1. Diabetes Charter (Appendix 1)
Key Takeaway: The Charter defines the rights and responsibilities of people living with diabetes, healthcare providers, governments, and organizations. The central theme is dignity, respect, and equity.
- The Vision: A country where people with diabetes live to their full potential.
- Guiding Principles:
- Treat people with dignity and respect.
- Advocate for equitable access to care.
- Enhance quality of life for patients and caregivers.
A. Rights of Canadians with Diabetes
- Respect & Dignity: To be free from stigma and discrimination.
- Access: Affordable/timely access to meds, devices, supplies, and healthy food regardless of income or location.
- Care Team: Timely diagnosis and education from an interprofessional team (nurse, dietitian, pharmacist, etc.).
- Decision Making: To be an active partner in decisions regarding their own care.
- Accommodation:
- Schools/Daycares: Full participation with reasonable accommodation and assistance.
- Workplaces: Supportive environments that do not discriminate and provide reasonable accommodation.
B. Responsibilities of Canadians with Diabetes
- Self-Management: Manage diet, exercise, and medication to the best of their ability and personal circumstances.
- Transparency: Be honest and open with health providers to allow for suitable care plans.
- Education: Actively seek information and support.
C. Responsibilities of Health-Care Providers
- Partnership: Treat people with diabetes as full partners in their care.
- Evidence-Based Care: Apply up-to-date clinical practice guidelines (CPG).
- Early Diagnosis: Diagnose diabetes as early as possible.
- System Navigation: Help patients navigate the healthcare system.
D. Institutional Responsibilities
- Schools/Daycares: Must ensure staff have accurate information, provide a safe environment for self-management, and protect children from discrimination.
- Workplaces: Must eliminate discrimination and provide accommodation.
- Governments: Guarantee fair access to care regardless of income/location and address disparities in vulnerable populations.
2. Etiology & Classification (Appendix 2)
Key Takeaway: While Type 1 and Type 2 are most common, you must recognize “Other Specific Types” often triggered by medications or genetics.
- Drug-Induced Diabetes: Be able to identify drugs that induce hyperglycemia:
- Glucocorticoids (e.g., prednisone)
- Atypical Antipsychotics (e.g., clozapine, olanzapine)
- Statins (HMG CoA reductase inhibitors)
- Thiazides (diuretics)
- Calcineurin inhibitors (transplant drugs)
- Genetic Syndromes: Commonly associated with diabetes include Down syndrome, Turner syndrome, and Klinefelter syndrome.
3. Physical Activity Prescription (Appendix 4)
Key Takeaway: “Smarter Step Count” prescription.
- Goal: Increase baseline step count by 3,000 steps per day within 1 year.
- Increments:
- If baseline <5,000 steps: Add 500 steps at first visit.
- If baseline 5,000-7,499: Add 750 steps at first visit.
- If baseline 7,500: Add 1,000 steps at first visit.
5. Self-Monitoring of Blood Glucose (SMBG) (Appendix 5)
Key Takeaway: Frequency of testing depends on the treatment regimen and glycemic stability.
- Basal-Bolus (MDI) or Pump: Test 4 times daily (before meals and bedtime).
- Oral Agents / Lifestyle only: If meeting targets, frequent testing is not usually required.
- Newly Diagnosed (<6 mos): Test 1 time/day at different times to learn how lifestyle affects BG.
- Safety Occupations: As required by employer/driving guidelines.
6. Insulin Pharmacokinetics (Appendix 6)
Key Takeaway: You must know the Onset, Peak, and Duration to troubleshoot hypoglycemia or hyperglycemia patterns.
| Insulin Type | Examples | Onset | Peak | Duration |
Rapid- | Aspart, Lispro, Glulisine | 10–15 min | 1–2 h | 3–5 h
|
| Short- Acting | Regular (Toronto) | 30 min | 2–3 h | 6.5 h
|
| Intermediate | NPH (Cloudy) | 1–3 h | 5–8 h | Up to 18 h
|
| Long- Acting | Glargine U-100, Detemir | 90 min | None | Up to 24 h
|
| Ultra-Long | Degludec, Glargine U-300 | 90 min | None | >30 h
|
7. Sick Day Management: "SADMANS" (Appendix 8)
Key Takeaway: When a patient is ill, dehydrated, or has acute renal decline, certain medications must be PAUSED to prevent acute kidney injury (AKI) or adverse effects.
Instructions: Stop the following meds if unable to maintain hydration; restart when well.
- S – Sulfonylureas (risk of hypoglycemia)
- A – ACE Inhibitors (risk of renal decline)
- D – Diuretics / Direct Renin Inhibitors (risk of volume depletion)
- M – Metformin (risk of lactic acidosis/reduced clearance)
- A – Angiotensin Receptor Blockers (ARBs) (risk of renal decline)
- N – Non-steroidal Anti-inflammatory Drugs (NSAIDs) (risk of renal decline)
- S – SGLT2 Inhibitors (risk of DKA/volume depletion)
Exam Tip: Remember that insulin should not inherently be stopped during sick days; often doses need adjustment (usually increasing) due to stress hyperglycemia, but the “SADMANS” list refers specifically to non-insulin meds that pose safety risks during dehydration.
8. Insulin Initiation & Titration in T2D (Appendix 9)
Key Takeaway: The standard approach for starting insulin in Type 2 Diabetes involves safety first (avoiding hypo) and gradual titration.
- Starting Basal Insulin:
- Start: 10 units at bedtime.
- Titrate: Increase by 1 unit per day until fasting glucose target (4.0–7.0 mmol/L) is reached.
- Exception: Degludec is titrated every 3–4 days (2 units) or once weekly (4 units) due to longer half-life.
- Safety Rule: Do not increase dose if the patient has >2 hypo episodes (<4.0 mmol/L) in a week or any nocturnal hypoglycemia.
- Adding Bolus (Basal Plus): Start 2–4 units at one meal (usually largest). Titrate by 1 unit daily to target 2hr post-meal 8.0 mmol/L .
9. Driving Guidelines (Appendix 10)
Key Takeaway: Assessment for fitness to drive focuses on hypoglycemia awareness and severity.
- Commercial Drivers: Disqualified if they have any episodes of severe hypoglycemia during waking hours in the past 12 months .
- Private Drivers: Assessment focuses on severe hypoglycemia in the past 6 months .
- Monitoring Rule: Drivers on insulin/secretagogues must monitor at least every 4 hours while driving.
- Supplies: Must have monitoring equipment and rapid carbs within reach in the vehicle.
10. Foot Care & Neuropathy Screening (Appendices 11, 12, 13)
Key Takeaway: Screening must be done annually using a 10g Monofilament or 128 Hz Tuning fork to assess risk of ulceration.
A. 10g Semmes-Weinstein Monofilament Test
- Technique: Apply perpendicular to skin until it buckles for ~1 second.
- Sites: Dorsum of great toe (screening) or plantar sites (comprehensive).
- Scoring (Screening):
- Test 8 stimuli (4 per foot).
- Score < 3/8 correct = Likely Neuropathy.
- Protective sensation is absent if 2 out of 3 applications at a single site are incorrect.
B. 128 Hz Tuning Fork (On-Off Method)
Apply to the bony prominence of the great toe.
Patient must identify when vibration is felt and when it stops.
C. Foot Care Checklist
- DO: Check feet daily, use mirror, trim nails straight across, buy shoes in late afternoon (feet swell).
- DO NOT: Soak feet, use hot water bottles, walk barefoot, use over-the-counter corn/wart removers.