Joanne Mercer, RN, Public Health Nurse

Joanne Mercer, RN, Public Health Nurse
Prevent Diabetes NOW! Speaker's Notes Hello my name is etc… We are here to share information about type 2 diabetes prevention. Type 2 diabetes is a major public health challenge and one of the fastest growing diseases in Toronto and Canada. Over the coming decades diabetes rates may grow, due to the aging population and increasing rates of obesity. Research shows that where a person lives within Toronto can impact their risk of developing type 2 diabetes. Toronto is one of the most multicultural cities in the world, and is home to some of the lowest-income neighbourhoods in the country. Joanne Mercer, RN, Public Health Nurse

Overview What is diabetes? What are the complications?
What are the risk factors? What are the symptoms of diabetes? What is your own risk of type 2 diabetes? How can I prevent type 2 diabetes?

} + Food consists of 3 major nutrients:
How do our bodies use food to get the energy we need to function? Food consists of 3 major nutrients: Carbohydrates Protein Fat All 3 nutrients are required for life for different reasons. We all eat a mixture of different foods glucose + other stuff Our main source of energy Circulating in our blood } So let’s begin by talking about “What is diabetes?” To answer this question, I’d like to take you through a series of pictures. First of all, we all know we need to eat to survive! We all eat a mixture of different foods and food consists of 3 major nutrients: carbohydrates, protein and fat. Some examples of foods that contain carbohydrates include: bread, rice, pasta, potatoes, milk and fruit. All three of these nutrients are required for life for different reasons. So once we’ve eaten food, how do our bodies use it to get the energy we need to function? (i.e. energy we need to breathe, move, etc.) In our bodies, the food breaks down into glucose and some other stuff – glucose is the main source of our energy and primarily comes from carbohydrates. We won’t focus on the other stuff right now (if asked, other stuff = basic derivatives of protein and fat, amino acids & fatty acids). So these products of digestion (glucose + other stuff) are now circulating in our blood.

circulating in our blood vessels
Glucose circulating in our blood vessels Blood body tissue But we need the glucose to go from our blood to the cells in our body’s tissues, this is where the energy gets used. Here you can see the glucose (represented by the green dots) moving around in our blood vessels. But we need the glucose to go from our blood to these pink cells in our body's tissues because this is where our energy actually gets used. So how does the glucose move into our cells? With insulin - a hormone made in our bodies that helps move glucose from the blood into the cells of the body's tissues. Analogy (if required) - the fuel in cars gets used up in the engine, well the glucose in our body gets used up in our cells. So how?

With insulin – a hormone that helps move glucose from the blood into the body tissue
Here you can see the glucose (represented by the green dots) moving around in our blood vessels. But we need the glucose to go from our blood to these pink cells in our body's tissues because this is where our energy actually gets used. Analogy (if required) - the fuel in cars gets used up in the engine, well the glucose in our body gets used up in our cells. So how does the glucose move into our cells? With insulin - a hormone made in our bodies that helps move glucose from the blood into the cells of the body's tissues.

Insulin is produced in an organ called the pancreas
Stomach Pancreas Ask: Does anyone know where insulin comes from in our bodies? Insulin is made in an organ called the pancreas- as you can see this organ sits just below the stomach If the pancreas does not produce insulin or does not produce enough insulin (or the insulin does not work well), glucose builds up in our blood instead of being used for energy Note: Please make sure that participants understand that diabetes is NOT caused by eating too much sugar. It is more complicated than that.

Blood body tissue glucose insulin If the pancreas does not produce insulin or does not produce enough insulin, glucose builds up in our blood instead of being used for energy. Ask: Does anyone know where insulin comes from in our bodies? Insulin is made in an organ called the pancreas- as you can see this organ sits just below the stomach If the pancreas does not produce insulin or does not produce enough insulin (or the insulin does not work well), glucose builds up in our blood instead of being used for energy Note: Please make sure that participants understand that diabetes is NOT caused by eating too much sugar. It is more complicated than that. This is diabetes Diagram:

