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Diabetes Program News
Queens Health Region, Prince Edward Island
Volume 4, No 2 September, 2004
In this issue
g Neuropathy and Diabetes g Foot assessment
g g g g Parents Day-2004 Client satisfaction survey Physicia n referrals Pregnancy and Diabetes workshop g Physicia n referrals g On going grow th g Co ng ratulations
Neuropathy and Diabetes
Neuropathy is a complication often invisible to those not living with it Diabetic neuropathies are a family of nerve disorders caused by diabetes People with diabetes can, over time, have damage to nerves throughout the body Neuropathies lead to numbness and sometimes pain and weakness in the hands, arms, feet, and legs Problems may also occur in every organ system, including the digestive tract, heart, and sex organs People with diabetes can develop nerve problems at any time, but the longer a person has diabetes, the greater the risk1 The National Diabetes Fact Sheet 20042 indicates 60 to 70 of people with diabetes have mild to severe forms of nervous
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system damage The highest rates are seen in people who have had diabetes for at least 25 years The 2003 Canadian Diabetes Association Clinical Practice Guidelines report Detectable
sensorimotor polyneuropathy will develop within 10 years of the onset of diabetes mellitus in people with type 1 or type 2 diabetes3 These guidelines also indicate that while people with type 2 diabetes often exhibit signs of neuropathy early upon or shortly after diagnosis, in those with type 1 diabetes neuropathy
http://diabetesniddknihgov/dm/pubs/neuropathies National Diabetes Fact Sheet 2004, http://wwwcdcgov/diabetes/pubs/factsheethtm Diabetes P rogra m
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2003 C linical Practical Guidelines for the Management of Diabetes in Canada Volume 4, No 2 September 2004
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Queens Health Region, Prince Edward Island is uncommon in the first 5 years after diagnosis Neuropathy also appears to be more common in those who have been unable to manage any or/a combination of blood glucose levels, blood lipid and blood pressure It is more common in those over age 40 and individuals who are overweight There are four types of neuropathy: peripheral, autonomic, proximal, and focal, with the latter two being less common Each type affects different parts of the body and has unique effects Peripheral neuropathy, also called distal symmetric neuropathy, is the most common and causes either pain or
loss of feeling in the toes, feet, legs, hands, and arms Autonomic neuropathy, second most common affects the autonomic nervous system and causes changes in digestion, bowel and bladder function, sexual response, and perspiration It can also affect the nerves that serve the heart and control blood pressure Autonomic neuropathy can also cause hypoglycemia unawareness, where people no longer experience the warning signs of hypoglycemia Hypoglycemia unawareness is seen more often in those who have had diabetes for a long time Proximal neuropathy causes pain in the thighs, hips, or buttocks and leads to weakness in the legs, while focal neuropathy causes muscle weakness or pain resulting from sudden weakness of one nerve or a group of nerves With focal neuropathy, any nerve in the body may be affected The symptoms of neuropathy are determined by which nerves are affected and the type of neuropathy The first sign is often numbness, tingling or pain in the feet, although some people experience no symptoms at all Nerve damage develops over a period of several years, so mild cases may go unnoticed Peripheral Neuropathy
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Perhipheral neuropathy is usually the first type of neuropathy to
develop Numbness and tingling in the feet is usually the first sign Other signs are: Unawareness or inability to feel pain or temperature changes Burning or prickling feelings Sharp pains or cramps Sensitivity to touch, even light touch Loss of balance and coordination
These symptoms are often worse at night Muscle weakness and loss of reflexes, especially at the ankle, leading to changes in gait walking often occurs with peripheral neuropathy Sores or blisters can often appear on numb areas of the foot with slight pressure or injury and go unnoticed Foot deformities, such as hammertoes and the collapse of the midfoot, can also occur Foot injuries require immediate treatment to prevent infection from spreading to the bone and causing gangrene and ultimately amputation of toes, foot or limb Comprehensive screening as recommended in the Canadian Diabetes Association Clinical Practice Guidelines is the best method of detecting and managing neuropathy The guidelines recommend: Screening for peripheral neuropathy should be carried out annually to identify those at high risk of developing foot ulcers Screening should begin at diagnosis in people with type 2 diabetes and after 5
years duration of type 1 diabetes in postpubertal individuals It is estimated
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Queens Health Region, Prince Edward Island that comprehensive foot care programs can reduce amputation rates by 45 to 854 Amputation of toe, foot or limb due to neuropathy is a major contributor to hospital stay throughout North America The Centre for Disease Control, Atlanta Georgia, reports: In North America it is estimated that foot complications in people with diabetes account for approximately 20 of all admissions to hospital In 2002, there were 830,000 discharges with a lower extremity condition as either the first-listed or secondary diagnosis In about 30 of these discharges, it was the first-listed diagnosis5 In the US, Autonomic neuropathy
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Autonomic neuropathy affects the nerves in the heart, stomach, intestines, bladder and sex organs It has many manifestations including: Gastroparesis is nerve damage which creates problems with the stomach and/or intestines by slowing down digestion and delaying passage of the food through the system This may result in variety of symptoms such as indigestion, belching, nausea, vomiting, diarrhea and
