Current Issues in Diabetes Management Flashcards
Diabetes Canada Guideline Recommendations for Nutrition Therapy (Diet)
• Nutrition therapy can reduce A1c by 1.0% to 2.0% and should be a foundational intervention for
management of anyone with diabetes.
• Reduced caloric intake to achieve and maintain a healthier body weight should be a treatment goal
for people with overweight or obesity.
• Replacing high-glycemic-index carbohydrates with low-glycemic-index carbohydrates in mixed
meals significantly benefits glycemic control.
• Consistency in spacing and intake of carbohydrate intake and meal consumption (intermittent
fasting) may help control blood glucose and weight.
• People with diabetes should be encouraged to choose the dietary pattern that best aligns with their
values, preferences, and treatment goals.
• People with diabetes should receive nutrition counselling by a registered dietician.
Diabetes Canada Guideline Recommendations
2018 Recommendations based on Canada Food Guide and macronutrient composition Carbohydrates come from Starches Sugars Fiber 45% to 60% of total energy from carbohydrates
have plenty of veggies, druits
eat protein foods, make water drink of choice, choose whole grain foods
Low Carbohydrate Diet
• <45% of daily energy from carbohydrates
– <130 gm of carbohydrates per day
– Very low carbohydrate diet (<50 gm/day)
• “Low Carb” ”Keto Diet” Atkins Diet
– Reduce the carbohydrate content of a diet by:
• Increasing the amount of protein and fat in the diet
• Using low-glycemic-index foods
– Scale used to identify how fast and how high a carbohydrate-containing food will raise the
blood glucose.
– Glucose is arbitrarily given an index value of 100
Low Carbohydrate Diet
Advantages / Uncertainties
• Advantages – Helps with weight management: Excess calorie intake and over- consumption of refined carbohydrates are major drivers of obesity and type 2 diabetes – Reduces A1c – Reduces daily insulin requirements • Uncertainties – Most studies are short-term (3-6 months) – High dropout rate – Long-term benefits …?????
Low Carbohydrate Diet
Diabetes Management Implications
• Increased risk of hypoglycemia if someone is using insulin, sulfonylureas,
or meglitinides
–> REDUCE DOSE or DISCONTINUE
• Increased risk of ketoacidosis if someone is using an SGLT2 inhibitor
–> ”Usually stop in community setting”
• Metformin, GLP1ra, DPP4 inhibitor, acarbose: need to consider risk versus
benefit on individual basis
• Blood glucose monitoring should be an integral part of this strategy
Insulin Analogues and Cancer
- Diabetologia issue in 2009 published 4 observational studies of glargine & cancer
- Biologically plausible mechanism: insulin analogues have altered affinity to IGF
- Numerous design flaws (poor definition of exposure, confounding by indication)
- ORIGIN Trial5 (large-scale RCT) found no association between glargine use and cancer risk
- BOTTOM LINE: No solid evidence that insulin or insulin analogues have any association with cancer risk
Pioglitazone and Bladder Cancer
Two observational studies found a significant association between pioglitazone
use and bladder cancer risk
– Neumann et al. (2012)2 HR: 1.22 (1.05-1.43)
• Pioglitazone users 0.49 per 1,000 person-years
• Non-exposed 0.43 per 1,000 person-years
– Lewis et al. (2011)3 HR: 1.2 (0.9-1.5) ever vs never
HR: 1.4 (1.03-2.0) >24mo therapy vs never
• Pioglitazone users 0.82 per 1,000 person-years
• Non-exposed 0.69 per 1,000 person-years
Pharmacoepidemiology Studies
Influencing Policy
• In response to the Neumann study…
– France and Germany withdrew pioglitazone from the market
• Based on observations from PROactive and the two observational
studies at the time…
– US Food and Drug Agency recommended pioglitazone should be avoided
in patients with previous bladder cancer
– European Medicine Agency followed FDA recommendation & extended
this to include patients with uninvestigated macroscopic hematuria
Current Evidence of Pioglitazone
& Bladder Cancer
• Subsequent observational studies and meta-analyses reported conflicting observations
• Recognition that there are issues with observational study design
– Sample size (low incidence rate of bladder cancer: <1 case per 1,000 person-year)
– Potential biases (surveillance bias, immortal time bias, misclassification bias, etc)
• Pooled analysis from 6 population-based studies concluded pioglitazone use was not associated with the risk of bladder cancer
Other Drug-Disease Interactions
Related to Diabetes
• Drugs associated with an increased risk of diabetes
– Atypical antipsychotics
– Antidepressants
• Drugs known to increase blood glucose
– Beta-adrenergic agents (e.g., OTC decongestants)
• Increases release of both insulin & glucagon, but the overall effect is an elevation of blood glucose levels
– Glucocorticoids
– Highly Active Anti-Retroviral Therapy (HAART)
– Interferon alpha
– Nicotinic acid
– Pentamidine
– Thiazide diuretics (Clinically important difference? …see next slide)
• Beta-blockers can cause or exacerbate hypoglycemia (inhibits hepatic glucose production)
and mask some of the symptoms of hypoglycemia
Thiazide Use and
Change in Fasting Blood Glucose
• Meta-analyses of randomized controlled trials
– Zhang X, Zhao Q. J Clin Hypertens 2015:18:1-10
• 26 studies
• Weighted Mean Difference: 0.27 mmol/L increase (95% CI: 0.15-0.39)
– Hall JJ, Eurich DT, Nagy D, et al. J Gen Intern Med 2020;35:1849-60
• 95 studies
• Weighted Mean Difference: 0.20 mmol/L increase (95% CI: 0.15-0.25)
– No substantive difference when considering dose, duration of treatment, comparison
with placebo or an active comparator, using thiazide as monotherapy or in combination
Hypoglycemia
Signs & Symptoms
beta blocker use can cause…
Beta-blocker use ü Blood pressure control ü Post-MI management ✘ Can cause hypoglycemia ✘ Can mask symptoms of hypoglycemia
know symptoms based on hypoglycemia:
- sweating, trembling, palpitations, anxiety
- hunger, nausea, headache, tingling
- disturbed sleep, weird dreams, weakness/dizziness, difficulty concentrating
- vision changes, drowsiness, difficulty speaking, unconsciousness
Is Blood Glucose Meter Accuracy a Big Deal?
• Health Canada: recognizes ISO 15197:2013
– International Organization for Standardization defines blood glucose
meter performance requirements
• When comparing the meter reading to a laboratory standard,
≥95% of measurements must fall within….
– ±0.8 mmol/L for blood glucose concentrations <4.2 mmol/L
– ±20% for blood glucose concentrations ≥4.2 mmol/L
– So if a blood glucose meter result was 4.5 mmol/L….
• What could the actual blood level be?
trend of accuracy of bg meters
getting more accurate since 2010- 2020
least accurate 2012
Flash Glucose Monitors
Measures glucose in subcutaneous interstitial fluid
• Delayed response to glucose changes in blood
• No standard (yet!) for assessing accuracy