Complications of Type 2 Diabetes
Vision Loss Cardiovascular/ Heart Disease Why is it important to know about diabetes? Diabetes, especially when not well managed, can lead to serious health problems : Ask: What are some of the complications of type 2 diabetes? Vision Loss Diabetic eye disease (diabetic retinopathy) can lead to loss of vision and blindness. Regular eye exams can help find problems that can be treated if found early. Cardiovascular Disease Over time, diabetes can damage arteries, which may result in high blood pressure. If not controlled, this can lead to stroke, heart failure or heart attack. Important for people with diabetes to monitor their blood pressure and cholesterol levels. Kidney Disease Kidney damage can develop in some people with diabetes. If left untreated can lead to kidney failure. Important for people with diabetes to have their kidney function tested regularly. Other Complications People with diabetes are more likely to develop other conditions such as dental disease and mental illness (depression). Emphasize the seriousness of the complications of diabetes. Kidney Disease Nerve Damage and Amputations

Type 1 versus Type 2 Diabetes
CANNOT be prevented Most often in children and young adults Pancreas does not produce insulin Person will need insulin Cause is not known Type 2 CAN be prevented Most often in adults. Sometimes in children and young adults Pancreas does not make enough insulin or insulin does not work properly Manage with healthy diet, physical activity, medications, and sometimes insulin Type 1 Diabetes: Only 10% of the people with diabetes have type 1 diabetes (also called insulin-dependent diabetes) Usually begins before the age of 30. Develops suddenly when the pancreas does not make insulin or makes very little insulin. Not preventable Patients require insulin Important to manage with healthy eating and exercise Type 2 Diabetes: Approximately 90% of people with diabetes have type 2 diabetes. Type 2 diabetes is also called adult-onset diabetes. It usually develops in adults over 40 but more and more children in the high risk groups are being diagnosed. It is caused when the body cannot make enough insulin or cannot use the insulin it makes properly. Type 2 diabetes develops slowly and can be prevented by making healthy food choices, being more physically active and by achieving a healthy weight. Gestational Diabetes: Approximately 4% of pregnant women develop gestational diabetes, which means they have high blood glucose during pregnancy. It is a temporary condition that ends after the baby is born. If a pregnant woman is diagnosed with gestational diabetes, both she and her child are at higher risk of developing diabetes in the future. Pre-diabetes - This is NOT a type of diabetes, but participants may ask you what it means to be pre-diabetic. People with pre-diabetes have higher than normal blood sugar level (i.e. a fasting plasma glucose level of 7.0 mmol/L or higher) that is not yet categorized as diabetes. They are at risk of developing diabetes but they can control blood sugar levels with healthy, balanced food choices and exercise.

Gestational Diabetes Occurs during pregnancy Occurs during pregnancy
Goes away after birth Baby will not be born with diabetes Occurs during pregnancy Gestational Diabetes: is a type of diabetes that occurs during pregnancy. Between 2-4% of pregnant women in the non-Aboriginal population All pregnant women should be screened for gestational diabetes within 28 weeks of pregnancy. Your body cannot produce enough insulin to handle the effects of a growing baby and changing hormone levels. The good news your baby will not be born with diabetes Gestational diabetes can be managed and you can expect to have a happy, healthy baby. In most cases gestational diabetes cannot be prevented. What does gestational diabetes mean for my baby? If left undiagnosed or untreated, gestational diabetes can lead to high blood glucose (sugar) levels. This increases the risk that your baby will weigh more than 4 kg (9lbs) and will have a difficult delivery. Gestational diabetes can also increase the risk of your baby becoming overweight and developing type 2 diabetes in the future. What does gestational diabetes mean for me? A diagnosis of gestational diabetes means you will be working closely with your health-care team to manage your blood glucose (sugar) levels and keep them in the target range. This will help you avoid complications in labour and delivery. After your baby is born, blood glucose (sugar) levels will usually return to normal. However, you are at greater risk for gestational diabetes in your next pregnancy and of developing type 2 diabetes in the future. Risk factors for gestational diabetes Being: 35 years of age or older Obese (BMI of 30kg/m2 or higher) Giving birth to a baby that weighed more than four kilograms (nine pounds) Having: Prediabetes Gestational diabetes in a previous pregnancy A parent, brother or sister with type 2 diabetes Polycystic ovary syndrome (PCOS) or acanthosis nigricans (darkened patches of skin) –

Risk Factors for Type 2 Diabetes
AGE Over the age of 40 FAMILY HISTORY Parent, brother, sister or children with diabetes ETHNICITY Aboriginal African, Caribbean East Asian (Chinese, Vietnamese, Filipino, Korean, etc..) South Asian (East India, Pakistani, Sri Lankan, etc.) Other Non-White (Latin American, Arab, West Asian, etc.) Additional information Recent immigrants to Canada are at high risk for diabetes compared with long-term residents of Ontario. The groups that show the highest risk are people from countries in South Asia, the Pacific Islands, Latin America, the Caribbean and Africa.

