures between 4 and 5 mmol/l, do not drive without eating extra food. Commercial drivers should have a blood glucose level greater than 6 mmol/l. If your blood glucose is less than 4 mmol/l, treat with 15 grams of fast acting carbohydrates, preferably in the form of glucose or sucrose tablets. Wait 15 minutes, then retest. If it is still below 4 mmol/l, treat again. If it is greater than 4 mmol/l, you can have some carbohydrate and protein. Do not resume driving for 45 to 60 minutes after treating a low blood glucose reaction. Ask your doctor or diabetes education team for more information on managing hypoglycemia. Certain factors give you a higher chance of having For more information on diabetes and commercial drivers, see: Canadian Council of Motor Transport Administrators (CCMTA) Determining Driver Fitness in Canada, September 2013: see Part 2, CCMTA Medical Standards for Drivers, chapter 7 on diabetes and hypoglycemia. Website is CCMTA.ca (search: driver fitness). Canadian Diabetes Association, Guidelines for Diabetes and Private and Commercial Driving at (search driving). The United States has a Diabetes Exemption Program that allows for case-by-case assessment of commercial drivers. Drivers who use insulin to treat diabetes are allowed to operate commercial vehicles in interstate commerce if they meet certain conditions. Visit the American Diabetes Association at (search commercial drivers). National Safety Code Medical Standards for Drivers with Diabetes (Search Diabetes and Driving: A Guide for Drivers) a severe low blood glucose reaction while driving. They include having had a severe low blood glucose reaction within the last year, having difficulty recognizing such reactions, or having a marked drop in A1C or an A1C within the normal range. (A1C is a test that measures blood glucose control over the last two to three months.) Your family doctor can help by regularly testing how well your diabetes is being managed, and checking for complications. To assure your own health, manage your diabetes well and be certain your blood glucose levels are within your target range. By making sure that you have your diabetes well under control before driving, you help to keep everyone on the road safe. ORIGINALLY WRITTEN BY: Janet Allsopp, RN, BScN, CDE, a diabetes nurse educator at the Diabetes, Hypertension, and Cholesterol Centre in Calgary, AB and published in the Spring 2006 issue of Managing Diabetes. Reviewed and updated for this issue by Dinah Santos, BSc (Pharm), CDE. M A N A G I N G D I A B E T E S 11 F A L L / W I N T E R

12 Emotions The of Diabetes Diagnosis Grieving and acceptance Where there is loss, there is grief. When I was diagnosed with type 1 diabetes 16 years ago, no one told me that I was beginning a long process of grieving this condition. Looking back, I realize I had to go through a number of stages to adapt to my diagnosis. Now, I counsel others grieving losses associated with diabetes and other chronic illness. I learn a great deal from their stories. Many people think that the grieving process only relates to the loss of a loved one. However, these stages (denial, anger, bargaining, depression, and acceptance) apply to many types of loss. Divorce, job loss, or the diagnosis of a life-changing and life-threatening disease like diabetes can all require adjustment. The stages are not in a consistent order, and people may go back and forth between different stages. Not everyone experiences all the stages. The way each person grieves is unique. On the day I was diagnosed, I was 24 years old and knew something was very wrong. Still, I was unable to believe I could actually have that condition diabetes. For months, I had been denying that I was sick despite serious symptoms. Kind and caring health professionals were there to help. Still, no one told me what to expect emotionally over the days, weeks and months to come. I felt stunned and very alone, despite visits from caring friends and family. I cried when a resident came to tell me that I was being discharged. I did not feel ready to start this new life. After diagnosis, I entered a new stage of denial. The whole time I was in hospital and for a week or two after going home, I believed a mistake had been made. There had to be a reason I would need insulin other than diabetes. Looking back, this makes no sense at all! My biggest worry was how embarrassed I would feel when people found out I did not have diabetes after all. Denial protects the mind from realities it is not ready to accept yet. A yoga teacher diagnosed with LADA (latent autoimmune diabetes in adults) told me that she spent five years in denial. Her onset was slower than other people with type 1, and that is what distinguishes LADA from type 1. However, she reached a point where taking insulin became necessary. Her blood glucose was consistently elevated. She was in denial, believing instead that she had a parasite. Surely a healthy lifestyle would cure her. Once she accepted she needed to start insulin, she cried for two M A N A G I N G D I A B E T E S 12 F A L L / W I N T E R

