Looking after your feet in during the winter months

My name is Shirley and I am the Chiropodist (foot specialist) at the Markham Family Health Team. Looking after your feet is a very important part of diabetes care.

It’s the middle of winter. Skin care is very important as the weather is drier and colder. Just like you apply a moisturizer on your hands, you should remember to apply moisturizer to your feet at least once daily. By applying a moisturizer to your feet daily, you will help to prevent fissures (cracks or grooves) from occurring on your skin. This is especially important for people with diabetes to help prevent skin infections that can come from bacteria entering small breaks in your skin.

—Shirley Cheung, D.Ch.

The diabetes care that is right for you

Driving to work I heard a blurb on diabetes on CBC radio (Diabetes Clip on CBC Radio). It talked about individualizing approach to chronic disease. Most of you on this blog are too young for the relaxation of targets for your A1C that they describe. However, it’s important to let your health provider know what you want to focus on in managing your disease or what concerns you. Becoming your own expert is key to self management.


—Sheri Devereaux, Nurse Practitioner

Small steps towards better health

I saw this in the Running Room magazine for January.  It was written by Tara Postnikoff , a registered nutritional consultant  on page 35 in her monthly column “Ask A Nutritionist”. The article is geared for runners but most of the suggestions would apply to all of us.  I will let Andrea, our expert dietitian, jump in with diabetes specific concerns.

I liked how she said nutrition is not “all or nothing”…..Just because you get sick and miss a day of work, that doesn’t mean you resign from your job.  Same goes for our nutrition goals.
I have put her 20 things to try in 2015 on my fridge as a daily reminder for myself.  The link for the full article can be found here: Ask A Nutritionist Article in Running Room Magazine
For quicker access, I will re-type the list here:
20 things to do in 2015:
-Drink more water
-Eat out less
-Eat more vegetables
-Reduce caffeine intake
-Choose a new food to try
-Have protein with every meal
-Reduce consumption of processed and packaged foods
-Take your supplements daily or as recommended by your health provider
-Stop eating when you are no longer hungry (vs. when you are full)
-Focus on FOOD QUALITY not quantity
-Get more sleep
-Consume breakfast daily
-Bring your lunch to work (it’s easy if you plan leftovers)
-Drink less alcohol
-Eat healthy fats like avocado, nuts, seeds, coconut oil & olive oil
-Reduce consumption of refined grains and flour products
-Fuel workouts appropriately
-Chew your food more
-Don’t eat in front of the computer, or the TV, or while driving
-Don’t eat a large meal right before bed
—Sheri Devereaux, Nurse Practitioner

Flavourful holiday recipes to lighten up your meals!

Here are some tasty side dishes to consider rather than the usuals.


Balsamic Roasted Squash and Root Vegetables:

Great option instead of mashed potatoes or a sweet potato casserole.  The flavour of the balsamic vinegar with the vegetables is sweet and tangy–delicious! Leftovers are great added to a salad of spinach with feta cheese and a balsamic vinegar dressing.


1 butternut squash, peeled and cut into 1 inch cubes (or 1-2 packages pre cut butternut squash)

4 Parsnips, peeled and cut into 1/2 inch chunks

4 medium carrots, peeled and cut into 1/2 inch chunks

1/3 cup balsamic vinegar

4 tbsp canola oil

salt and pepper


Preheat oven to 425F

Mix all ingredients together into an oven proof glass dish.

Roast in oven until tender, about 30-45 minutes, stirring once or twice while cooking.


Kale and Brussels Sprouts Salad (from Epicurious.com).

Even if you don’t love Brussels Sprouts, you will love this salad.  It’s been a big hit with all of my family, and even some co-workers who were not big fans of Brussels sprouts.


1/4 cup fresh lemon juice
2 tablespoons Dijon mustard
1 tablespoon minced shallot
1 small garlic clove, finely grated
1/4 teaspoon kosher salt plus more for seasoning
Freshly ground black pepper
2 large bunches of Tuscan kale (about 1 1/2 pounds total), center stem discarded, leaves thinly sliced
12 ounces brussels sprouts, trimmed, finely grated or shredded with a knife
1/2 cup extra-virgin olive oil, divided
1/3 cup almonds with skins, coarsely chopped
1 cup finely grated Pecorino


Combine lemon juice, Dijon mustard, shallot, garlic, 1/4 teaspoon salt, and a pinch of pepper in a small bowl. Stir to blend; set aside to let flavors meld. Mix thinly sliced kale and shredded brussels sprouts in a large bowl.