Risk Factors for Type 2 Diabetes
Physically inactive Overweight or obesity High blood pressure High cholesterol Pre-diabetes Smoking What is “Pre-Diabetes”? If your blood sugar is higher than normal, but not high enough for a diagnosis of type 2 diabetes. Also called “impaired glucose tolerance” At this stage, lifestyle changes such as eating healthier foods, being physically active and being smoke-free can help prevent or delay type 2 diabetes.

Diabetes and Smoking Smokers are at least 50% more likely than non-smokers to get type 2 diabetes. Among people who have diabetes, those who smoke are more likely to develop: Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice. Revised. Toronto, Canada: Registered Nurses’ Association of Ontario. Among people who have diabetes, those who smoke are more likely to develop: diabetes-related kidney damage, nerve damage, eye problems and heart disease (complications we talked about earlier). Additional information Smoking aggravates insulin resistance. The amount a person smokes matters. Heavier smokers are more likely to become diabetic. Just like high blood glucose levels – the chemicals in cigarette smoke damage blood vessels and impair the body’s ability to get oxygen to tissues. The deadly combination of high blood glucose and smoking damages the blood vessels that feed the heart, brain, eyes, kidneys and peripheral nerves. The risk of complications associated with tobacco use and diabetes is 14 times higher than the risk of complications among either smokers or diabetics alone. (Selby, P. (2008) Smoking Cessation and Diabetes. Endocrinology Rounds, 8, 3) Ask: What are some of the signs or symptoms that someone with type 2 diabetes may have?

Signs & Symptoms of Type 2 Diabetes
Unusual thirst Frequent urination Weight change (gain or loss) Feeling tired Blurred vision Ask: What are the signs and symptoms of type 2 diabetes? This is a list of signs that you may have diabetes or high blood glucose levels.

Signs & Symptoms of Type 2 Diabetes
Frequent or recurring infections Cuts and bruises that are slow to heal Tingling or numbness in the hands or feet Trouble getting or maintaining an erection Ask: What are the signs and symptoms of type 2 diabetes? This is a list of signs that you may have diabetes or high blood glucose levels.

Seek Medical Attention
Ask: What are the signs and symptoms of type 2 diabetes? This is a list of signs that you may have diabetes or high blood glucose levels.

In some cases, a person can have diabetes but NOT have any signs or symptoms.
Regular check-ups with a health care provider are an important factor in preventing or managing diabetes. Remember: Many people who have diabetes may not notice any signs or symptoms. Don't just watch for these signs — know the risk factors for diabetes.

The Canadian Diabetes Risk Questionnaire: CANRISK
Before You Begin Here are some key points to re-enforce with participants: There is no right or wrong answer. If the answers you provide are honest, the score will give you the best understanding of your risk for having diabetes. This is a self reported questionnaire. What answer best describes you or your situation? Answer all questions - don’t leave check-boxes blank. The risk score is not intended as a substitute for an actual clinical diagnosis (which will require a blood test by a physician).

Question 1 As you get older, your risk of developing diabetes goes up.
Select your age group: 40-44 years = 0 points 45-54 years = 7 points 55-64 years = 13 points 65-74 years = 15 points Additional information As with any chronic disease, as you get older, your risk of developing diabetes goes up. The relationship between age and diabetes risk is an upward-sloping curve.

Question 2 Males are at a higher risk for developing type 2 diabetes.
2. Are you male or female? Male = 6 points Female = 0 points Additional information Males are at a higher risk for developing type 2 diabetes than females. This gender-based difference is due to a combination of physiological and behaviour-based differences between the sexes.

Question 3 Body shape and size can affect your risk of type 2 diabetes. Body Mass Index (BMI) is the ratio of your weight to your height. Body fat stored around the abdomen (rather than the hips and thighs) is a risk factor for developing type 2 diabetes. 3. How tall are you and how much do you weigh?

Body Mass Index (BMI) Chart
Additional information The body mass index (BMI) is used to classify individuals as underweight, normal weight, overweight, or obese in this report. The BMI is a unit of measurement that describes an individual's weight in relation to height, and is calculated by dividing weight in kilograms by the square of the height in metres (kg/m2).