13 weeks. She was finally moving forward in her grieving process. Certain memories of the grieving process stand out for me. They involve the way other people responded to my diagnosis. Though comments were meant to be reassuring, they still stung. Well, at least it s not cancer! or I know somebody with diabetes, and it doesn t seem like a big deal. It can be difficult to process grief when others are saying that you shouldn t feel sad. You end up feeling angry and hurt. Those who have not grieved the diagnosis of a life-changing illness cannot understand. Often the person who is grieving does not realize what is happening. Although I was studying psychology in university, I did not recognize that I was grieving! My way to cope was to try to manage my diabetes perfectly, so I could feel the way I used to feel. If I just did it right, everything would be okay. Once this bargaining stage faded, the reality of the diagnosis began to sink in. It would hit me at different times when I woke up for the day shaky from a low, or looked at bruises from injections, or refilled prescriptions at the pharmacy. I have diabetes. For a long time, it was hard to believe. Of course, eventually it became hard to remember what it was like before diabetes. Sometimes our attempts to master diabetes can be a form of bargaining. For the first six months after diagnosis, I wrote down every blood glucose reading and carbohydrate consumed. I told everyone I was fine. I worked three jobs the summer right after my diagnosis. Maybe I believed somehow everything would be okay if I just worked hard enough. I needed someone to tell me what I tell others learning to cope when it comes to diabetes, there is no perfect. When I took a break from writing down blood glucose results, I did not want to start again. I was suddenly overwhelmed by the thought of doing it forever. Now I counsel people with diabetes. Though many label themselves as lazy or unmotivated, it is not that simple. For instance, depression can sap people of the energy needed to manage diabetes. Denial can also be the root of problematic behaviour. You don t want to believe you have diabetes, so you skip injections. You don t want to think about it, so you ignore or refuse to even check your blood glucose levels. Often, feelings of depression or anger diminish once people have the chance to discuss and grieve their diabetes. Some have waited a long time to tell their stories. For others, a significant stressor such as a relationship breakup triggers a period of diabetes distress. The reality of living with diabetes becomes overwhelming again. Losses can add up, one loss onto another. Many people are diagnosed within a year or two of a traumatic event in their family. Of course, the first loss adds to the impact of diabetes diagnosis. Anniversaries can be tough. As the one-year mark of diagnosis approaches, it is normal to experience intense feelings of sadness, depression or anger. As symptoms of grief are much like those of depression, doctors may recommend medication. But if grief is the issue, therapy or increased personal support may help more than taking medication. Insomnia, loss of appetite, unstable mood, fatigue, and loss of interest in usual activities are normal symptoms of grief. In my case, the one-year mark was a very intense time. I really needed to mourn the losses associated with diabetes, and did not know what to do with those emotions. With time, the feelings lessened. I was able to work towards acceptance of a new normal. Communication and support For those with diabetes You may be struggling with your diabetes, and find that people close to you are judgmental or hurtful in some way. Remember, you have the right to distance yourself and spend time with those who make you feel better. Your grief is unique to you and no one can tell you how you should feel. However, give those close to you a chance to improve their communication. Assert yourself. Let them know that you need a different kind of support. Many young adults I work with say their parents are supportive, but do not provide the right type of support. They must explain that they need more listening, and less advice. If parents can honour this request, it can be easier to accept advice when it is truly needed. For family and friends of someone with diabetes If someone you know is dealing with any kind of diagnosis or illness, do not minimize their distress. It is not reassuring to hear that it could be worse. Often, it is best to say simply, I am so sorry to hear about what you are going through. Actions speak louder than words, and small acts of kindness go a long way. If you can offer support in other ways, do so. When a person is grieving, it is nice to have someone who will just be there. Take a moment to listen to Brené Brown s M A N A G I N G D I A B E T E S 13 F A L L / W I N T E R

14 OneTouch Verio IQ Meter OneTouch Verio Meter See what you ve been missing. Experience the difference of the OneTouch Verio Family of Meters. Each one is designed with colour-coded features that make it quick and easy to understand results at a glance. UPGRADE with to to a a FREE* OneTouch Meter Meter today, today and get more from your meter. the purchase of 100 OneTouch Verio Test Strips. * With the purchase of 100 OneTouch Verio Test Strips. Ask your Safeway pharmacist for details and get more from your meter. OneTouch.ca All trademarks are used under licence by LifeScan Canada Ltd LifeScan Canada Ltd. AW A 06/15

15 work on empathy in her online Ted Talks. This can educate you on how to truly support others. For health care professionals Health care professionals who deliver the news of a diagnosis have a very important role. Diagnosis is sometimes described as a flashbulb moment to the person hearing it for the first time. It is traumatic and scary. If you are the one delivering this news, this person may remember you forever. Do not try to gloss over the reality of living with diabetes. A false promise of a cure in the next ten years will not help. People being diagnosed and those supporting them need an expression of empathy, and a realistic statement about what this diagnosis means. For instance: I am really sorry that I have to deliver this news to you. The diagnosis is diabetes, and there is a lot of learning to do to manage it. However, it is possible to live a healthy, happy life with diabetes. You will need a lot of support. Honesty and empathy must extend beyond that first key moment. Patients are more likely to listen to your guidance if you listen to their thoughts and feelings first. Whether you are a nurse doing a simple check, an educator teaching a newly diagnosed patient, or a dietitian meeting about carbohydrate counting, your approach matters. Take the time to specifically ask about your patient s well-being. How are you coping these days? How are you feeling about everything? If your patient has the courage to open up, reflect those feelings back. Yes, it is hard living with diabetes. It really is a full time job. People struggle with diabetes management because it really is difficult. There is no perfect when it comes to diabetes. Some helping professionals shy away from these remarks because they do not seem positive or particularly helpful. However, those with diabetes know how helpful a realistic acknowledgement can be. Even the highest performing, seemingly self-sufficient people have their own vulnerabilities. Hearing that they are doing a good job makes a difference. When you care for people who have diabetes, remember to smile at them. Show interest in them as people. Put aside the file and just talk about how they are doing. I promise you these simple actions can help you to connect, and make a difference. If you suspect that a person who has diabetes is struggling with denial, anger, depression, bargaining or acceptance, consider describing the stages of grief and their impact. It is very reassuring to have a framework to understand the intense physical and psychological symptoms you are experiencing. As you grieve your diagnosis, expect the process to be a rollercoaster ride of emotions. If you are a friend, family member, or health care professional, provide reassurance that you will be there to lean on. WRITTEN BY: Michelle Sorensen, M.Ed, a clinical psychological associate with the College of Psychologists of Ontario, in Ottawa, ON. W I N A I R M I L E S R E W A R D M I L E S Sending in this form and your comments about this magazine enters you in a chance to win 5000 reward miles. Name: Comments: Address: City: Province: Postal Code: Phone: AIR MILES Collector number: address: Check here if you would like to be periodically informed of upcoming diabetes programs in your area. Mail completed form to: Attn: Pharmacy Department - Contest Sobeys West Inc. - Safeway Operations P. O. Box 864, Station M, Calgary, AB T2P 2L6 CIRCLE ONE TO RATE CONTENTS OF MAGAZINE: (1 = poor, 5 = excellent) TM Trademarks of AIR MILES International Trading B.V. Used under license by LoyaltyOne, Co. and Safeway. By sending in this form I hereby give permission to your company to enter my name for a chance to win 5000 reward miles. Limit of one entry per household. Offer expires January 31, Congratulations to Mary J of Calgary, Alberta, the winner of 5000 AIR MILES reward miles from the draw in the last issue of Managing Diabetes. M A N A G I N G D I A B E T E S 15 F A L L / W I N T E R

