Diabetes Autumn 2014 by Diabetes New Zealand

Diabetes Autumn 2014

Living well with diabetes

Young & talented

Developing tomorrow’s diabetes leaders

COELIAC DISEASE & DIABETES

10 things you need to know

When it's okay to say ‘diabetes sucks’

Asana-tastic

The benefits of yoga

NEWLY DIAGNOSED? Kickstart your journey

T2 drug trial + easy composting + sugar addiction

Don’t brush it off – use Colgate

Did you know that people with diabetes may be more at risk of gum disease? Colgate Total toothpaste reduces up to 90% of plaque germs that can cause gum disease*.

Visit your dentist regularly and protect your gums with Colgate Total. Colgate Total 12 Hour Protection Toothpaste. With regular brushing, fights gingivitis, cavities, plaque and protects gums. Always read the label and use as directed. If symptoms persist see your Dental professional. Colgate-Palmolive Ltd., Lower Hutt. TAPSPP1101. * Fine, et al. (2006). Journal of the American Dental Association, 137: 1406-1413 CPL MW42186

Diabetes: the national magazine of Diabetes New Zealand | Vol 26 no 1 Autumn 2014

INSIDE autumn 2014 4 5

From the Chief Executive From the President

Upfront

News, views and research

Focus

10 The link between coeliac

disease and type 1 diabetes

Living with diabetes

12 Billie Brown's story Gardening

14 Easy composting Care and prevention

16 Kickstart your T2 journey –

tips for the newly diagnosed

Community

18 Developing tomorrow's

diabetes leaders

34 Diabetes Youth Research

20 New drug hope for children with type 2 diabetes

Let's get active

22 Yoga for diabetes Families and children

24 Diabetes sucks… and it's okay to say so

Food

26 Tips for reducing sugar intake 29 Recipes: cooking on a budget Obituary

30 Rachel O'Brien: doing what she loved

Profile

32 Diabetes Projects Trust COVER PHOTO ©MADELEINE WARE

EDITOR: Caroline Wood email: editor@diabetes.org.nz DESIGN AND PRINTING: Kraftwork, Wellington MAGAZINE DELIVERY ADDRESS CHANGES: Freepost Diabetes NZ, PO Box 12 441, Wellington 6144 Telephone 0800 342 238 Email: membership@diabetes.org.nz ISSN: 1176-4406 Disclaimer: Every effort is made to ensure accuracy, but Diabetes New Zealand Inc. accepts no liability for errors of fact or opinion. Information in this publication is not intended to replace advice by your health professional. If in doubt, check with your own doctor, nurse, dietitian, or health care professional. Editorial and advertising material does not necessarily reflect the views of the Editor or Diabetes New Zealand Inc. Advertising in Diabetes does not constitute endorsement of any product, and no advertiser may use publication of an advertisement in the magazine to support the marketing of any product. Copyright of all editorial is held by Diabetes New Zealand Inc. No article, in whole or in part, should be reprinted without permission of the Editor.

Not yet a member of Diabetes New Zealand? Call 0800 369 636 now to join or visit www.diabetes.org.nz Membership includes a free subscription to Diabetes magazine

FRO M TH E CH I EF EXECUTIVE

The world around us I was privileged to attend the New Zealand Society for the Study of Diabetes physicians’ weekend at the end of last year. It had a clear focus on the challenges of people living with type 1 diabetes. For example, the transition from adolescence to adulthood and how hospital services can best support a young person. We heard about the impact of diabetes on mental health and the conversations that need to take place within families to help young people cope with living with type 1. We also learned about the benefit of pump therapy for some and the need to find people with the skills to support those moving to a pump. During the weekend we were brought up to speed on changes in nursing and dietetics, current

research and development and the politics surrounding the world of diabetes. It was an amazing opportunity to share a consumer view with the many physicians and diabetes nurse specialists that care for people with diabetes. Overall, we are doing so much but there's much more still to be done to ensure all people with diabetes have the necessary support to live well. But we can't do it alone – as a community we need to rally round the issue and be prepared to support each other and what we need to deliver. If you haven’t joined Diabetes New Zealand yet, or would like to work with us, please think about it – it takes the whole community to speak out for change. The growth in the number of people living with diabetes (all types) and those at risk was the focus of the International Diabetes Congress in Melbourne. Over 10,000 representatives from member organisations, governments, people with diabetes, health workers, researchers and academics attended

to hear and understand the shocking statistics and the need for information, support, technologies and medicines for those affected by diabetes. Some of the take home messages for me were: no country has ‘solved the problem’; New Zealand is better off than many in terms of services and medicines but not as good as it could be; and much more can be done to support people with diabetes and those at risk. Resourcing (people and funding) restricts us but working together achieves change. We need consistency in our messages, clarity around targets (and the resources to achieve them). Above all it means being prepared for the future and the challenges ahead.

Joe Asghar Chief Executive

Welcome to Diabetes magazine Our mission is to help you live well with diabetes. Every issue of Diabetes includes: • Trusted expert advice • Latest research and treatment options • Inspiring personal stories • Delicious diabetes-friendly recipes • Lifestyle advice on food, exercise, travel • Spotlight on children and diabetes

SUBSCRIBE today and have four issues of Diabetes delivered straight to your door for just $18 per annum. Diabetes is published by Diabetes New Zealand. Join today for just $35 waged (or $27.50 unwaged) and receive a free subscription to the magazine. Email: admin@diabetes.org.nz or call 0800 342 238 to find out more.