What is your BMI? Body Mass Index (BMI) is the ratio of your weight to your height. Body fat stored around the abdomen (rather than the hips and thighs) is a risk factor for developing type 2 diabetes. White (BMI less than 25) = 0 points Light grey (BMI 25 to 29) = 4 points Medium grey (BMI 30 to 34) = 9 points Black (BMI 35 and over) = 14 points Additional information Central or visceral obesity is strongly linked to insulin resistance and to an increased risk of type 2 diabetes. Decreasing body fat (especially visceral fat around the waist) has been shown to decrease the progression from pre-diabetes to type 2 diabetes. If your participant cannot find his/her exact weight on the BMI table, find approximately where it would be, and draw a line from there. If it looks like the participant falls between an un-shaded and a shaded area, round the BMI up to the higher area.

Question 4 4. Using a tape measure, place it around your waist at the level of your belly button. Measure after breathing out (do not hold your breath). This is not the same as the ‘waist size’ on your pants. Additional information Body fat stored around the abdomen (rather than the hips and thighs) is a risk factor for developing type 2 diabetes. The risk of developing type 2 diabetes is higher if fat is stored around the abdomen (rather than the hips and thighs). BMI assessments do not take into account where fat is stored. Please advise your patients to measure their waist circumference while they are standing (this measurement is different from their “pant size”) and under their loose clothes (remove jacket or thick sweater).

Question 4 MEN Waist circumference: inches OR cm
Less than 94 cm or 37 inches = 0 points Between cm or inches = 4 points Over 102 cm or 40 inches = 6 points

Question 4 WOMEN Waist circumference: inches OR cm
Less than 80 cm or 31.5 inches = 0 points Between cm or inches = 4 points Over 88 cm or 35 inches = 6 points

Question 5 Your level of physical activity and what you eat can affect your risk of developing diabetes. 5. Do you usually do some physical activity such as brisk walking for at least 30 minutes each day? Yes = 0 points No = 1 point Additional information Increasing physical activity is a key element in controlling weight and reducing the likelihood of developing type 2 diabetes.

Question 6 6. How often do you eat vegetables or fruits?
Every day = 0 points Not every day = 2 points

Question 7 High blood pressure, high blood sugar, and pregnancy-related factors are associated with diabetes. 7. Have you ever been told by a doctor or nurse that you have high blood pressure OR have you ever taken high blood pressure pills? Yes = 4 points No, or don’t know = 0 points Additional information Diabetes and high blood pressure are often clustered together. Many people with undiagnosed type 2 diabetes have high blood pressure.

Question 8 8. Have you ever been found to have high blood sugar either from a blood test, during an illness, or during pregnancy? Yes = 14 points No, or don’t know = 0 points Additional information Previous test results indicating abnormally high blood sugar are an indication of temporary metabolic problems or possible diabetes. They are a warning sign that a participant may be at risk for developing full-blown diabetes in the future. This question measures if they were ever told their blood glucose was high or abnormal (even once, regardless of whether they have been given medications).

Question 9 9. Have you ever given birth to a large baby weighing 9 pounds (4.1 kg) or more? Yes = 1 point No, or don’t know = 0 points Additional information Giving birth to a large infant over 4.1 kg (macrosomia) is related to high maternal weight gain during pregnancy, which is associated with gestational diabetes. Gestational diabetes is a risk factor for developing type 2 diabetes later on, post-partum.

Question 10 Some types of diabetes run in families.
10.Have any of your blood relatives ever been diagnosed with diabetes? Check ALL that apply. Mother =2 points Father =2 points Brothers/Sisters =2 points Children =2 points Other =0 points No/don’t know =0 points Additional information Diabetes risk is strongly related to family history among close relatives (mother, father, sister, brother, child). This reflects the combined effect of shared genetic material as well as shared lifestyles and cultural behaviours (e.g. sharing food together at the same dinner table). This response includes: Any form of diagnosed diabetes that is treated with diet and exercise, pills or insulin, type 1 diabetes This response does not include: gestational diabetes pre-diabetes (i.e. reported “borderline diabetes” etc, that is, any other condition that has not been diagnosed by a physician as diabetes) a spouse, step-children or relatives who are not related by blood.