16 B L O O D G L U C O S E M E T E METER STRIP BLOOD SAMPLER MEMORY BG REQUIRED TEST TIMES FEATURES ACCU-CHEK AVIVA* Accu-Chek Aviva Strips Accu-Chek Lancing Device 500 tests 0. 6 µl 5 Rediscover simplicity with Accu-Chek Aviva with improved Test & Go technology: no coding,easy strip handling, and advanced accuracy. ISO certified for accurate results. ACCU-CHEK AVIVA NANO* Accu-Chek Aviva Strips Accu-Chek Lancing Device 500 tests 0. 6 µl 5 Ultra-portable with a small, sleek design, Easy to read with a brilliant backlit display & *ISO certified for accurate results. BAYER'S CONTOUR NEXT* Bayer s CONTOUR NEXT Test Strips Bayer's Microlet tests 0. 6 µl 5 Features Bayer s No coding technology with Next Generation accuracy. Simple and easy to use. Second-Chance sampling tells your patient to apply more blood to the same test strip if needed. BAYER S CONTOUR NEXT EZ* Bayer s CONTOUR NEXT Test Strips Bayer s MICROLET tests 0.6 µl 5 Features Bayer s No Coding technology. Designed for next-generation accuracy and has easy-to-use, personalized features (including meal markers, customizable alarm reminders and 7, 14, and 30 day averages). BAYER S CONTOUR NEXT* USB Bayer s CONTOUR NEXT Test Strips Bayer s Microlet tests 0. 6 µl 5 Small, practical design with next-generation accuracy. New easy-to-log carbs and insulin dosing; Second-Chance sampling; upgraded GLUCOFACTS DELUXE diabetes management software. FREESTYLE * FREEDOM LITE * FreeStyle Lite Freestyle Lancing Device 400 tests 0. 3 µl Up to 4 Large display window. Backlight display. Ability to add blood for up to 60. FREESTYLE INSULINX * FreeStyle Lite Freestyle Lancing Device 990 tests 0. 3 µl Up to 4 Mealtime insulin calculator to provide dosing advice. Touch screen meter. Automated log book. FREESTYLE LITE * FreeStyle Lite Freestyle Lancing Device 400 tests 0. 3 µl Up to 4 Small meter. Ability to add more blood for up to 60. FREESTYLE PRECISION NEO* FreeStyle Precision Test Strips Freestyle Lancing Device 1,000 tests 0. 6 µl 5 Icon-driven display, insulin logging, high and low trend indicators. Large numbers and bright screen. GE200 BLOOD GLUCOSE METER GE200 Test Strips GE Lancing Device 1000 test memory µl 5 True Auto coding. Large, easy to handle plastic test strips. Unique design eliminates possible contamination due to contact with blood. Back light for viewing in low light. Sleek, modern, compact design. ONETOUCH ULTRA 2* ONETOUCH Ultra Test Strips ONETOUCH Delica Lancing Device 500 tests 1 µl 5 Easy to use and helps link food choices to blood glucose results. Uses the OneTouch Ultra Test Strip with DoubleSure Technology that automatically checks each sample twice to confirm the result. ONETOUCH ULTRAMINI * ONETOUCH Ultra Test Strips ONETOUCH Delica Lancing Device 500 tests 1 µl 5 Effortless accuracy and easy testing without the need for manual coding. Uses the OneTouch Ultra Test Strip with DoubleSure Technology that automatically checks each sample twice to confirm the result. ONETOUCH VERIO * ONETOUCH Verio Test Strips ONETOUCH Delica Lancing Device 500 tests 0. 4 µl 5 Colour-coded range indicator and automatic messages help you better understand results without any extra work. *Not available in all locations. Fee for service may apply. At Safeway Pharmacy we can help you manage your diabetes We carry a full line of insulin pump and blood glucose testing supplies. We direct bill most insurance plans and offer competitive pricing on insulin pump and blood glucose testing supplies. All locations have Diabetes Meter Trainers that are trained on the latest technology and can assist you in choosing the best blood glucose meter for your needs. We have a team of Certified Diabetes Educators* that can help you with your diabetes management. Ask at the Pharmacy if you qualify for an Immunization or Medication Review. M A N A G I N G D I A B E T E S 16 F A L L / W I N T E R