DIABETES | Summer 2013

FROM TH E PRESIDE NT

Snippets from a congress diary Day 1: Am 36 hours late getting to Melbourne and need to hit the ground running. Delayed because asked to speak at a Ministry of Health workshop for district health board staff on the importance of including us people with diabetes in the planning of diabetes services – should not be rocket science. Had better be worth it – the speaking and this, the IDF World Diabetes Congress! Registration straightforward and quick. Am ‘bar-coded’ so I can be scanned before entering sessions. Everything very simple given the enormity of the affair – nearly 11,000 delegates from almost every country on earth. Amazing – for the first time ever I am part of a truly international event. All modes of dress, all languages – thank goodness English is the official one. I spy someone from Syria. Imagine how ghastly life might be there for someone with diabetes. I sit beside a

lady from Fiji to listen to a delegate from Qatar describe how his organisation thinks oil companies have responsibility for the escalation of diabetes in his homeland. They ask for (and get) millions of dollars from these companies for their diabetes education and prevention programmes. My Fijian neighbour calls out to ask for their change. Rich and poor – same problem, different responses, all interesting. Day 2: I hear what it is like to have diabetes in Nigeria and Pakistan, China and Bhutan – of the blatant and appalling discrimination against sufferers in some places. I listen to the special challenges of diabetes for indigenous peoples and am struck by their similarity regardless of whether they live: in the frozen reaches of Canada, the Australian outback or New Zealand’s East Cape. Equally striking is the uniformity of their best solutions. I give silent thanks for my good fortune when I hear of insulin being so expensive it is beyond families’ budgets and so the child with diabetes is abandoned while the parents focus on feeding its siblings. There are seven ‘streams’ in the programme; each with a raft of

papers, symposia and presentations. The programme is immense – listed in a 600-page book! Three x twohour sessions per day with various add-ons; collaboration between us to minimise duplication and still we barely scrape the surface. One could just spend all week in the hall exhibiting the posters; I manage two hours. So much and all of it about diabetes. Day 3: Melbourne is wet and very cold but no matter. We are like sponges but it isn’t rain we soak up. This week demonstrably shows the ubiquity of diabetes – rich, poor, young, old, brown, white, urban, rural – everyone can be affected. Strangely there is comfort in experiencing the enormity of this community. It is hard to tell the health professional or academic from the person with diabetes. Many are both (another surprise). So much to tell, my head spins. The experience blew my mind – was it worth it? You bet!

Chris Baty National President

See our website for advice, tips and ideas on how to live well with diabetes: www.diabetes.org.nz

Diabetes New Zealand PATRONS: Lady Beattie and Sir Eion Edgar PRESIDENT: Chris Baty CHIEF EXECUTIVE: Joe Asghar COMMUNICATIONS MANAGER: Lisa Woods DIABETES NEW ZEALAND INC. NATIONAL OFFICE: Level 7, Classic House 15 Murphy Street Thorndon, Wellington 6144 Postal Address: PO Box 12 441, Wellington 6144 Telephone 04 499 7145; Fax 04 499 7146 Email: admin@diabetes.org.nz

Diabetes New Zealand is a national organisation that acts for people affected by diabetes. We work to raise awareness, educate and inform people about diabetes, its treatment, management and control. We offer local support to individuals with diabetes through a network of diabetes branches across the country. We also support research into the treatment, prevention and cure of diabetes.

Call now to make a donation 0800 DIABETES (0800 342 238)

Summer 2013 | DIABETES

UP FRO NT

NEWS, VIEWS AND RESEARCH

Google’s ‘glucose monitoring’ contact lens

Advisory council elections

Internet giant Google is funding research to develop a contact lens that will monitor blood glucose levels via a person’s tears, avoiding the need for invasive finger-prick testing for the 382 million people with diabetes worldwide who need insulin. The prototype of a tiny contact lens loaded with tens of thousands of miniature electronics that would wirelessly transmit glucose levels to a handheld device was announced earlier this year, garnering huge publicity worldwide.

Diabetes New Zealand set up the Advisory Council in 2012 to help it improve life for people with diabetes at a local level and ensure it better meets the needs of people affected by diabetes. The council is made up of diabetes experts from across the sector, including two elected directly by individual members. This year the two elected positions on the council are up for election and Diabetes NZ is calling for nominations from interested people. If you would like to stand, or to find out more information, visit www.diabetes.org.nz or ring 04 499 7145. The election will take place by postal vote, opening in May and closing on 1 August. Voting papers and information on the candidates will be sent to members with the next issue of Diabetes.

The contact lens, which was developed in the secret Google X lab, is one of several medical devices being designed by companies to make glucose monitoring easier in a market worth a reported $16 billion. Researchers are racing to become the first to develop a new technology that works. Diabetes organisations have welcomed the development but say it is important that any device provides timely and accurate information and is proven over time. Google says its device will take at least five years to reach consumers.

Tax on fizzy drinks could save lives A 20 percent tax on carbonated drinks could save 67 lives a year and generate revenue of up to $40 million, according to research led by Professor Cliona Ni Mhurchu, from the University of Auckland. The research published in the New Zealand Medical Journal in February says a tax intervention will improve health, save lives and increase revenue for other health initiatives.

Is your child’s type 2 diabetes misbehaving? If diet, exercise, or medication is not helping your child with their type 2 diabetes, you may be interested in this research study. It is evaluating an investigational drug

“Given its cost-effectiveness, a 20 percent tax on carbonated drinks could be a simple, effective component of a multifaceted strategy to tackle New Zealand’s high burden of diet-related disease,” the authors write.

for children between 10 and 17 years old to see if it helps control their blood sugar levels. Every child who participates will receive: n Study-related care for type 2 diabetes

n Diet and exercise counseling n Study medication (may include inactive placebo) n Glucose meter and testing supplies

n All at no cost

US students study diabetes in NZ

Ask a member of our staff today for more information about the potential benefits and risks of study participation and to see if your child may qualify.

American students from Worcester Polytechnic Institute, a private research university in Massachusetts, travelled to Wellington in February to carry out a research study looking at the knowledge and understanding of type 2 diabetes in the New Zealand population.

CAN YOUR CHILD PARTICIPATE? JUST ASK US. Please contact: Auckland (09) 923 7897 t2dm@auckland.ac.nz Christchurch (03) 3640 448 jinny.willis@cdhb.health.nz

Pediatric Type 2 Diabetes Research Study

20111109-US-ENG

DIABETES | Summer 2013

They carried out a survey of over 400 people in the greater Wellington region, and interviewed representatives from Diabetes NZ about its evidencebased prevention programmes. The study is being supported by the Universities of Otago and Victoria and Wellington’s Child Obesity and Type 2 Diabetes Prevention Network. The results will be collated and published in a future issue of Diabetes.

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Ask your doctor if you meet the criteria.

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Always read the manufacturer’s instructions and use strictly as directed. NZMS, Auckland. TAPS NA6067

UP FRO NT

NEWS, VIEWS AND RESEARCH

Hospital mortality risk

Artificial pancreas hope

Researchers studied more than 10 million hospital admissions over a twoyear period in England and found patients with recorded diabetes had a 6.4 percent greater risk of dying (2,052 more deaths over two years) compared with similar patients without recorded diabetes. Commenting on the study, which was published in Diabetic Medicine, Wellington endocrinologist Dr Jeremy Krebs (pictured) said: “This study from the UK collated a large number of hospital admissions and demonstrated that diabetes confers a greater risk of death in hospital.