Question 11 11. Please check off which of the following ethnic groups your biological (blood) parents belong to? Choose only one score, the highest. White (Caucasian) = 0 points Aboriginal = 3 points Black (African, Caribbean) = 5 points East Asian = 10 points South Asian = 11 points Other non-white = 3 points Additional information Certain ethno-cultural groups are at higher risk of developing diabetes. The risk due to ethnicity cannot be interpreted by itself without considering the added effect of other factors towards the overall CANRISK score. If a participant’s Mother (or Father) is of European ethnicity, ask them to check off “White (Caucasian)”. NOTE: some persons living in “Latin America” may choose to self-identify as “White (Caucasian)” if they believe their parents were Spanish-Caucasian rather than Mestizo (mixed European and Native American heritage). Your score cannot be more than 11 points for this section. Do not add mother plus father scores together.

Question 12 Other factors are also related to developing diabetes.
12. What is the highest level of education that you have completed? Some high school or less =5 points High school diploma =1 points Some college/university =0 points University or college degree =0 points Additional information An individual’s health status improves with level of education. Education improves people's ability to access and understand information to help keep them healthy. Education is closely tied to socioeconomic status, and effective education for children and lifelong learning for adults are key contributors to health.

What’s your Score? TOTAL SCORE
Add up your points from questions 1 to 12 After everyone has completed the questionnaire, help them add up their scores (your calculator may be useful here) and read out the Risk Scores. Additional information A person’s risk of developing type 2 diabetes cannot be fully described by any single risk factor, so it is important to consider the overall CANRISK score rather than the point score for any single question. For instance, East Asian ethnicity has a relatively high point score for that question, but the prevalence of obesity in East Asians is relatively low – so the overall risk level for the typical East Asian is likely low to moderate on average, reflecting the combined results of all risk factors together. On an individual basis though, an obese East Asian would likely be high risk. Some lifestyle-related risk factors are modifiable, while others like age, ethnicity and family history of diabetes are not. However, it is important to be aware of the “non-modifiable” factors, since they contribute to an individual’s overall risk. Persons with similar BMI and waist circumference but with different ethnicity and family history would have considerably different risk scores. TOTAL SCORE

What’s your risk? Lower than 21 LOW RISK Your risk of having pre-diabetes or type 2 diabetes is fairly low, although it always pays to maintain a healthy lifestyle.

What’s your risk? 21-32 MODERATE RISK Based on your identified risk factors, your risk of having pre-diabetes or type 2 diabetes is moderate. You may wish to consult with a health care provider about your risk of developing diabetes.

What’s your risk? 33 and over HIGH RISK Based on your identified risk factors, your risk of having pre-diabetes or type 2 diabetes is high. You may wish to consult with a health care provider about getting your blood sugar tested.

Type 2 diabetes can be prevented or delayed!
The Good News Is… Type 2 diabetes can be prevented or delayed!

What Things CAN you Change ?
Be more physically active. Eat healthier foods more often. Achieve a healthy weight that is right for you. Ask: What do you think are some of the things you CAN change to help prevent type 2 diabetes? Be more physically active Increasing physical can help control weight, can also reduce your chances of developing type 2 diabetes. Aim to accumulate at least 150 minutes of moderate to vigorous intensity physical activity per week. Go for a brisk walk, dance, play sports, garden or play with your children or grandchildren. Eat healthier foods more often Adding more vegetables and fruit to your diet, in addition to eating foods that are rich in fibre and low in sugar and fat, can help you maintain or lose weight. In addition to monitoring the foods you eat, you should also monitor portion size, while still ensuring that they contain enough healthy nutrients. Achieve a healthy weight that is right for you Being overweight or obese puts you at risk for developing type 2 diabetes. Even a small change in body weight can reduce your risk of diabetes. Measure your waist circumference. The risk of developing type 2 diabetes is higher if fat is stored around the abdomen (rather than the hips and thighs).

Lower high blood pressure and high cholesterol levels.
See your health care provider. Be tobacco free. Lower high blood pressure and high cholesterol levels and see your health care provider Studies show that managing your blood pressure, cholesterol, and glucose (sugar) levels can substantially reduce the risk of diabetes complications such as heart disease and stroke. A healthcare provider can help to create a plan to monitor and manage your blood pressure, cholesterol and glucose. Be tobacco free Smoking increases risk of developing type 2 diabetes. If you smoke, it’s never too late to quit. Every step you take to improve your health counts.

Diabetes: True or False
People with type 2 diabetes cannot eat sweets. True False People with type 2 diabetes need to watch their weight and maintain a healthy, balanced diet. But in moderation, and as part of a healthy meal plan, desserts or other sugary foods are not off limits.