constipation Blood glucose levels can be difficult to manage due to abnormal food digestion Rapid fluctuations in blood pressure hypotension when moving from a sitting to standing position causing lightheadedness, dizziness or faintness Decreased sexual function in both males and females Failure to get an erection [in men] impotence occurs in about 40 of males with diabetes Vaginal dryness and decreased nerve sensation in females is common Neuropathy can affect bladder control and emptying resulting in incontinence and increased incidence of bladder, kidney and urinary tract infections Damage to the nerves of the heart that make it difficult for the heart beat to respond to changes in activity Sweat glands may be unable to regulate body temperature and there can also be profuse sweating at night or while eating
hospitalizations for lower extremity conditions have increased significantly since 1980 and continue to increase DrStewart Harris reports that diabetes increases the risk of lower limb amputation by 20 fold and projections for amputation in Canada by 2006 are estimated at 10, 5736
National Diabetes Fact Sheet-2004, http://wwwcdcgov/diabetes/pubs/factsheethtm
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4
Ibid
Time For Action , Diabetes, An Epidemic of the New Millennium Program Policy Implications for Canada, Dr Stewart Harris, University of Western Ontario, May 2003
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Queens Health Region, Prince Edward Island The pupils of the eyes become less responsive to changes in light with neuropathy This makes it difficult to drive at night or adapt to lights being turned on and off Diagnosis, treatment prevention Diagnosis of neuropathy is usually based on the symptoms expressed by the client and a physical exam There are a number of components that may be examined including blood pressure and heart rate, muscle strength, reflexes, and sensitivity to position, vibration, temperature, ability to feel touch dependent on the symptoms Essential to all people with diabetes is a foot examination Treatment of neuropathy varies depending on the condition and symptoms experienced, however the first step is to bring blood glucose levels within the normal range Symptoms may often get worse when blood glucose is first brought under control, 4-7 mmol/L before meals and 5-10 mmol/L 2 hours after meals however over time and with improved
control neuropathic symptoms will improve Most importantly, blood glucose levels in the target range help to prevent further nerve damage and may prevent or delay the onset of further problems For pain and symptom relief, medications are used as needed, depending on the type of nerve damage Prevention is key with neuropathy Regular checkups including an annual foot exam, not smoking and trying to maintain good blood glucose control are essential steps in reducing the development of neuropathy
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Foot Assessment One year later- what have we seen? On July 1, 2003, clients of the Diabetes Program in Queens were offered a foot assessment when the 
y were seen for initial, re-referral or annual visits This initiative was based on the Clinical Practice Guidelines for the Management of Diabetes in Canada which recommend, Foot examinations in adults by both patients and healthcare providers should be an integral component of diabetes management to decrease the risk of foot lesions and amputations Foot examination should include assessment of structural abnormalities, neuropathy, vascular disease, ulcerations and evidence of infection Foot examinations should be performed
at least annually in all people with diabetes, commencing at puberty and at more frequent intervals in those at high risk Low risk feet are considered those with intact protective sensation, where pedal pulses are present and there are no severe deformities, prior foot ulcers or amputations High risk feet are those with loss of sensation, absent pedal pulses, severe deformities, previous foot ulcer or prior amputation Over the past year, 149 exams were performed at the Diabetes Program office in Queens This was about 19 of the clients who received service during that year Only 11 of new clients and 15 of re-referrals had a foot exam, while 66 of clients who booked themselves for a yearly followup had a foot exam Foot exams are often not done on the first visit with the former two client groups, so many more of these clients may have a foot exam in the upcoming future Of these clients 43 had low risk feet and 57 had high risk feet As can be seen in the following graph, 50 of those newly referred had foot exams which indicated they had high risk feet
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How are we doing? Client Satisfaction
In an effort to
determine the level of client satisfaction in our services a satisfaction survey was developed One hundred surveys were mailed out to families receiving services from the Queens Region Diabetes Program Copies of the survey were also placed in our waiting area for clients to fill out at their leisure The results of the survey have been compiled and are encouraging 829 of clients rated the overall service received as either good or very good Diabetes Management 805 of clients reported that their overall diabetes management had improved since using the services of our program Many reported better meal planning skills, increased activity, improved blood sugar control, and an overall increase in awareness and understanding of their diabetes Who responded? Over 70 of clients surveyed had type 2 diabetes, with 83 of the respondents indicating they were over the age of 49
As would be expected, clients re-referred to the program usually to improve control or for treatment changes had a higher rate of high risk feet Sixty-six percent of those re-referred clients who had foot exams had high risk feet One important component of the foot exam is education on daily foot inspections and good