Clinical trials of the Bio-Inspired Artificial Pancreas (BiAP) have begun in the UK. The BiAP attaches to the abdomen via a small tube and works by combining a continuous glucose monitor with an insulin pump to release insulin into the body when needed. Another artificial pancreas system is being developed at De Montfort University in Leicester and is expected to be ready for human trials by 2016.

“The New Zealand Society for the Study of Diabetes is undertaking a nationwide stocktake of services for managing diabetes in hospital inpatients. There is considerable variability around the country in terms of resources allocated to inpatient diabetes management. The results of the present study would suggest that there is a need to look carefully at how we might better support these patients during hospital stays.”

The University of Auckland’s Liggins Institute is inviting pregnant women who are overweight to take part in a clinical trial to assess the effectiveness of regular, moderate exercise in reducing health risks due to obesity for women and their babies.

Follow Team Novo Nordisk Team Novo Nordisk is the first professional sports team of its kind, consisting entirely of athletes with diabetes to promote diabetes awareness, advocacy and research while striving to inspire, educate and empower everyone affected by diabetes. Aaron Perry, 26, from Rotorua (pictured), is starting his second year with the men’s pro cycling team, which competes in major professional races around the world. He is one of just 19 professional riders from 10 different countries. The timings, results and full details of all races will be reported on teamnovonordisk.com, and supporters can also follow the team at facebook.com/ TeamNovoNordisk and twitter.com/TeamNovoNordisk

DIABETES | Summer 2014

Lead investigator Dr Nick Oliver, diabetes consultant at Imperial College Healthcare NHS Trust, told a UK newspaper: “There is a race on, that’s why what we are doing is incredibly exciting. There are lots of avenues that will lead to – potential cures for type 1 and type 2 diabetes and if I could see it in my career that would be incredibly exciting.”

Mums-to-be needed for exercise trial

The IMPROVE – exercise in pregnancy study – aims to demonstrate that a programme of moderate, supervised exercise during pregnancy will benefit both mother and baby by reducing longer term health risks, including diabetes. To take part in the study, women must be less than 20 weeks pregnant and have a BMI of 25 and above but weigh under 130kg. Participants will receive a free exercise bike. For more information see: www.liggins.auckland.ac.nz

Lifting weights lowers T2 risk in women Women who regularly do muscle-strengthening exercises are less likely to develop type 2 diabetes, according to a new US study. Women who lifted weights and did some kind of aerobic moderate and vigorous activity showed the biggest decline in diabetes risk. Researchers from the Harvard School of Public Health followed nearly 100,000 middle-aged and older women over eight years. The found that women who worked out with weights at least 150 minutes a week were 40 per cent less likely to develop type 2 diabetes. The findings were published in PLOS Medicine.

Monitor your child’s glucose levels from the comfort of your own bed Introducing the Dexcom G4® Platinum Continuous Glucose Monitor The Dexcom G4® Platinum updates glucose levels every 5 minutes so you can track your child’s glucose continuously day and night. Monitor their highs, lows and how fast they’re getting there from the comfort of your own bed1 for added peace of mind.

For more information or to arrange a trial to see the benefits for yourself, please contact us between 9am5pm, Mon - Fri on 0508 634 103 W www.nzms.co.nz P 09 259 4062 E nzms@nzms.co.nz Dexcom G4TM Platinum is not currently indicated for children under 2 years of age. Always read the manufacturer’s instructions and use strictly as directed. 1 Dexcom G4® Platinum transmitter range is 6 metres. Dexcom G4™ User Guide, May 2012. LBL-011277 Rev 04, LBL-011346 Rev 02.

FO CU S

TH E LINK BETWEEN COELIAC DI S EAS E A ND TYPE 1 DI A BETES

Could you have coeliac disease? People with type 1 diabetes are up to six times more likely to have coeliac disease than the general population. Both conditions are autoimmune diseases and the two are genetically linked. Many adults are unaware they have coeliac disease but it can have potentially devastating health consequences if it is not diagnosed, as Caroline Wood reports.

Quentin Bright wasn’t feeling quite right, he was tired, lacking in stamina and had difficulty concentrating but he put it down to the fact he had a young family and a stressful job. Once every few months his stomach would blow up like a balloon but he thought it was nerves or indigestion. Then his sister, who also has type 1 diabetes, was diagnosed with coeliac disease and Quentin’s diabetes specialist said he should be screened too. It took two years to get a definitive diagnosis because the tests came back negative at first. Communications consultant Quentin, 52, from Auckland, has had type 1 diabetes since he was 15 years old. He was diagnosed with coeliac disease in 2010 but believes he has probably had the condition since his 30s but didn’t realise because the symptoms were so mild and he didn’t always react after eating gluten-containing foods, such as bread.

“I think it's very important to look on the positive side…” – Quentin Bright

“It was so periodic, it wasn’t a big deal because it didn’t affect me greatly. But when I look back I realise that something was going on for quite a while. It’s something you need to keep monitoring. Just because you think you have no symptoms, it doesn’t mean you don’t have it,” he said. “It’s like having high blood sugar, you don’t feel 100 per cent, you feel weakened and tired and something isn’t quite right but you just get used to it.”

10 things people with diabetes need to know about coeliac disease 1 2 3 4 5

One in 100 people in New Zealand have coeliac disease. Most people (up to 80 percent) don’t know they have coeliac disease. Coeliac disease is up to six times more common in people with type 1 diabetes. An estimated 10 per cent of T1s have coeliac disease. Everyone with T1 diabetes should get tested – adults and children. Do not give up gluten until you have been tested, it can cause a false test result. The majority get T1 diabetes first then coeliac disease (but it can happen the other way round).

6 7 8 9

Some people have a ‘silent’ form with no symptoms and are only diagnosed after screening. Undiagnosed coeliac disease can cause hypos in people with diabetes. Long-term untreated coeliac disease can have serious health impacts. Once diagnosed, a gluten-free diet may change your blood glucose control. Type 1 diabetes and coeliac disease are both auto-immune conditions and are linked genetically.

10 There is no link between type 2 diabetes and

coeliac disease but people with T2 can still have coeliac disease. Sources: Coeliac NZ, Coeliac UK, Diabetes NZ.