17 R C O M P A R I S O N C H A R T METER STRIP BLOOD SAMPLER MEMORY BG REQUIRED TEST TIMES FEATURES ONETOUCH VERIO FLEX * ONETOUCH Verio Test Strips ONETOUCH Delica Lancing Device 500 tests 0. 4 µl 5 Three-colour range indicator instantly shows when your blood glucose results are in or out of range. Compact, slim design makes it easy to take anywhere. ONETOUCH VERIO IQ* ONETOUCH Verio Test Strips ONETOUCH Delica Lancing Device 750 tests 0.4 µl 5 Automatically searches for repeated highs and lows, alerting you right on screen. The first meter with a colour LCD screen, illuminated testing area and large easy-to-read numbers. SANOFI BGSTAR * BGStar Test Strips BGStar Lancing Device µl 6 No coding required, large backlit display, programmable test reminders, hyper and hypoglycemic alerts, mealtime tags, 14, 30 and 90 day averaging. TRUERESULT TRUEtest Test Strips TRUEdraw 500 results with time/ date 0. 5 µl As fast as 4 No coding. 7,14 and 30-day averaging. 4 test reminder alarms. Audible fill detection. Ketone test reminder. Alternate site testing. Strip release button. TRUE2GO TRUEtest test strip TRUEdraw Up to 99 - test memory 0. 5 µl As fast as 4 No coding. Easy-to-read display. Glucose control detection. Alternate site testing. Strip release button. Automatic on/off. THE FOLLOWING METERS ARE ALSO AVAILABLE BUT MAY REQUIRE SPECIAL ORDER EZ HEALTH ORACLE * EZ Health Oracle EZ Health Oracle 450 tests 0. 7 µl 6 Unique talking function allows you to see and hear your results, coding not required, large display, single button operation, alternate site testing. EZ HEALTH ORACLE ONYX EZ Health Oracle Glucose Test Strips EZ Health Oracle Lancing Device 150 with Date and Time 0. 7 μl 6 Backlight display for easy reading. Autocode. Computer downloadable results. Shows Good Results. MEDI+SURE Medi+Sure Medi+Sure Lancing Device 960 tests 0. 6 µl 6 or less Affordable high quality & accurate testing. Simple to use. No coding required. Lifetime no-questions-asked warranty. Large buttons with easy to read screen. NOVAMAX * PLUS NovaMax Test Strips and NovaMax Plus Ketone Test Strips Sureflex Lancing Device 400 tests 0. 3 µl 5 Coding not required for ease of use. Tests blood glucose levels as well as ketones. Less blood for quick palm or finger testing. Fast and accurate results. WHICH METER IS BEST? Ask a Safeway Pharmacy team member about the individual advantages of the various meters on the market. Make an appointment for individual teaching to determine which blood glucose meter will best meet your needs. * Blood Glucose Data Management computer programs available. These programs are available to print out the memory, down load numerous test results, see averages, graph results and watch for trends. Ask a pharmacy staff member for more information. Safeway Pharmacy Diabetes Centre Locations Surrey Centre King George Boulevard, Surrey Collingwood 3410 Kingsway, Vancouver Tower Lane Mall 505 Main Street, Airdrie Crowfoot 99 Crowfoot Crescent NW, Calgary Whitehorn Avenue NE, Calgary SouthCentre Bonaventure Drive SE, Calgary Glenmore Landing Avenue SW, Calgary Southgate 100A Street NW, Edmonton Safeway Health Care Consultants Kelly Gasmen Winnipeg (204) Shauna Nowakowski Saskatoon (306) Rose Marie Boychuk Calgary (403) Donna Hansen Calgary (403) Ana Maria Trotter Calgary (403) Caralee Robinson Edmonton (587) Tanya Zenner Edmonton (587) Jasvir Bhupal Surrey (604) Sarvjit Dhami Vancouver (604) M A N A G I N G D I A B E T E S 17 F A L L / W I N T E R

18 UPGRADE to the TRUEresult System Today! Blood Glucose Monitoring System Receive a FREE Meter with purchase of a box of 100 ct. TRUEtest Strips (Limit 1)! NO CODING Tiny, 0.5 microliter blood sample Uses TRUEtest Strips featuring Quad-Electrode Laser Accuracy Clinically Proven Accuracy. TRUEresult was proven comparable to the leading name brand systems. 1 Ask at the pharmacy for details. 1. Accuracy Study of Blood Glucose Monitoring Systems: Evaluation of the TRUEresult, OneTouch Ultra 2, Ascensia CONTOUR, and FreeStyle Freedom Lite Systems. NICO /14 Nipro Diagnostics, Inc.

19 Syringes, Pen Needles and Insulin Pens The term medical sharps refers to used syringe, lancets and/or pen needles. In order to ensure that used sharps are not a hazard to others, they must be taken to an approved disposal facility. Most Safeway Pharmacy locations accept used sharps for return in a legitimate sharps container. Ask your local store for details and for your free sharps container. PEN NEEDLES GAUGE LENGTH PKG. SIZE INSULIN PENS DOSE ADJUSTMENTS DOSE RANGE BECTON DICKINSON LILLY ` B-D Ultra-Fine III Mini and Short Pen Needle B-D Ultra-Fine Original Pen Needle *BD Autoshield Duo Safety Pen Needle NOVO NORDISK NovoFine Plus Pen Needle 31 G 5 or 8 mm 100s 29 G mm 100s 30 G 5 mm 100s 32 G 4 mm 100s Humapen Luxura HD Available in green Humapen Savvio Available in red, charcoal, *pink, * green, *silver or *blue *KwikPen Prefilled with Humalog, Humalog Mix25 or Mix50, Humulin N or R; no cartridge to load; disposable 1 2 unit increments 1 unit increments 1 unit increments units /dose 1-60 units / dose 1-60 units / dose NovoFine Pen Needle 32 G Tip ETW 6 mm 100s NOVO NORDISK NovoFine Pen Needle 30 G 8 mm 100s NovoFine Autocover Pen Needle 30 G 8 mm 100s NovoTwist Pen Needle 32 G Tip ETW 5 mm 100s *NovoPen Echo Available in red and blue; digital display confirms time and amount of last dose NovoPen 4 Available in silver or blue 1 2 unit increments 1 unit increments units/dose 1-60 units/ dose STERICYCLE *Ulticare Pen Needle 31 G 6 or 8 mm 100s *Ulticare Pen Needle 32 G 4 mm 100s DOMREX PHARMA *Insupen Pen Needle 30 G 8 mm 100s *Insupen Pen Needle 33 G 4 mm 100s *Insupen Pen Needle 32 G 4, 6 or 8 mm 100s *Insupen Pen Needle 31 G 6 or 8 mm 100s FlexTouch Prefilled with NovoRapid or Levemir ; no cartridge to load; disposable SANOFI AVENTIS ClickSTAR Available in grey and blue SoloSTAR Prefilled with Lantus or Apidra ; no cartridge to load; disposable 1 unit increments 1 unit increments 1 unit increments 1-80 units/ dose 1-80 units/ dose 1-80 units/ dose AUTOCONTROL MEDICAL *Unifine Pentips 32 G 4 mm 100s *Unifine Pentips 31 G 5, 6 or 8 mm 100s *Unifine Pentips 29 G 12 mm 100s SHARPS CONTAINERS COLOUR SIZE Safeway/Lifescan/BD Yellow 1. 4 L BD Yellow 1.4, 3.1, 5.1, or 10.3 L INSULIN SYRINGES GAUGE LENGTH VOLUME SIZE BECTON DICKINSON B-D Ultra-Fine Insulin Syringe 31 G 6 mm 3/10cc,1/2cc,1cc 100s B-D Ultra-Fine Insulin Syringe 30 G 8 mm 3/10cc 100s B-D Ultra-Fine Insulin Syringe 30 G 8 mm 1/2cc,1cc 100s *BD Safetyglide Syringe 31 G 8 mm 3/10cc 100s *BD Safetyglide Syringe 29 G 8 mm 1/2cc,1cc 100s AUTO CONTROL MEDICAL *Ulticare Ulti-Fine Insulin Syringe 29 G mm 3/10cc,1/2cc,1cc 100s *Ulticare Ulti-Fine Insulin Syringe 30 G 8 mm 3/10cc,1/2cc,1cc 100s * AVAILABLE IN SELECT STORES. MAY REQUIRE SPECIAL ORDER. M A N A G I N G D I A B E T E S 19 F A L L / W I N T E R

