B. Caregiver Challenges

Being a working parent caring for a child with type 1 diabetes can be challenging. Cyndi Orth works for a school district in Abbotsford, BC, and is a caregiver for her daughter Sophia who lives with type 1 diabetes. Sophia was diagnosed at three years of age and is now 18 and off to university. “When Sophia was young, I didn’t have any support for her in school and I had no family that lived close by. I had to go give her insulin injections at school. At that time, I was very fortunate and had an amazing boss. If I got an emergency call or text from the school that Sophia was running low, he would just say ‘go.’”

Sophia was hospitalized with diabetic ketoacidosis three times during her primary school years. When she was in hospital, Orth says, “I used up my sick days to be there with her. Fortunately, I had the flexibility to use them in that way and was never sick during her younger years.” When she ran out of sick days, Orth had to take days off without pay.

When Sophia was younger, either Orth or her husband would wake every day between 1:00 a.m. and 2:00 a.m. to check her blood sugar. “We were tired because of our interrupted sleep, which, of course, impacted our performance at work,” says Orth. “You try to get used to it, but you don’t, because sleep is important.”

Sophia is always top of mind for Orth and her husband. When Sophia was younger, they asked themselves, “How do we work today knowing that she is safe?” “We always arranged our schedule so one of us would be able to get to the school and look after her. I always had to have my phone on standby and close to me.”

Sometimes when Orth was presenting at work, she’d get a text or phone call. “I’d think, Sophia might be experiencing a low. Do I take it, or do I continue?”

When Orth knew that she wouldn’t be able to take a call, her husband, who used to be a travelling salesperson, arranged his schedule so he would be in the community that day in case Sophia needed help at school.

C. Diabetes Management

People living with diabetes must manage their blood sugar levels through lifestyle choices, diabetes technology and medication. The objective is to avoid life-threatening hypoglycemia (low blood sugar) and the potential of long-term damage of hyperglycemia (high blood sugar).^{44, 45} 

D. Diabetes Care – A Team Effort

“Diabetes support takes a healthcare team,” explains Quiambao. This may include family doctors, endocrinologists, nurses, dietitians, chiropodists, mental- health practitioners and pharmacists, along with social support from family and caregivers. “Coordinated care may be required because healthcare providers often work in silos, which can be challenging for people living with diabetes,” she says.

E. Diabetes Educators

Diabetes educators are a key member of the diabetes care team. They are health professionals who specialize in diabetes treatment who partner with people with diabetes and their families to teach, coach and guide them to develop behaviour-change goals to improve their health and to develop a management plan that fits their lifestyle, beliefs and culture.

“The approach of diabetes educators has been changing,” says Ontario-based Certified Diabetes Educator and Registered Nurse Connie Tanner. In the past, a diabetes educator would tell the person with diabetes what they needed to do and expect them to follow the instructions, she says. “Our role now is to provide the person with diabetes with the skills and knowledge they need to manage their condition, to help access resources they need, and support behaviour change and empowerment. In essence, we help the person with diabetes to identify what is important to them and support them in working toward their priorities.”

F. Whole Person Model for Holistic Care⁵²

To deliver a better experience and generate positive outcomes, diabetes care should consider the whole person and look beyond simply their medical condition(s). Although a medical prognosis may be the same for two people, the best sup-port could be vastly different for each of them. Knowing the whole person allows their care plan to be tailored to the individual, and results in better outcomes.

“Our experience demonstrates that people living with diabetes have a higher incidence of being treated for heart disease, gastrointestinal issues and mental-health issues,” says Colleen Adams, manager, health & digital product solutions, Medavie Blue Cross. “This demonstrates the need to treat people living with diabetes holistically, with solutions that address more than just monitoring blood sugar levels.”

G. Glucose Levels^{53, 54, 55}

Checking blood glucose levels is important for people with diabetes because the results help guide decisions about what to eat, physical activity and medication use to ensure that blood sugar levels are stable and in the healthy range.

ii. Time in Range^{70, 71, 72, 73, 74, 75}

Instead of measuring average blood sugar via the A1C test, there is growing interest from diabetes experts in tracking time in range (TIR): the percentage of time that a person’s blood glucose level is in their recommended target range (see Glucose Targets). The A1C average does not capture glycemic variability, the fluctuations in glucose values of people living with diabetes. Two people can have the same A1C value but have a wide range of high and low blood glucose values, which results in a different TIR (see Figure 1).