DIABETES | Summer 2013

THE LINK BETWEEN CO ELI AC DI S EAS E A ND TYPE 1 DI A BETES

FOCUS

Coeliac disease is an immune reaction to gluten in food and can cause a wide range of mild to severe stomach and bowel symptoms (see panel right). Undiagnosed coeliac disease can lead to a range of health issues, such as anaemia, osteoporosis, some gastric cancers, infertility, depression and dental problems. In children it can lead to lack of proper development, short stature and behavioural problems. Quentin removed all glutencontaining foods from his diet and it made a significant difference. He now has more energy and no abdominal discomfort. “I think it’s very important to look on the positive side [of the diagnosis]. It can cause problems if left untreated. My nana died of bowel cancer in the 1950s and our family suspects she had undiagnosed coeliac disease,” he added. “I found it easy to adapt dishes to make them gluten-free for me. Fibre is hard to find but there are plenty of cereals, just check the sugar in them.” If you think you may have coeliac disease, talk to your diabetes healthcare team, who can do a simple blood test. You will then be referred to a gastroenterologist (a specialist in gut problems) who will take a small tissue sample of your gut to give you a definite diagnosis. Sue Clay, Executive Officer of Coeliac NZ, said: “Coeliac disease can lead to long-term serious health effects so it’s important to be tested, especially if you have type 1 diabetes. “It’s vital that you don’t start following a gluten-free diet until a definite diagnosis has been made. If you remove gluten it makes the tests unreliable and you may be falsely negative.”

When gluten causes trouble Gluten is a protein found in wheat, rye and barley. Some people with coeliac disease also react to oats. Gluten is a combination of the proteins gliadin and glutenin, which cause an immune reaction when ingested by someone with coeliac disease. The body’s immune system attacks villi on the lining of the small bowel as if the gluten proteins were an ‘invading’ external organism. The subsequent damage to the bowel’s lining can lead to nutrients not being absorbed and a host of health problems. Symptoms vary from person to person and may include abdominal pain and discomfort, lethargy and breathlessness, vomiting and diarrhoea. These symptoms can manifest within hours of eating gluten or be delayed. Some people have very mild or no symptoms. Many coeliacs inherit the condition from a member of the family and anyone who has coeliac disease in their family should be tested. The only treatment currently for coeliac disease is to follow a strict gluten-free diet.

Resources There is lots of useful information on the Coeliac New Zealand website (www.coeliac.org.nz) including advice on diagnosis and how to live gluten-free plus member stories and a telephone helpline. It also has an information sheet about living with type 1 diabetes and coeliac disease, including 10 top diet tips. Living with Diabetes and Coeliac Disease (RRP $10.50) is written by Coeliac Australia and Diabetes Australia. It was mainly devised as a resource for parents of children with type 1 diabetes but it can be modified to guide adults with coeliac disease and type 2 diabetes. Available from www.coeliac.org.nz. See Diabetes New Zealand’s website (diabetes.org.nz) for an article by dietitian Naomi Johnson about how to live healthily on a gluten-free diet. Coeliac disease and type 1 diabetes mellitus: epidemiology, clinical implications and effects of gluten-free diet Marchese A et al (published online, Endocrine, July 2012) This editorial article explains the relationship between T1 and coeliac disease.

Autumn 2014 | DIABETES

LIV ING W ITH D I A B E TE S

k BILLIE BROWN' S STO RY

“ Billie blazes a trail

My daughter has a big heart and a great work ethic so who knows what the future holds. She doesn’t let her lifethreatening condition stifle her love of sports participation. My daughter’s name is Billie Brown and her marae is Whakaaratamaiti (Putaruru), although we live in Kerikeri. She is 10 years old.

Billie Brown is a promising young athlete and her whānau is proud of her sporting achievements and positive attitude towards life. Billie’s type 1 diabetes diagnosis was a wake-up call for everyone, as dad Harko Brown, from Kerikeri, explains.

I thought I’d drop you a line about Billie’s recent participation in the North Island Colgate Games, which is the largest event in New Zealand for kids aged seven to 14 years. Over 1,000 children attended the games this year in Whangarei. Billie made the 100m finals, qualifying in 14.90sec, and came second in the high jump and fifth in the long jump. She also made the 200m semis in 31.28sec. It was her first year and she

DIABETES | Autumn 2043

PHOTO: MADELEINE WARE

Billie Brown with sister Yves playing ki-o-rahi against visiting French school La Providence.

Billie loves all kinds of sport from athletics to ballet, tennis to rugby.

BI LLI E BROWN' S STO RY

really enjoyed it and made two new friends who she is keeping in contact with. Billie has had type 1 diabetes since she was six years old. The diagnosis came out of the blue but it ended up being really good for the family. We have six kids and both her mum and I were teachers. It made us reassess everything about our lives and how we lived. I stopped work so I could help Billie with her injections and we became more aware about good diet and exercise. We stopped chasing the dollar, we’re a cool family now. It’s been a massively positive experience for all of us. We changed the way we eat and I lost 10kg through sensible eating. Billie has great numbers, some of the best in the North Island, her nurse says. It gets a bit tricky trying to stabilise her blood sugar levels when she is using so much energy all day. But we have found that exercise really

helps her condition and lessens the total amount of insulin she needs in a day. She injects herself twice a day with a long-lasting insulin called Protophane and four times a day (with meals) with insulin called Novorapid. So there’s hope for the many children who develop this disease. Physical activities are a great benefit, although unfortunately many parents don’t let their children get too physical in case they get ‘lows’ and go into unconsciousness. But careful management and it’s all good. Nothing you don’t know about r. We are grateful she has recently attracted a very supportive benefactor, a nurse in the US, who heard through the grapevine (via Facebook) of Billie’s condition and her love of running. She noticed she didn’t have have any running shoes in the photos and is sending over a pair of Nike spike track shoes for her.

LI V I NG WITH DI ABE TES Other than that Billie makes decorative ki (Māori game balls) to sell at art festivals to cover some of the costs of her many sports interests. She exhibited at the week-long Far North Arts Festival in Waitangi in December. She sold one and got two more commissions (total $180). They are made from New Zealand native vines. Billie doesn’t let her lifethreatening condition stifle her love of sports participation. She also does kapa haka, tennis, netball, ballet, ki-o-rahi and rippa rugby. She got the scholar’s award in her class last year and is off to Kerikeri High School this year. The whānau are really proud of her efforts.