foot care Over the next year, one goal of the program will be to increase the rate of foot exams amongst all client groups
Parents Day
Parents Day for parents of children with diabetes was held on Friday May 14, 2004 The keynote speaker for the day was Dr Arita Mokashi, Pediatric Endocrinologist from the IWK Health Centre, Halifax, Nova Scotia Approximately 40 people attended this interesting day where there were a variety of presentations and case studies from Diabetes Program staff and QEH pediatricians There were also opportunities for networking over lunch and breaks Feedback from parents indicated the need to have more regular sessions and included other family members as well
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Only 30 of these clients reported that they had visited our website wwwpeidiabetesca This may be reflective of the individuals who answered the survey
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Queens Health Region, Prince Edward Island What else did we learn? Of those who responded, 78 indicated that referral to our program came from their family physician Although more than 73 of clients responded that the Diabetes Programs hours were convenient, many respondents noted having to take time
off work to attend classes and appointments They also suggested that evening and weekends would be easier Most of our clients live close to the Diabetes Program office On average clients travel 10 km to our program facility located in the Sherwood Shopping Centre Physician referrals The Diabetes Program recently examined physician referral trends over the past two years During the 2002-2003, sixty five physicians referred clients to the Diabetes Program in Queens In 2003-2004, this number increased to 70 The average number of referrals per physician was 10, ranging from one referral per year to a high of 33 Referrals to the program were made mainly by family physicians, with nine specialists in 2002-03 and ten in 2003-04 including obstetricians, internists and pediatricians also referring regularly In 20032004, seven clients referred had no regular family physician See chart below
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Pregnancy and Diabetes workshop
On June 11, 2004 a Pregnancy and Diabetes workshop was held at the QEH for health professionals from across the province The program was well attended by obstetricians, internists, diabetes program staff, dietitians, maternity and physician office staff, and students
from a variety of disciplines Keynote speakers for the day were Dr Anthony Armson, Dr Allan Shlossberg and Lois Ferguson, RN, CDE from the IWK Health Centre, Halifax, Nova Scotia They shared practical information on the management of gestational diabetes and pre-existing diabetes and pregnancy The day also provided an opportunity for face to face interaction with health professionals who talk primarily by phone and fax Dr Armson reviewed neonatal morbidity comparing those without diabetes, to that of women with gestational diabetes and pre-existing diabetes In all cases of mothers with either of the latter conditions, the neonates were at increased risk for shoulder dystocia, hypoglycemia, jaundice, respiratory distress syndrome or asphyxia See following All presenters encouraged careful management of gestational diabetes as management improves pre-natal outcomes, by:
ß ß ß ß ß ß ß perinatal m orbidity macro somia neo natal hypo glycem ia resp iratory distress syn dro me/hyperbilirubinem ia m aternal traum a long-term obes ity in neona te glucos e intolerance in neon ate
Re ferrals
2002-2003 Do ctors
2003-2004 Do ctors
5 or less 6 to 10 11 to 15 16 to 20 21 to 25 26 to 30
over 30 Total
31 8 10 8 5 2 1 65
33 9 9 8 9 0 2 70
The team indicated gestational diabetes identifies females at risk for type 2 diabetes, impaired fasting glucose, impaired glucose tolerance, dyslipidemia and allows for earlier preventative intervention Risk
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factor identification in early pregnancy was stressed At the first pre-natal visit measurement of body mass index BMI to determine those with elevated BMI greater than 30 and identify other risk factors may help to provide better prenatal outcomes With regard to pre-existing diabetes and pregnancy, it was noted that management by a diabetes healthcare team can help to decrease risk of: spontaneous abortions
congenital malformations pregnancy-induced hypertension progression of retinopathy in the mother
the number of referrals to the program, with the increase being reflected in the number of re-referrals The re-referrals increased by 23, while for the first time in many years, the number of new referrals to the program remained about the same; 374 in 2003-2004 versus 386 in 2002-2003 See chart which follows The type of
clients remained stable, with the exception of more At Risk those with Impaired Fasting Glucose or Impaired Glucose Tolerance individuals being referred to the program In additional to the new and re-referral clients, the Diabetes Program in Queens also sent Yearly followup notices to over 600 clients
Appropriate management of pre-existing diabetes and pregnancy is estimated to provide a cost savings of 34,000 US per pregnant female Feedback from this interesting workshop from all attendees was very positive Copies of the material presented are available by contacting the Diabetes Program at 368-6438
Congratulations
Congratulations are extended to Michelle Hogan, RN, Diabetes Nurse Educator from our office and her partner Ronnie, on the birth of their daughter Daria Grace, September 2, 2004 at the Queen Elizabeth Hospital in Charlottetown Michelle is now busy at home with new tasks and we wish her every success with the challenges of parenthood
Ongoing Growth
The number of clients referred to the Diabetes Program in Queens continued to rise during the 2003-2004 fiscal year There was a 7 increase in
Diabetes P rogra m For further information or to provide feedback about
newsletter contents, contact the Diabetes Program at 902-368-4959 or e-mail:info@p eidiabetespeca
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