Measure 1/2 cup oil into a cup. Spoon 1 tablespoon oil from cup into a small skillet; heat oil over medium-high heat. Add almonds to skillet and stir frequently until golden brown in spots, about 2 minutes. Transfer nuts to a paper towel–lined plate. Sprinkle almonds lightly with salt.

Slowly whisk remaining olive oil in cup into lemon-juice mixture. Season dressing to taste with salt and pepper. DO AHEAD: Dressing, kale mixture, and toasted almonds can be prepared 8 hours ahead. Cover dressing and kale mixture separately and chill. Cover almonds and let stand at room temperature.

Add dressing and cheese to kale mixture; toss to coat. Season lightly with salt and pepper. Garnish with almonds.

Barley and Pomegranate Salad

A great side dish that can be made ahead of time–a nice light option with great flavours and colour.  A great option to take to potlucks!


1 cup pearl barley
6 celery sticks (leaves picked and reserved), cut into small dice
4 tbsp olive oil
3 tbsp sherry vinegar
2 small garlic cloves, crushed
2/3 tsp ground allspice
3 tbsp chopped dill
3 tbsp chopped parsley
300g pomegranate seeds (2 large pomegranates)
salt and black pepper


1. Rinse barley with cold water, the place in a medium saucepan and cover with plenty of water. Simmer for 30-35 minutes until tender, but still al dente.
2. Drain, and transfer to mixing bowl. While hot add all ingredients except for dill, parsley and pomegranate seeds which are to be added when cold


Happy Holidays and Happy Eating!

Assess your Diabetes and Pre-Diabetes Risk

This post is for those who have not yet been diagnosed with diabetes–so you may be pre-diabetic, or have been told that your sugars are a little high.  Maybe your sugar levels are fine, but you want to check in with your health and see whether you are at risk of developing diabetes.  Maybe you are concerned about a friend or a family member and their risk for developing diabetes (especially if there is a family history).  Whatever the case, there is a handy website to visit that will help you to assess your risk of developing pre-diabetes and/or diabetes in your lifetime.

Go to this website and complete the CANRISK test (see the green box):

Don’t Be Risky

Completing the survey can help you to know if you are at risk for developing diabetes.  This knowledge can help you consider making lifestyle changes that can make you happier and healthier for longer–for example, eating more vegetables, reducing your portion sizes, quitting smoking or moving your body more.  Did you know that a 5% reduction in your weight can reduce the risk of progression from pre-diabetes to diabetes by 60% (1)–that’s huge!  Keep in mind, that for someone who weighs 200 lbs, a 5% weight loss means losing 10lbs.  This does not need to be done in the next month as even a gradual reduction over a year will pay off with big health benefits!  To help make this happen, you could skip the can of regular pop in the day, reduce the amount of cream and sugar used in your coffee, skip an evening snack if you’re not actually hungry!

The more we know about our health, our bodies and healthy behaviours, the more power we have to change our lives.  Take the test!  Send it to your loved ones!  If you have any questions about the test or the results, or if you want help with making lifestyle changes, talk to your healthcare provider or your diabetes team–support can make all the difference!




1. Ransom T, Goldenberg R, Mikalachki A et al.  Reducing the Risk of Developing Diabetes.  Can J Diabetes:2013; 37 (suppl 1): S16-S19.

Nov 5th – Diabetes Educator Day!

November 5th is Diabetes Educator Day!


Certified Diabetes Educator (CDE)®  is a health professional, committed to excellence in diabetes education and who has a sound knowledge base in diabetes care/management and education processes, as well as good communication skills and who has passed the Canadian Diabetes Educator’s Certification Board (CDECB) exam.

At the Markham Family Health Team you are lucky to have two CDE’s working at the practice, myself, Sheetal (Clinical Pharmacist) and Andrea (Registered Dietitian). We each have our own areas of expertise but overall have a good command of diabetes care and management.  We often like to see patients together so that we can provide the most comprehensive approach to diabetes care and with the help of our diabetes team which includes doctors, nurse practitioners, nurses, chiropodist, and social workers you can pretty much get all your diabetes needs met here at the practice. Keep in mind however that diabetes care can extend even beyond our walls. As a patient you may be referred to a Diabetes Education Centre (DEC), LMC clinic, endocrinologist and/or nephrologist. You may also get diabetes care through your community pharmacist. It can get confusing with all the different players that may be involved but keep in mind the most important is you!

Here are a few tips that I recommend to patients to get the most out of their diabetes care; (and a few documents to get you on your way!)