”

*Do you have an inspiring story to share with Diabetes readers? Email editor@diabetes.org.nz.

Autumn 2014 | DIABETES

GARD EN I N G

MAKING COMPOST

Easy composting You only need basic equipment and a little effort to make compost to feed your garden. Set up a compost heap now and you will have it ready in time for feeding your spring garden. Gardening expert and compost guru Rachel Knight (www.thekitchengarden.co.nz) explains. A good supply of rich compost is worth its weight in gold in your garden. It fixes most of the problems in any soil and will make your plants thrive. You’ll save time and money taking green waste to the tip. Even better, your rubbish bag will be smaller and smell better if you put

your kitchen scraps in the compost. Kids seem to take to the idea of making compost really quickly, often because they do the same at school. Perhaps it’s also because they love the worms and other creatures they find in a thriving compost heap. You need only basic equipment and a little of your own effort to make compost easily. A plastic compost bin or a few pallets nailed together will work well. Cover with old carpet or tarpaulin to keep the moisture in and the rain out if it doesn’t have a lid. Put it somewhere outside that’s easily accessible. If you’re using kitchen scraps, wrap them in a sheet of newspaper and keep them in a covered bucket under your bench to empty every few days. The newspaper makes the bin easier to empty and soaks up moisture. Composting is a natural process decomposing dead animal or vegetable matter. Three things will affect the speed at which your ingredients decay: • Their size – the smaller the pieces, the greater the surface area and the quicker they will rot.

• Moisture – a dry compost heap is a slow one. • Air – an open texture will avoid a smelly, slimy heap. Turning once or twice will introduce more air and you can check it’s moist enough too. The easiest way to build a compost heap is by layering ingredients as we gather them. After a weekend in the garden our bin might be full, but a week later there will be room for more. Eventually you will need a second bin to start filling whilst the first decomposes. If you’ve got a plastic bin that lifts off completely you can move it to a new spot and start again, covering the first heap with a tarpaulin until it’s ready to use. This might take six months or a year depending on the ingredients. Don’t worry if the compost is lumpy and stringy. Toss any larger pieces back on the next heap and spread the remainder where the worms will pull it down into the soil. The key to making compost easily is to start with the ingredients you have (see below), water well and allow enough time. You’ll find you’re soon digging up gold in your own garden – black gold.

What to include

What to leave out

Vegetable trimmings, fruit peel, pips and stones (including citrus), corn cobs, tea bags, coffee grounds, tissues, kitchen towel, torn up cardboard, shredded office paper, eggshells, wood ash, pet and human hair, cut flowers, annual weeds, lawn clippings, bedding and manure from pet rabbits, guinea pigs and chooks, seaweed, hedge clippings, autumn leaves, vegetable garden waste including toxic leaves such as potato and rhubarb, comfrey and other green manures.

Uncooked potatoes (zap them in the microwave to stop them re-sprouting) meat, fish, dairy, bones, plastic or laminated packaging, dog and cat faeces, disposable nappies, perennial weeds such as couch grass, convolvulus, ivy, oxalis and other bulbs (put them in a rubbish bin full of water for six months and use the water as a fertiliser tea, add the remaining sludge from the bin to the compost heap once completely rotted), lawn clippings that have been recently treated with pesticides or weed killer.

DIABETES | Autumn 2014

Autumn 2014 | DIABETES

C ARE A N D PRE VE NTI O N

TIPS FOR TH E NEWLY DI AG NO S ED

Kickstart your diabetes journey Being diagnosed with diabetes can be a daunting prospect for many people but help is at hand. Here are five top tips* to bring you up to speed on what you need to know if you've just been diagnosed with type 2 diabetes.

You’re the boss

Do it together

Managing type 2 diabetes and many long-term conditions is about you being the boss of your condition. By acting on the practical steps agreed in partnership with your health professional (see below), you’ll be taking the first steps to better health.

Family/whānau support is key when it comes to successfully managing diabetes, especially if more than one family member has the condition. Deciding to make healthy eating and lifestyle changes as a family, with a partner or a friend is a great start. This might involve changing your family’s diet or embarking on an exercise programme with a friend.

Be informed You’re likely to have discussed an individual care plan and been given supporting diabetes information when diagnosed. Your diabetes plan should involve a discussion with your health professional around your lifestyle and your family/ whānau needs. You can then agree on a plan of action to achieve goals that you can manage. Every person with diabetes should have an annual review with their doctor or specialist (though your doctor or specialist may recommend a more regular checkup). Ask your GP or nurse what you are entitled to through your local Diabetes Care Improvement Plan or Care Plus Programme.

If you’ve just been diagnosed with diabetes, you’re not alone. More than 225,000 New Zealanders have diagnosed diabetes and many more don’t know they have it. 16

DIABETES | Autumn 2014

Get involved Take every opportunity to speak to other people about your journey with diabetes. Ask your GP, nurse or specialist about how to connect with your local diabetes support group or see www.diabetes.org.nz. For many people, belonging to a support network of people living with the same challenges can be incredibly valuable. Whether this means connecting with a local church group or being part of some cooking classes, it’s about making things fun!

Work at it For most of us, being more active and eating more healthily can be harder than it sounds. Many diabetes support groups get together on a regular basis to take part in organised exercise sessions. For many people, the Green Prescription programme has enabled them to join a gym or pool for free, or at a very reduced price. Healthy eating conversations should be part of regular discussions with your GP or diabetes nurse, and also in your wellness plan. Talk to your health professional if you feel you need additional support to modify your diet, lose weight or access more information about eating healthily with diabetes.

*Thank you to the Ministry of Health’s Long-term Conditions team for their assistance with this article. The tips were developed following interviews with patients about their diabetes diagnosis and treatment. Some of the interviews are available as a series of case studies on the Health Improvement and Innovation website (see www.hiirc.org.nz).

TIPS FOR TH E NEWLY DI AG NO S ED

Brian Kelly keeps active and recently scooped two gold and one silver medal for blackpowder rifle shooting at the New Zealand Masters Games in Dunedin.