20 If you have diabetes, you likely know that making good food choices is key to managing blood glucose levels. A healthy diet prevents conditions associated with diabetes, or keeps them from getting worse. Eating fibre is a good idea for a variety of reasons, especially for people who have diabetes. According to the Canadian Diabetes Association, fibre is important to overall health. Benefits include controlling blood glucose (sugar), managing blood pressure, reducing blood cholesterol, increasing the feeling of being full, controlling weight, and regulating bowel movements. Soluble fibre is a soft fibre that helps control blood glucose. It delays stomach emptying, and slows the absorption of carbohydrate. Glucose is released more slowly into the bloodstream, reducing the rise of blood glucose after a meal. With diabetes, the focus should be on balanced eating, in both nutrient balance and quantity of nutrients consumed. When planning meals, consider the proportion of protein, fat, and carbohydrates. Quantity and quality of carbohydrates are especially important for people who have diabetes. Plant proteins and fats have been shown to help promote a healthy inflammatory response. This means that eating these foods may help with chronic diseases like diabetes. What are hemp hearts? Hemp hearts are tiny, soft seeds that taste a bit like pine nuts and sunflower seeds. They offer fibre, protein, fats and other nutrients, and are very easy to use. Hemp hearts contain fibre - Fibre helps slow the impact of carbohydrates on the body. Hemp Hearts A simple way to add fibre to your diet A plant-based source of protein and fats - One 30-gram (2 tbsp) serving of hemp hearts provides close to 10 grams of protein and 10 grams of omegas. A higher fibre carbohydrate - Hemp hearts are not a significant source of sugar. Their carbohydrate content comes mostly from dietary fibre. In a 30-gram serving of hemp hearts, there are three grams of carbohydrates from fibre. Adding hemp hearts to your diet Hemp hearts are an easy way to add taste and nutrition to foods you already enjoy. Start your day with delicious hemp heart pancakes: tinyurl.com/mhhempcakes Try sprinkling hemp hearts on soups and salads instead of using croutons, cheese, bacon or dried fruit. They can top fruit, vegetables, beans or grains. tinyurl.com/mhhempsoup Smoothies are another easy way to add extra nutrition and fibre: tinyurl.com/cinnamonsmoothie tinyurl.com/greenhempshake tinyurl.com/hempfruitshake Find more tasty hemp recipes at manitobaharvest.com/recipes It's easy to make these tasty drinks - just place all ingredients in a blender and pulse until smooth and creamy. Pour into glasses and enjoy! M A N A G I N G D I A B E T E S 20 F A L L / W I N T E R

21 Razzmatazz 2 scoops Manitoba Harvest hemp protein powder (any flavour of your choice) 2 cups dairy, hemp, rice or almond milk 1 cup papaya, peeled and chopped 1 cup frozen raspberries Awesome Oatmeal 2/₃ cups oatmeal ½ cups water 1 Bartlett pear (washed, cored and chopped coarsely) ¼ cup Manitoba Harvest hemp hearts 3 tbsp maple syrup Blueberry Maple Hemp Shake 1 tbsp Manitoba Harvest hemp oil 1 tbsp Manitoba Harvest hemp hearts 1 cup frozen blueberries 1 cup Hemp Bliss organic hemp beverage (or soy or rice milk) 4 tbsp maple syrup 1½ tsp natural vanilla extract Creamy Dreamy Hemp Milk 2½ cups water, more if desired 1½ cups hemp hearts 1-2 tbsp. raw agave nectar or 2-3 dates, pitted (optional) M A N A G I N G D I A B E T E S 21 F A L L / W I N T E R

22 Type 1.5 Diabetes Could you have LADA (Latent Autoimmune Diabetes in Adults)? Much to your surprise, you were recently diagnosed with diabetes. Once you researched the disease, you discovered that there are two basic kinds. Type 1 affects about 10 per cent of people who have diabetes. Since you are 40 years old, you do not meet the age or symptom criteria for that type. Most people with diabetes have type 2. However, you have always been very active and your weight is not an issue. You do not really match the criteria for type 2 either. Finally, you come across references to a type of diabetes called LADA (latent autoimmune diabetes in adults). Could this be the type of diabetes affecting you? To understand LADA, you must first know the two basic types of diabetes and how autoimmune diseases work. In an autoimmune disease, the body s immune (defence) system is overactive. The body attacks its own cells, destroying them. In type 1 diabetes, the immune system has destroyed the beta cells of the pancreas. These beta cells make insulin. Insulin permits the cells of the body to use glucose, the sugar from food, for energy. Without beta cells, the body has no insulin. The amount of glucose in the blood and urine increases, and this can occur very quickly. Type 1 diabetes is usually diagnosed in children and young adults. It was previously known as juvenile diabetes. Those who have type 2 still do produce some insulin. However, the insulin does not work as well as it should. The cells of the body resist the insulin. The glucose stays in the blood, and the result is high blood glucose. This type occurs most often in adults. Type 2 diabetes is linked with obesity, metabolic syndrome, and high blood pressure and cholesterol, rather than having an autoimmune cause. LADA is both an autoimmune disorder and a subtype of type 1 diabetes. With LADA, the body attacks and destroys beta cells, much like type 1 diabetes although at a much slower pace. At first, some cells still make insulin, but eventually they are destroyed as the disease progresses. LADA appears in people older than the age when type 1 diabetes typically starts. As it affects adults over age 30, it is often confused with type 2 diabetes. LADA does not fit either category, and so is sometimes called type 1.5 diabetes. It can be inherited. What are the signs of LADA? Although both type 2 diabetes and LADA start later in life, the two are quite different. People who have LADA often share certain characteristics. They: are diagnosed with diabetes as adults appear at first to be a person of healthy weight with type 2 diabetes M A N A G I N G D I A B E T E S 22 F A L L / W I N T E R