1. Be prepared for your visits.


2. Know your targets, goals and results. 


3. Know your diabetes team.


4. Write things down!



Sitting is the new smoking…

Maybe you’ve heard this phrase before but it really highlights the need for all of us to optimize our behaviours to become less sedentary. I thought I’d blog about this issue as it relates to diabetes but the issue of physical activity transcends diabetes and is something we all should prioritize.

According to Statistics Canada, less than 15% of Canadian adults meet the physical activity requirements outlined in Canadian guidelines updated in 2011 (http://www.csep.ca/cmfiles/guidelines/csep_guidelines_handbook.pdf).

Over the years health professionals have stressed again and again, the need to be physically active. The evidence supporting the benefits for physical activity is abundant. Studies show the health benefits of exercise can include:

  • Improved blood sugar control in patients with diabetes
  • Lower rates of obesity
  • Lower risk of heart disease, stroke and hypertension
  • Lower risk if developing type 2 diabetes
  • Lower risk of osteoporosis
  • Lower risk of premature death
  • Improved mental health
  • As we age – improved independence and mobility

It’s not news to anyone that exercise improves health outcomes but how do we get motivated to be more active? How do we change our behaviours to encourage physical activity? There are numerous barriers to being more active in our society. Cities are often designed with the automobile in mind so something simple like walking to pick up our groceries is often not an option. So many of our jobs, including mine, are spent sitting at a desk. Canadians spend a great deal of time watching TV or working at a screen of some sort. We need to do better as a society. As we often say to patients in the office, it’s not the gap between what we know and what we don’t know, it’s the gap between what we know and what we do that’s the problem. How do we start to change our behaviour?

There is a growing body of literature that is looking at the effects of being sedentary, and in particular sitting, on health outcomes. We’ve been stressing exercise for years to our patients but in addition to that we really have to combat our sedentary behaviour that is so ingrained in our modern culture. So how do we get moving? Here are just a few suggestions:

  • Walk/cycle to the store or the coffee shop instead of jumping in the car.
  • When you move, think about whether your new home location will encourage you to walk vs drive.
  • At work – think about walking meetings. Stand up to take a phone call instead of sitting. Walk at lunch. Start a walking club.
  • Park the car a good distance from your destination and walk the rest of the way.
  • Get off the subway or bus a stop ahead and walk that extra block.

There are a multitude of little things we can do in our everyday lives to be even a little more active. These are just a few suggestions.

Coming back to the idea of motivation – how do we motivate ourselves to get moving, to get off our behinds and do what we already know what’s good for us? There is a lot written recently about “nudge theory”. This theory talks about tiny little things we can do that “nudge” us to make even a small change in our behaviour to achieve a more active life. We know that behaviour change is always challenging especially if it is a big change. The idea with nudge theory is that it if we can make a really small change in our behaviour then we can start to make more small changes and eventually manifest enough change to result in a better health outcome. One of the things that have nudged me to be more active this year is getting a pedometer.

Pedometers have been around for a long time but the newer high tech fitness trackers that are now available bring the concept of tracking activity to a whole new level. If you’re a bit of a gadget lover this may be for you. I actually got this idea from a patient of mine who was trying to keep herself and her diabetic husband more active. It was really working for them and I was inspired. There are a number of activity trackers on the market at the moment. Some of the brands are Fitbit, Nike Fuelband, Jawbone and Garmin Vivofit just to name a few. The new, soon to be available, Apple watch will have a tracking function as well. Most of them clip to your belt/pocket/clothing or you can wear it as a wristband. If cost is an issue you can stick with an inexpensive low-tech pedometer which will track your steps accurately.

Personally I love my device. It tells me how many steps I’ve done each day. I set a personal goal as to how many steps I want to get. It links to my phone and nudges me along to keep active throughout the day. It’s a constant reminder all day that I need to be vigilant against inactivity. It doesn’t let me forget that I need to stay active and keep my health at the forefront of my priorities. These trackers often have a cool feature where you can compare (in real time) your activity with friends and family who also have a similar device. This allows you to tap in to your natural competitiveness and allows your friends to nudge you (or taunt you!) to keep moving. It’s a fascinating phenomenon that starts to happen when you wear these trackers and stay connected with friends and family who are also trying to stay active. It becomes a bit of a high tech support group over time.

I hope this post reminds you to not just stay active (ie exercise) but to combat our sedentary lifestyles every day.

So how do you stay motivated to keep active? What’s your secret? Please share in our comments section so we can learn from one another. We need all the tips and tricks that we can get to stay healthy.

Dr. Bill

To test or not to test?