CARE AND P RE V ENTION

Diagnosis a shock Brian Kelly was surprised when he was diagnosed with type 2 diabetes because no-one else in his family had the condition. That was 10 years ago and Brian, now 72 from Greymouth, manages to live well with diabetes by moderating his diet and keeping active. Brian’s advice to the newly-diagnosed is to take time to learn about the condition. He said: “The world doesn't end just because I have diabetes. Look after yourself, eat well and exercise, but don’t give up on all of life’s pleasures!” He says the biggest on-going challenge is controlling his ‘healthy’ appetite. Over time Brian has learned which foods he can eat in moderation and those best to avoid. Nectarines and chocolate are out but he still likes to enjoy a cool beer on a hot summer’s day, even if it’s a low-alcohol, low-sugar brand! A few years ago Brian’s GP suggested he try a Green Prescription to increase his activity levels and help maintain a healthy weight. Brian joined a local gym and was given an individual fitness programme, which has increased his mobility and fitness. He also takes part in group walks organised through the Green Prescription scheme. “I must admit, I really enjoy the sociability of it as well. I go to the gym once a week and I go to the pool as often as I can. I’m really pleased with the results, and I feel better,” he said. Brian also has regular three monthly check-ups with a diabetes nurse and sees a diabetes specialist once a year as part of a regular maintenance programme.

Eight diabetes checks for good health

Have your HbA1c level measured at least once a year. It measures your overall blood glucose control and will help you and your diabetes healthcare team set an individual target to aim for over the following year.

2 3 4 5 6 7 8

Get your blood pressure measured and recorded annually. Set a personal target and ask for advice on how to achieve it. Measure your cholesterol (blood fats) once a year. Again ask for your own target that is realistic and achievable. Ask for an eye screen for signs of retinopathy every year. The specialist will check your eyes for any diabetes-related damage to your retina. Have your feet checked annually. Make sure they check the skin, circulation and nerves of your feet for signs of any damage. Have your kidney function measured every year. You should have a urine test for protein and a blood test to measure kidney function. Get your weight checked and ask them to measure your waist to see if you need to lose weight.

Ask for help if you need to give up smoking or lose weight – both increase the risk of heart disease and stroke.

Resources There are lots of local support networks set up in each community, so you don’t have to manage diabetes alone. Ask your health practitioner to recommend some local networks and information which might suit you best. Diabetes New Zealand (www.diabetes.org.nz) has lots of information on its website and 22 branches across the country. Joining a branch allows you to meet up with other people with diabetes, join a support group, access diabetes education and lots more. The Ministry of Health has dedicated diabetes pages on its website with links to news and resources (www.health.govt.nz keyword: diabetes). There is a downloadable guide available called Keeping Well with Diabetes for people with type 2 diabetes, in English, M¯aori, Samoan and Niuean.

Source ©Diabetes New Zealand

Autumn 2014 | DIABETES

CO M M U N IT Y

ID F'S YOUNG LEAD ERS ’ PRO G RA M M E

Inspiring the next generation Carrie Hetherington represented New Zealand at the International Diabetes Federation’s Young Leaders’ Programme and World Diabetes Congress. She was recommended by Diabetes New Zealand for the programme, which is designed to help young people develop their leadership skills and become diabetes champions in their own country. This is her first-person report on the experience and what it meant to her. It’s very hard to put the experience of a lifetime into words. How do you express what it feels like to spend 10 days with over 140 people from 73 countries who have diabetes? People your own age, people just

like you. Testing, injecting, carb counting, listening, supporting one another, being understood in a way that only other people with diabetes can. Before I left I worried about being the only young leader from New Zealand, the first person to ever represent our country in the programme. Little did I know I was about to walk away with precious friends, unforgettable memories and a lifelong global family. I was lucky enough to be part of the 2013 International Diabetes Federation’s Young Leaders’ Programme and the World Diabetes Congress in Melbourne, Australia last November. The programme challenged us to ask ‘what can you do to change the world? How can you help people with diabetes in your country or region?’ The programme’s key message was to use your positivity to make a difference. The first five days involved sitting through intense seminars from morning till night, working during

Young leaders: Carrie (right) with new friend Rossitza, from Bulgaria, at the World Diabetes Congress.

lunches and dinners and taking short coffee breaks. We immersed ourselves in diabetes. We should have been exhausted, but we were running on adrenaline and enthusiasm. We absolutely loved every minute of our sessions. We spent days learning about the incredible research happening at a global level – the development of an artificial pancreas, genetic testing and the latest diabetes management technology. We had the privilege of hearing from Dr Fran Kaufman, who believes there will be a cure in our own lifetime because the trials and testing she is involved in are getting so close to passing that final step.

PHOTO: BRIT LEGITT

But it was the personal anecdotes that really moved us. Friends we had made during the first few days stood in front of us and bravely shared their own experiences. The situations they had faced due to their diabetes left us speechless and emotional. In China you have to fight to be able to get an education because some schools and universities will reject your application if you have diabetes. United in action: young people from around the world gathered to connect, share and empower each other to make a positive change for diabetes.

DIABETES | Autumn 2014

I DF' S YO UNG LEA DERS ’ PRO G RA M M E

And your partner’s parents will likely end a relationship or engagement, or press for a divorce, due to a diagnosis. Some leaders had even been fired from their jobs. In India the same stigma is rife: diabetes will seriously hinder your marriage prospects, education and survival. In other countries it is seen as a spiritual curse and medication is ignored or withheld because removal of the ‘curse’ is the only solution they see as being necessary. These anecdotes were shocking to hear and I felt lucky to be from a liberal country, whose government offers diabetes support, technology and funding. I realised that diabetes has the potential to destroy a young person’s future in some parts of the world. People live in fear and they hide their diabetes because of the serious impact it will have on their life. How can you create support groups and help people with diabetes when they are unable to reveal their condition in public? How can you save lives in developing countries when there is no money to buy insulin? These are the questions that remained in our minds, the things that need to change. It is confronting to hear about these global issues when you have the same condition. I think it made all the young leaders stronger, more focused and more excited about creating projects to make a positive change. You can imagine that most of the young leaders arrived with the intention of learning how to improve the situation in their own country, and most of us left bursting with extra ideas about changing the rest of the world. Our enthusiasm seemed to snowball during each day of the conference. For the remaining five days we could select our own choice of seminars at the World Diabetes Congress. People of all statuses attended lectures together and I found myself chatting to CEOs, the heads of major pharmaceutical companies, even global leading diabetes specialists. We were blown away that they wanted to learn about our upcoming projects and had seen us walk on the stage during the opening ceremony. Presenters at the World Diabetes Congress helped teach us how to advocate diabetes, how to put our condition on the map by supporting our own countries and then extending that internationally. The primary goal of the Young Leaders’ Programme is for each attendee to return to their home country and successfully implement a project over the next two years to be completed by the Vancouver 2015 conference. This project could be anything from setting up a small support group, leading a youth camp or a large global initiative. Keep your eyes and ears open because 140 young leaders are about to go out there and try to confront world issues, and make the world

COM MUNITY

a better place to live in for people with diabetes. The quote we were left with was by Mahatma Ghandi: ‘Be the change you wish to see in the world.’ The Young Leaders’ programme challenged us to use our positivity to make a difference and that’s what I hope to do.