Type 2 diabetes is life-threatening. True False Diabetes, which is a major cause of heart disease and stroke, is the 6th leading cause of death in Canada (2011 Statistics Canada). Type 2 diabetes accounts for 90 of all diagnosed cases of diabetes. Overall, the risk for death among people with diabetes is about twice that of people of similar age who don’t have diabetes.

People who have type 2 diabetes have: Too much insulin Too much blood sugar (glucose) Both of the above Neither of the above Diabetes is caused by problems related to the hormone insulin, which helps turn blood sugar (glucose) into energy. With type 2 diabetes, a problem called insulin resistance happens when the body's cells can’t use insulin properly So the pancreas makes an abundance of insulin to overcome the increase in blood glucose levels. When this happens, the pancreas can gradually lose its ability to make insulin; the increased amount of sugar in the blood can damage nerves and blood vessels. Chronically elevated blood sugars lead to such complications as heart disease, stroke, and kidney disease.

Which of the following is a common symptom of elevated blood sugars? Excessive thirst Vomiting Diarrhea All of the above Excessive thirst is a major symptom of high blood sugars. Other major symptoms include dry mouth, increased hunger (especially after eating), frequent urination, fatigue, unexplained weight loss, blurred vision, and headaches. These symptoms are all caused by high blood sugar. Other symptoms of type 2 diabetes may include slow-healing wounds, itching, numbness and tingling of the hands and feet, weight gain, frequent yeast infections, and impotency.

You can have type 2 diabetes without any symptoms. True False People with type 2 diabetes don't always have symptoms.

Children don’t get type 2 diabetes. True False Type 2 diabetes was once called adult-onset diabetes, and the vast majority of people with type 2 diabetes are adults. But it can develop at any age, and health care providers are finding that children are being diagnosed with it more frequently.

Type 2 diabetes can be prevented. True False Type 2 diabetes usually doesn't start suddenly. Some people are first diagnosed with prediabetes (also known as impaired glucose tolerance or impaired fasting glucose). Lifestyle changes, such as weight loss if you are overweight, dietary improvements, and exercise, can often ward off full-blown diabetes. Some people at high risk for developing type 2 diabetes can reduce their risk further by taking the prescription drug metformin -- but lifestyle change is a must.

Regularly drinking which of the following may reduce your risk of type 2 diabetes? Coffee Red wine Orange juice None of the above People who often drink coffee may be less likely than other people to have type 2 diabetes, according to a review of studies published in the Journal of the American Medical Association. Experts say the benefit is not related to caffeine, but to other components of coffee -- possibly antioxidants or magnesium and chromium, which help the body use insulin. Still, no studies have proven that drinking coffee prevents type 2 diabetes.

Which of the following is a risk factor for type 2 diabetes? A high-sugar diet A high-salt diet Obesity All of the above High-sugar or high-salt diets are not, in themselves, risk factors for type 2 diabetes. But if either leads to obesity, it contributes to the risk of developing type 2 diabetes. Other risk factors for diabetes include age, family history, inactivity, and ethnicity But having one or more of the risk factors doesn’t mean you’ll get type 2 diabetes.

Type 2 diabetes increases the risk for: Blindness Arthritis Prostate cancer All of the above Elevated blood sugars can cause eye damage and blindness, heart disease, nerve and blood vessel damage, kidney disease, and other major health problems. There is no evidence that diabetes causes prostate cancer or arthritis.

Type 2 diabetes is associated with an increased risk of: Depression High blood pressure Gum disease All of the above Depression and diabetes often go together. According to the CDC, depression is twice as common among people with diabetes as among other people. But it's not clear which comes first, the depression or the diabetes, or that one causes the other. High blood pressure is a common complication of diabetes, and gum disease is also more common in people with diabetes.

Contact Toronto Public Health
For general information about Toronto Public Health programs and services: Phone: 3-1-1 24 Hours a day

Want more information? The Public Health Agency of Canada
Canada's Food Guide Online CANRISK Canadian Diabetes Association

Want more information? Stand Up to Diabetes EatRight Ontario-Speak with a Registered Dietitian Canadian Society for Exercise and Physiology (CSEP) for Canadian Physical Activity Guidelines Smokers Helpline

Joanne Mercer, RN, Public Health Nurse

Similar presentations

Presentation on theme: "Joanne Mercer, RN, Public Health Nurse"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Joanne Mercer, RN, Public Health Nurse

Similar presentations

Presentation on theme: "Joanne Mercer, RN, Public Health Nurse"— Presentation transcript:

Similar presentations

About project

Feedback