“How often should I test my blood sugar?”  This is very common questions I get and my answer always is…”it depends!”


Self monitoring of blood sugar (or SMBG as medical people call it) is not a one size fits all approach.  Previously as diabetes educators, we were trained to tell patients to do routine testing but the benefits of that approach have come into question due marginal benefits and significant costs. There has also been studies to show routine testing may be associated with depression and reduced quality of life.

The thinking now is that the frequency of  SMBG should be based on your current diabetes management. This can be broken down into 3 categories;

1. For most patients on insulin +/- other diabetes medications – SMBG should be tailored to fine tune insulin therapy to acheive optimal blood glucose control. If on once daily long acting insulin (i.e. basal insulin) you should be doing no more than 14 tests for the week on average. If on 2+ insulin injections per day, more testing may be required but speak to your diabetes educator to determine an meaningful and realistic schedule.

2. For most patients on diabetes medications (other than insulin) – routine SMBG is not recommended. Periodic testing can be done in certain situations but only if it helps determine a specific course of action. Examples of situations include: changes to medications, having an illness,  diet and/or exercise changes and to confirm a low blood sugar.

3. For most patients who control their diabetes through diet and exercise – routine testing is not required unless you are trying to reinforce diet/lifestyle changes.

Bottom line is test meaningfully…if testing does not change a specific course of action then don’t bother!




Signing the Diabetes Charter of Canada

What is the Diabetes Charter of Canada?

Briefly, the Diabetes Charter of Canada is a document that the Canadian Diabetes Association has created to ensure that all people in Canada, living with diabetes, are treated with the dignity and respect they deserve.  The goal of the charter is also to advocate for equal access to the best possible diabetes care and support, and to improve the health and quality of life for those living with diabetes, their family members and caregivers.

Click on the link above to read and review the diabetes charter in full!

Click on the link below to add your name to the thousands of Canadians who have already signed in support of the Charter.

World Diabetes Day is November 14, 2014 and the Canadian Diabetes Association would like to have 25,000 signatures by them.  Pass this along to family and friends to encourage them to show their support as well!

Sign the Diabetes Charter

Sleep Hygiene

Sleep.  We all wish there were more hours in the day to get everything done, and still get enough of that deep, restful, restorative sleep!  With busy lives and many things on the go at all times, it can be hard to wind down at the end of the day, or even get to bed at a time that we feel is appropriate.

What are the down sides of not getting enough sleep?

Lack of sleep can make it hard for us to concentrate, be productive at work, can affect our driving and even our social life.  Studies have also shown that fatigue can lead to changes in our food take because of the effect that lack of sleep can have on our hormones that regulate hunger!  Often we crave more carbohydrate rich foods, or have an increased appetite when our bodies don’t get enough rest–often leading to overeating or poor food choices.  For those who are chronically sleep deprived, some studies have shown that it may increase the risk of heart disease, stroke, diabetes and kidney disease.

How much sleep do we need?

The National Heart, Lung and Blood Institute recommends that adults aim to get 7-8 hours of sleep per night.

So, then what can we do to help maximize our sleep quality and quantity??

Try to maintain a regular sleep and wake schedule–aim to hit the sack and wake up around the same times every day to get your body into a pattern.

Exercise regularly–it can help you feel more energized during the day, but also help you sleep at night. Try not to exercise 2-4 hours before going to bed.

Avoid or limit caffeine, alcohol and/or nicotine–these stimulants can keep you up and/or disturb your sleep.  Caffeine can last in your body up to 8 hours, so try to avoid having caffeinated coffees, teas, pop (colas or Mountain Dew) or energy drinks in the afternoon or evening hours.

Have a regular sleep routine–find ways to relax and shut your mind off before bed.  Maybe it’s reading, or taking a bath, or doing some meditation or relaxed yoga.  Whatever works for you, stick to it and your body will learn to prepare for sleep.

Consider where you are sleeping–a quiet, cooler, darker room can help you sleep.  Also try to remove any distractions like computers, TVs or other electronics.  Keep your bedroom as a relaxed retreat that you can go to unwind at the end of the day!

Try not to eat a heavy meal too close to bed time or drink large amounts of fluids within 2 hours of going to sleep.  


As I am writing this, I am actually feeling quite sleepy after being out late last night curling and having to be up early for an appointment!  So I certainly need to work on a few of the above!   I hope the tiredness hasn’t caused too many mistakes in this post 🙂



University Health Network Sleep Hygiene Handout

What are Sleep Deprivation and Deficiency?

University of Maryland Medical Centre: Sleep Hygiene