Carrie Hetherington is a high school teacher and Diabetes Youth volunteer. She has worked with Diabetes Youth since she was diagnosed with type 1 diabetes at the age of 19. She started by helping to run teen camps and is currently organising the National Diabetes Walk on November 16. This year Carrie, 25, is due to start an MA in Development Studies at the University of Auckland focusing on diabetes in developing countries. She will be teaching in Morocco for a month at the end of November and is planning to spend time in a diabetes clinic in Rabat talking to families about their experiences with diabetes. Carrie will also be working with other young diabetes leaders to help clinics in rural Indonesia obtain diabetes supplies through the Life for a Child programme.

Severe obesity is a major cause of type 2 diabetes. Find out what you can do about it.

Tel 09 623 2409 Email info@awls.co.nz www.aucklandweightlosssurgery.co.nz

Autumn 2014 | DIABETES

RES EA RCH

KIWI KIDS NEED ED FOR G LO BA L STUDY

New drug hope for

children with type 2 diabetes

The number of children with type 2 diabetes is increasing worldwide but many cannot control their blood glucose levels using metformin alone and risk developing lifethreatening complications. New Zealand researchers hope a new class of drug will offer a new and more effective treatment for children. Caroline Wood reports.

Kiwi families are being asked to take part in an international drug study that could lead to a more effective treatment for children with type 2 diabetes. A small but growing number of children have type 2 diabetes in New Zealand, about 1 in 10 of all new paediatric cases, although many may be going undiagnosed (see panel). Research shows that children with type 2 diabetes donâ&#x20AC;&#x2122;t respond as well to lifestyle interventions as adults and metformin fails earlier in children. If this happens the only option is to progress to daily insulin injections. New Zealand is one of several countries taking part in a worldwide study that will test a new class of oral diabetes drug for use in children with type 2 diabetes. More than 600 young people aged 10 to 17 years are being recruited worldwide to take part in the potentially groundbreaking study. Doctors say there is an urgent need to develop new therapies to treat type 2 diabetes in children because research shows they are at higher

DIABETES | Autumn 2014

risk of developing complications earlier than children with type 1 diabetes. It is vital to lower blood glucose levels in young people, as it is in adults, to reduce the risk and rate of development of complications, such as kidney and cardiovascular disease. But metformin doesnâ&#x20AC;&#x2122;t work as well in children with type 2 so research is taking place worldwide to find an alternative oral treatment. Sitagliptin, a DPP-4 inhibitor, is an approved medicine in some countries for adults with type 2 diabetes, including New Zealand. However, the safety and effectiveness of the drug in children aged less than 18 years has not been established. The Pediatric Type 2 Diabetes Research Study is one of two international studies that will investigate whether sitagliptin would provide a safe and effective alternative to metformin as initial single therapy (or as an acceptable add-on therapy with metformin) in young people with type 2 diabetes and inadequate glycaemic control on diet and exercise alone.

KIWI KI DS NEEDED FO R G LO BA L STUDY

Study Co-ordinator Dr Jinny Willis, from the Don Beaven Medical Research Centre in Christchurch, explains: “Good food choices and increasing exercise can be effective for all age groups with type 2 diabetes. But such changes can be difficult to implement or maintain, particularly in young people with type 2 diabetes. “Those unable to control their blood glucose levels using lifestyle changes alone will need to move onto an oral hypoglycaemic drug therapy. There are multiple oral drugs available for adults diagnosed with type 2 diabetes but metformin is the only broadly approved oral agent for firstline therapy in children. “Metformin is effective in lowering HbA1c but studies reveal that 3550 per cent of paediatric patients need additional therapy within a year of diagnosis. At present insulin injections are the only option for paediatric patients.”

What is sitagliptin? In healthy individuals, food is broken down into simple sugars in the gut. The gut produces hormones called incretins when simple sugars are present. The incretins signal the pancreas to release insulin. In people with diabetes there is a deficiency of incretins, as well as a relative lack of insulin. Selective dipeptidyl peptidaseIV (DPP-4) inhibitors, such as sitagliptin, are a new class of drugs for type 2 diabetes. These drugs prevent the breakdown of incretins, which in turn increases insulin release. They have been used in adults with type 2 diabetes but their safety in children has not been tested. To find out more about the potential benefits and risks of study participation, contact Dr Jinny Willis: jinny.willis@cdhb.health.nz (03 3640448) or Suzanne Mannering t2dm@auckland.ac.nz (09 923 7897).

RE SEARCH

WHAT YOU NEED TO KNOW Who can participate in these research studies? • Children between the ages of 10 and 17 years who were diagnosed with type 2 diabetes within the last 12 months and are not currently on medication for their diabetes. • Children between the ages of 10 and 17 who were diagnosed with type 2 diabetes more than two years ago and are currently on metformin therapy. What does participation involve? Every child who participates will receive (free of charge): • Study-related monitoring of their type 2 diabetes through regular clinic visits and blood tests. • Oral study medication – investigational medication, metformin or an inactive placebo. • Health assessments including height, weight, and blood pressure. • Diet and exercise counselling. • Glucose meter and testing supplies. The study centres are in Auckland and Christchurch but anyone can take part (assistance for travel costs may be available).