23 have a slender build with normal body weight or are just slightly overweight do not have a strong family history of type 2 diabetes do have a personal or family history of auto immune disease test positive for antibodies that attack beta cells become dependent on insulin more quickly than those who have type 2 diabetes have minimal insulin resistance. Is LADA common? LADA is thought to affect 10 to 15 per cent of all people diagnosed with type 2 diabetes. This suggests that about five to 10 per cent of those with diabetes have LADA, although this number may be significantly higher. How is LADA diagnosed? As it usually appears later in life, LADA is often initially diagnosed as type 2 diabetes. Although people may respond well to oral medications at first, the effect may be short-lived (months to a few years). Sometimes they are not effective at all. People over age 30 who are newly diagnosed with diabetes, have a slender build, and no family history of type 2 diabetes, might want further tests to check for LADA. How is LADA treated? Even after LADA appears, the body still makes some insulin at first. Lifestyle factors, such as eating a healthy and balanced diet, may be enough to manage the disease for a while. Medications that treat insulin resistance are not effective, since insulin resistance is minimal or not occurring. The specific role of metformin and other insulin sensitizing drugs is not known, as no studies have evaluated their effect on LADA. Oral anti-diabetes medications can be effective early on. Sulfonylureas have proved effective in controlling blood glucose levels, as long as some beta cells in the pancreas still make insulin. Debate exists about whether to prescribe insulin immediately or delay it until needed. Since the beta cells that make insulin are continually and gradually destroyed, insulin will eventually be required. Some believe that using insulin earlier allows the remaining beta cells to survive longer. However, this is yet to be determined. On average, half of those who have LADA require insulin within four years of being diagnosed. Those who have true type 2 diabetes usually have over 10 years. A future with LADA Long-term complications of LADA are the same as for people with type 1 and type 2 diabetes. The need for blood glucose control and targets are also the same, though targets are often set individually for each person. Special care must be taken to avoid hypoglycemia and hyperglycemia. These can result in very serious complications. Checkups with the doctor and an eye care specialist must be done regularly. One major benefit is that once people with LADA have their blood glucose under control, they usually do not have the high risk of heart problems found with type 2 diabetes. insulin secretion level measurements (measuring C-peptide) Testing for LADA Certain following tests can help decide whether you have LADA. tests for autoantibodies glutamic acid decarboxylase antibody test islet cell antibody test Although LADA is becoming better known, your doctor may not be aware of it. Adults who have LADA are often incorrectly diagnosed at first as having type 2 diabetes. They are often put on oral type 2 diabetes medication with minimal or short lasting effectiveness. If you are not benefiting from traditional diabetes medications and suspect you have LADA, ask your doctor to test you for it. If this is the type of diabetes affecting you, correct diagnosis can get you on the right track with your diabetes management. WRITTEN BY: Audrey McLelland, BSc (Pharm), CDE, currently doing diabetes consulting in Saskatchewan. M A N A G I N G D I A B E T E S 23 F A L L / W I N T E R

24 CELIAC Diabetes and Disease Understanding the connection In celiac disease, the lining of the small intestine is damaged by gluten, a protein in grains such as wheat, rye, barley, oats and triticale. When these are eaten, the body s immune (defence) system reacts, damaging cells in the intestine that help absorb food. Since food passing through the intestine is not well absorbed, a variety of symptoms usually appear (see sidebar). Some people with celiac disease may have no symptoms if their bodies still have enough undamaged cells to absorb food. Celiac disease can affect anyone irrespective of age, ethnic background and sex. According to the Canadian Celiac Association, almost one per cent of Canadians have celiac disease. You may also be at higher risk if someone in your family, such as a parent, brother, sister or child, has celiac disease. Type 1 diabetes also increases the risk. It is thought that between four and nine per cent of children with type 1 diabetes also have celiac disease. What s the connection between celiac disease and type 1 diabetes? Type 1 diabetes and celiac disease appear to have a common genetic link found on several chromosomes (structures that carry genes) in the body. In those at risk, the immune system damages cells after being exposed to something in the environment. Researchers are working to identify the role the environment plays, but we do not yet know the trigger. A similar process happens in both type 1 diabetes and celiac disease. With type 1 diabetes, the immune system damages the islet cells in the pancreas that produce insulin. In celiac disease, the immune system harms cells of the small intestine. It is possible that for some people, gluten alone or with another factor, may damage the immunity of the body and increase the risk of type 1 diabetes. How do I know if I have celiac disease? In celiac disease, the immune system makes antibodies when the body is exposed to gluten. If you have symptoms, or family members with the condition, your doctor will order blood tests to check for these antibodies. If blood tests show them, you should have a small sample of tissue from the intestine removed to check for damage. This will require referral to a doctor who performs this type of procedure. M A N A G I N G D I A B E T E S 24 F A L L / W I N T E R