Time in range goals may be individualized for each person; however, generally people with diabetes should aim to be in-range as much as possible, with a recommendation of least 70% TIR. Evidence is growing that increased TIR reduces the likelihood of diabetes complications. Experts indicate that a TIR of 70% equates to an A1C of about 7%, and each 10% increase in TIR equates to a 0.5% decrease in A1C.

iii. Evidence-Based Guidance for Blood Glucose Monitoring

Diabetes Canada recently updated its blood glucose monitoring recommendations^{77, 78} for Canadians living with diabetes to reflect new and emerging research that has been conducted within the past few years. The recommendations on glucose monitoring type and frequency prioritize safety and improved outcomes for people living with diabetes. These recommendations offer healthcare providers evidence-based guidance on the types of devices that are best suited to people living with diabetes based on their disease type, medications and treatment goals. 

Benefit plan managers may find it helpful to refer to these recommendations to determine coverage of glucose monitoring devices for employees or their family members living with diabetes. 

iv. Benefits of Glucose Monitoring Devices^{79, 80, 81, 82, 83, 84, 85}

According to Diabetes Canada, glucose monitoring devices such as intermittently scanned continuous glucose monitoring (isCGM) (formerly known as flash glucose monitoring) and real-time continuous glucose monitoring (rtCGM) (also known as continuous glucose monitoring or CGM) “have the potential to improve blood sugar management and quality of life for people living with diabetes, resulting in physical, social, emotional, and functional benefits.”⁸⁶

Glucose monitoring technologies allow the person with diabetes to collect more data about their glucose, says Tanner, and “drive behaviour and lifestyle changes to improve their condition and make the day-to-day life with diabetes easier.”

Not only do the devices eliminate many of the finger pricks required by more traditional glucose

meters, but they also help people with diabetes stay within their target blood sugar range. Traditional blood glucose monitoring and A1C tests don’t capture glucose variability (the ups and downs of sugar levels) and don’t provide any indication of trends. 

The devices may have alarms that alert people or their caregivers when their levels drop too low, for example, overnight while sleeping or while a child with diabetes is at school. 

This can be particularly helpful for people with hypoglycemia unawareness. 

Glucose monitoring devices can track and report glucose historical trend information, which allows the person with diabetes and their healthcare team to analyze glucose patterns and adapt treatment as needed. The devices allow remote tracking by healthcare providers to support digital diabetes care. In addition, real-time continuous glucose monitoring (rtCGM) can be integrated with insulin pumps to develop hybrid closed-loop insulin delivery systems (HCL), which automatically adjust insulin delivery based on rtCGM input. 

v. Insulin Treatment⁸⁹

Insulin therapy is required for the management of type 1 diabetes and sometimes type 2 diabetes. It is prescribed by healthcare providers based on people’s goals, lifestyle, meal plan, age and general health, as well as social and financial factors. 

Insulin is injected by pen, syringe or insulin pump, and healthcare providers work with people with diabetes to determine the number, timing and dose of daily injections needed per day and whether an insulin pump is appropriate. The objective is to achieve blood glucose levels that are as close to target as possible to decrease hyperglycemia and avoid hypoglycemia. 

v. Insulin Pumps^{90, 91,92,93}

Insulin pumps⁹⁴ are an alternative to multiple daily insulin injections, and their clinical effectiveness is well documented. Diabetes Canada’s Clinical Practice Guidelines state that insulin pump therapy can be beneficial for some people with type 1 diabetes. 

Pumps can closely mimic the normal action of a healthy pancreas and allow glucose levels to be managed more precisely. They can be programmed to increase or decrease the amount of insulin delivered for a specified period or can calculate recommended insulin correction doses. 

Insulin pumps can be life-changing for individuals living with type 1 diabetes, says Tanner. “Imagine having diabetes from a very young age, needing insulin injections four or more times per day. In one year alone, you would need a least 1,460 injections. An insulin pump takes away some of this burden.” 

An insulin pump also allows flexibility with insulin delivery, explains Tanner. “A person can adjust their insulin depending on what they are doing and what they are eating, allowing them to match their insulin more precisely to their individual needs.” 

Evidence shows that insulin pump users can achieve lower blood sugar levels, more time in range, less risk of hyperglycemia and hypoglycemia, and fewer associated long-term diabetes complications. 

vii. Type 2 Diabetes Glucose-Lowering Medications⁹⁵ 

As a complement to healthy behaviour interventions and lifestyle modifications, there are a variety of medications that may be used to treat type 2 diabetes that can help people achieve their target blood glucose levels. Diabetes Canada provides medication recommendations and encourages healthcare providers to work together with their patients to determine which medication(s) can help them achieve their best health.