25 How is celiac disease treated? Staying healthy with celiac disease and diabetes means avoiding all foods that contain gluten. Most breads, pasta and cereals contain gluten. Following a gluten-free diet relieves symptoms, heals the intestine and prevents further damage. (See Safe Choices sidebar below). Some people with diabetes and celiac disease may notice improved blood glucose control and less hypoglycemia on a gluten-free diet. For those with diabetes who are diagnosed with celiac disease but have no symptoms, it is uncertain how much following a gluten-free diet will help. Researchers are working to identify the best treatment for people without symptoms. It is possible that even though you have no symptoms, damage still occurs. For this reason, it may be worth avoiding gluten. Symptoms of celiac disease diarrhea weight loss tiredness cramps bloating Safe choices lactose intolerance (trouble digesting the lactose in milk) irritability children may not put on weight or grow well. I have celiac disease and diabetes what can I eat? Carefully check ingredients on all food labels for grains and other ingredients that may contain gluten. Do this even with products you use often, as ingredients in a processed food may change. To be certain a product is still gluten-free, check food labels regularly and monitor the Canadian Celiac Association website for notices on food products and recalls. Additional help Many other foods are safe for people with celiac disease. Contact your dietitian for more information about celiac disease and foods included in the celiac diet. By caring properly for both your diabetes and celiac disease, you can feel better and avoid the risk of complications. Blood tests may show: anemia (a low number of red blood cells) low levels of certain vitamins. WRITTEN BY: Catherine Freeze, M Ed, RD, CDE, registered dietitian, seniors policy advisor, Charlottetown, PEI. Vegetables Vegetables prepared with no added sauces are a good choice. Avoid breaded coatings and batters. Meat & Alternatives Plain meat, fish, chicken, eggs, dried peas, beans, lentils, aged cheese, cottage cheeses and tofu are all safe choices on a gluten-free diet. Be aware that meat substitutes, cheese spreads and sauces, processed meats, imitation fish products (such as imitation crab), seasoned and dry roasted nuts and seeds may contain hydrolyzed wheat protein, wheat starch and other fillers containing gluten. Milk & Alternatives Milk, evaporated milk, milk powder and cereal cream are gluten-free choices. Fruits Fruits prepared with no added sauces or toppings are a good choice. The Canadian Celiac Association cautions that since dates may be dusted with dextrose or wheat flour, it is best to check the ingredient list or ask the grocer before buying bulk dates. Grains & Starches Breads, crackers, pasta and cereal made with rice, corn, soy and potato flours are generally safe choices. These foods are found in some grocery stores and specialty food shops, or can be made at home. Other choices This food group includes sugars and snack foods. Brown and white sugar, corn syrup, molasses, maple syrup, honey and jam are all gluten-free. Check food labels carefully to ensure there are no ingredients that contain gluten. Remember to talk with your dietitian about using snack foods. Extras Foods in this group, such as coffee, tea, diet drinks, spices, seasonings and condiments, are low in carbohydrate and calories. Check food labels carefully as some products, such as curry paste, seasoning mixtures, flavoured teas and coffees and specialty mustards, may contain ingredients with gluten. Fats Butter, margarine and vegetable oils do not contain gluten. Avoid salad dressings and cooking sprays that include wheat flour or wheat starch. For more information The Canadian Celiac Association provides information on celiac disease, gluten-free foods and recipe books through newsletters and meetings. Check to see if there is a branch near you. The Canadian Celiac Association: or M A N A G I N G D I A B E T E S 25 F A L L / W I N T E R

26 FreeStyle Precision Neo A simple meter that alerts you to highs and lows. Trend arrows reveal highs and lows Easy to read bright screen and large numbers Ask your pharmacist about FreeStyle Precision Neo today. Receive your meter FREE when you purchase 100 compatible test strips IMPORTANT: The information provided is not intended to be used for medical diagnosis or treatment or as a substitute for professional medical advice. For In Vitro Diagnostic Use Only. Refer to package insert/label accompanied with your product for detailed instructions and indications for use. FreeStyle and related brand marks are trademarks of Abbott Diabetes Care Inc. in various jurisdictions.

27 Could my Pet have Diabetes? We see and hear so much about diabetes that pet owners often recognize the signs in a pet. Still, it can be hard to believe that a cat or dog has been diagnosed with diabetes. As in humans, diabetes in pets can be insulin dependent (similar to type 1 diabetes) or non-insulin dependent (similar to type 2 diabetes). Typically, dogs are affected with insulin dependent diabetes. The cells of the pancreas are damaged and can no longer make insulin. To control the disease, insulin must be given. Cats can have either insulin dependent or non-insulin dependent diabetes. With the non-insulin dependent type, cells in the body fail to properly respond to insulin. Insulin injections may be necessary. What signs might I recognize? Signs of diabetes are very similar in cats, dogs and humans. The majority of the animals have a history of being obese or at least overweight. Other signs include recent weight loss, drinking water more often, urinating larger amounts and more frequently, and having accidents in the house. The animal also appears generally unwell. Poor appetite and weight loss are linked to a lack of regulation of metabolic processes that deal with glucose, fat and proteins. These metabolic problems can all cause lethargy, lack of coordination, and weakness in cats and dogs. Excessive thirst and passing more urine are tied to the high concentration of glucose in the bloodstream, which pours out into the urine to dilute the sugar. As a result, the most common sign in cats is larger, heavier clumps in the litter box. In dogs, the most common sign is accidents in the house. Protect the health of your furry friend M A N A G I N G D I A B E T E S 27 F A L L / W I N T E R

28 Flu ShotS Get yours at SaFeway Pharmacy Talk to our pharmacist for details. Stop by our pharmacy or book your appointment online! Visit to schedule your flu shot. Talk to your healthcare professional, including your Safeway Pharmacist, about having your own immunization record reviewed to determine your individual needs. Vaccines may not be suitable for everyone and do not protect all individuals against development of disease. Some vaccines may require a prescription. Vaccines may not be available in all locations. Age restrictions may apply. Check with our pharmacist for further information.

29 More advanced cases of diabetes in cats can also show as diabetic neuropathy. Normally, cats walk on their toes. Instead, the cat seems to walk like a kangaroo, with the hock (ankle) flat against the ground. A common sign of advanced or long-standing diabetes in dogs is a bluish cast to the eyes. A cataract may appear in one or both eyes. How is diabetes treated in cats and dogs? Regardless of the type of diabetes, initial treatment likely involves giving the pet insulin. Many different kinds of insulin are available. The type of insulin, number of times a day it is given, and adjustments to the dose should all be determined with a veterinarian s supervision. Most doctors recommend a change in diet and exercise for the pet. This attempts to better regulate daily changes in blood glucose. Most dogs will require insulin twice a day. They also need close monitoring of what and when they eat. With cats, it may be possible to regulate diabetes with diet and weight-loss alone. Special food and close monitoring are required. In newly diagnosed cats, it is now possible to induce a remission. With administration of specific insulin, complemented by specific foods and exercise to reduce excessive body weight, they will have few or no symptoms of their diabetes. Many vets also recommend monitoring a pet s glucose levels at home, where the pet is less stressed. This may result in more accurate readings. Cats are particularly likely to have a glucose spike in a hospital setting due to stress. When appropriate, urine testing can also be done at home to monitor glucose levels. Keeping good records of home testing of your pet s glucose levels can make a huge difference. This information helps your vet improve the regulation of your pet s glucose level. If diabetes is not regulated well, your pet will typically suffer more complications as the disease progresses. Controlling the diabetes gives pets a much better chance at better health and a longer, more normal life. How can I help my pet? If you notice that something seems off, have your pet seen by a vet. A thorough physical examination will be done. Your observations provide key information in diagnosing the cause of your pet s illness. The veterinarian will likely want to do some blood and urine tests to get an accurate diagnosis. Ask questions. It is important that you are comfortable, know what needs to be done, and understand what to do if you think that your pet is not responding properly. If you have any doubts at all, call your vet or the nearest veterinary emergency hospital for advice. WRITTEN BY: Michael Fife, DVM, a veterinarian practising in Chatham, ON. M A N A G I N G D I A B E T E S 29 F A L L / W I N T E R

30 Insulin Types INSULIN TYPE ONSET OF ACTION 1 PEAK OF ACTION 1 DURATION OF ACTION 1 RAPID ACTING Humalog (lispro) NovoRapid (aspart) Apidra (glulisine) 5 to 15 minutes 60 to 90 minutes 4 to 5 hours SHORT ACTING Humulin R (regular) Novolin ge Toronto Hypurin Regular (pork) 30 to 60 minutes 2.5 to 4 hours 5 to 8 hours INTERMEDIATE ACTING Humulin N Novolin ge NPH Hypurin NPH (pork) 1 to 3 hours 5 to 8 hours Up to 18 hours LONG ACTING Lantus (glargine) Levemir (detemir) 90 minutes No peak Up to 24 hours Toujeo (glargine U300) Develops over 6 hours* No peak Beyond 24 hours *Develops over 6 hours following an injection. After multiple daily doses, once the steady state is achieved, the action is constant throughout a 24-hour period. Steady state insulin concentrations are reached by approximately 4 days of once daily subcutaneous administration. PREMIXED SHORT ACTING AND INTERMEDIATE ACTING2 Humulin 30/70 Novolin ge 30/70 Novolin ge 40/60 Novolin ge 50/50 30 to 60 minutes 2.5 to 4 hours and 5 to 8 hours Up to 18 hours PREMIXED RAPID ACTING AND INTERMEDIATE ACTING 3/4 Humalog Mix 253 Humalog Mix 503 NovoMix to 15 minutes 60 to 90 minutes and 5 to 8 hours Up to 22 hours 1 Insulin action may vary in different people and at different times in the same person, so consider these times to be estimates only. 2 The first number is the percentage of short-acting insulin, the second the percentage of intermediate-acting (NPH) insulin. For instance, Humulin 30/70 is 30 per cent regular insulin and 70 per cent NPH insulin. 3 Humalog Mix 25 is a mixture of 25 per cent lispro insulin (rapid-acting insulin) and 75 per cent lispro protamine insulin (intermediate-acting insulin). Humalog Mix 50 combines 50 per cent lispro insulin and 50 per cent lispro protamine insulin. 4 NovoMix 30 is a mixture of 30 per cent aspart insulin (rapid-acting insulin) and 70 per cent aspart protamine insulin (intermediate-acting insulin). IT S EASY! Many vaccinations offered. Flu, shingles, meningococcal, pneumonia, Human Papillomavirus (HPV) and more. Convenient services available right in the pharmacy Vaccination services also available for businesses and other organizations. See Pharmacy for details. Fee for service may apply. Age restrictions do apply. Available vaccinations vary by location. Vaccines are not suitable for everyone. Talk to your doctor or pharmacist for more complete information. M A N A G I N G D I A B E T E S 30 F A L L / W I N T E R

31 Pharmacy Caring for your well-being. At Safeway Pharmacy we can help you manage your diabetes. We carry a full line of diabetes products including insulin pump supplies. Each prescription is carefully checked against your personal file for drug interactions. All locations accept sharps for disposal. Ask us for details. If you take more than one prescription, ask how Safeway medpaks can make taking your medication easier. Our medreminders program automatically refills selected prescriptions several days before they run out. Use our Safeway in-store blood pressure station. Ask about our SmartCard to help you keep track of up to 10 readings. Refill and transfer * requests can be done at online. * By law, not all prescriptions are transferable. Not all locations have Certified Diabetes Educator Pharmacists. EZ-Rx 24 Hour Refill Request Line You may qualify for an important service called Medication Review. During the Medication Review we will assess each medication you are on one by one to help you feel your best while taking them. Ask your pharmacist if this is the right service for you! All locations can provide training on the latest technology of blood glucose meters, insulin pens and blood pressure monitors. We also have a team of Certified Diabetes Educator Phamacists that can help you with your diabetes management.

32 REDISCOVER SIMPLICITY WITH ACCU-CHEK AVIVA Easy testing with a sleek design. No coding Easy strip handling Advanced accuracy Visit your Safeway pharmacy to get the FREE* Accu-Chek meter of your choice. Limit one Accu-Chek meter offer per customer. Offer expires May 30 th, Experience what s possible. *Free with the purchase of 100 Accu-Chek Aviva test strips. ACCU-CHEK and ACCU-CHEK AVIVA are trademarks of Roche Roche Diagnostics. All rights reserved. accu-chek.ca