Children with t2 not being diagnosed The number of young people with type 2 diabetes is small but growing and experts believe a third of all cases may be going undiagnosed. Type 2 in children was hardly seen until the mid-1990s but the number has been increasing in New Zealand and the rest of the world since then. Common risk factors include family history and being overweight or obese. Ethnicity is also an important risk factor in New Zealand, with higher prevalence rates in Maori and Pasifika children. More than 100 children aged 10–14 had type 2 diabetes in 2012. A further 213 young people aged 15–19 were living with the condition, according to figures compiled by the Ministry of Health for Diabetes and featured in our special report in Spring 2012. No records are currently kept of the number of adults and children with diabetes in New Zealand. Ministry of Health analysts used prescribing data from Pharmac to estimate the number of children with type 2 diabetes for our article. The data did not include children who may have been controlling their condition with lifestyle changes alone. Starship Hospital diagnoses about 5–10 children a year with type 2. In Christchurch there are currently around 5 young people presenting with type 2 diabetes each year, compared with a complete absence of cases in this age group two decades ago. Dr Jinny Willis, from the Don Beaven Medical Research Centre in Christchurch, said: “There are a small number of children diagnosed every year with type 2 diabetes but we believe there may be one undiagnosed young person for every two who are diagnosed.” Dr Willis and the Paediatric Society of New Zealand’s National Child and Youth Diabetes Clinical Network Group are working on a project that aims to identify how many children and adolescents in New Zealand have type 1 and type 2 diabetes.

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Gardening: Back step veges

Autumn 2014 | DIABETES

LE T ’S G E T A CTI VE

YOGA FOR D IABETES

Asana-tastic Yoga is great exercise for everyone, including those with diabetes. Madhu O’Brien, who specialises in yoga for diabetes, explains. I personally believe that yoga is a valuable component of any lifestyle package for someone wanting to manage their diabetes, reduce stress and improve their quality of life. It doesn’t cost much to learn and you can practise at home for free once you’ve learned the basics. You feel great afterwards and the benefits of yoga not only help with diabetes, they extend into all areas of your life. Originating from India, yoga is a system of practices designed to balance the physical body as well as purify all the layers of the mind. Some of these practices include ethics, breathing exercises, concentration, meditation, and, what we in the West generally think of when we talk about yoga – the physical postures. In Sanskrit, the language of ancient India, these physical yoga postures are called ásanas. The definition of ásana is a posture in which one enjoys physical comfort and mental composure. Ásanas are easy postures which are held with proper inhalation and exhalation. They exercise the nerves, tissues, glands and organs of the human body. Ásanas have some similarities to physical exercise, such as running, and some distinguishing features. They were developed thousands of years ago by yogis, who observed animals in the forest. These yogis copied the positions and movements made by the animals and noticed what effect they had on their own body and mind. For this reason, many of the postures are named after animals, for example hare, tortoise, fish, peacock, cat, dog and cow.

DIABETES | Autumn 2014

How can copying animal postures help manage diabetes? When you perform ásanas, your body is moving in and out of different positions, often timed with your breathing. While holding these postures, pressure is being applied gently to your internal organs, so in effect, certain internal organs are getting a gentle massage. Just as when you get a back massage, the muscle tissue enjoys improved blood supply, therefore improved nutrient supply and waste removal resulting in improved tissue functioning. Yoga has the same effect on your internal organs, gently massaging them and helping them move closer to their optimal functioning. In the case of endocrine glands, such as the pancreas, optimal functioning would mean a more balanced secretion of hormones (insulin and glucagon). People with diabetes would usually be recommended ásanas that benefit the pancreas, as well as the liver and colon. When you digest your food, the sugars (along with most nutrients) are first taken to the liver, where they are stored and then released according to the body’s need, all under the control of hormones. A healthy liver is important for blood sugar balance. It is also an important organ for processing toxins in the body. If you are suffering from constipation, chances are this is putting more strain on the liver. An example of an ásana that is recommended for people with diabetes is bellows pose, called bhastrikásana in Sanskrit. In this ásana you would lie on your back,

and as you exhale, bring the right leg to the chest, hold it with both hands with the breath exhaled, then after eight seconds, breathe in and stretch your leg back onto the ground. This process is repeated with the left leg, then with both legs together, each eight times. This ásana massages the pancreas and the bowel. As you know, stress can have a negative impact on diabetes management as stress hormones (adrenaline and cortisol) increase blood sugar. Yoga is well known for helping to reduce stress, which it does in several ways. Ásanas have a balancing effect on the endocrine glands, including the adrenals, which make the stress hormones. They also assist with muscle relaxation and slowed breathing during the practice (have you noticed that when you are stressed you breathe faster?). Many of the complications of diabetes are due to impaired circulation or nerve damage (from high blood sugar). Yoga postures are beneficial because they encourage the stretching of muscles, blood vessels and nerves. Through regular practice, the elasticity of the blood vessels is improved thereby helping circulation. The contraction of muscles also helps with the circulation of blood back to the heart, similar to the way it does in regular exercise. To get the full benefit of the ásanas, you need to integrate a daily practice routine once you are confident to practise by yourself. Try it and notice the benefits for yourself!

YO GA FO R DI A BETES

YOGA TIPS • You can learn yoga at any age and you don’t have to be in great physical condition before you start. • Look for a qualified yoga instructor and a class near you on community noticeboards, online or in your local paper. You will find many different styles on offer, such as Hatha, Iyengar, or power yoga. Try out some different classes until you find a style that suits you.

LE T ’ S GE T ACTIVE

Yoga teacher Madhu O’Brien has been practising yoga for 15 years. She worked as a community health worker at the wha¯nau ora unit of Te Awhina Marae, in Motueka, and ran yoga classes and wellness weekends for people with diabetes. Madhu recently launched the Mahana Wellness Centre, in Motueka, where she offers yoga detox weekends.

• Make sure that you tell your instructor if you have diabetes, high blood pressure, any other medical condition, injury, or if you are pregnant or menstruating, as some postures may not be suitable. • Check with your health care provider it is ok for you to do yoga and whether you can go barefoot (if you have neuropathy or vascular problems with your feet). • Still make time for cardio workouts in your exercise schedule. Most kinds of yoga don’t raise your heart rate unless you do power yoga or hot yoga classes.

Autumn 2014 | DIABETES

FAM I LI ES A N D CH I LD RE N

D IABE TES EDUCATI O N FO R TEENAG ERS

Diabetes sucks

…and it’s okay to say so Developing diabetes education that appeals to teenagers and is relevant to their needs can be a challenge. The 4-Teens Day programme is a workshop designed specifically for groups of 14-year-olds and the model has been so successful it is being extended to younger children. Two of the course designers, clinical psychologist Jo McClintock and diabetes dietitian Sonya Fraser, of the Waikato Paediatric Diabetes Service, explain.

DIABETES | Autumn 2014

One of the most liberating things you can do when working with teenagers with diabetes is to give them permission to say they don’t like diabetes. One of the ways we do this is to give our education day for 14-year-olds the title Diabetes sucks – how to deal with it . The key message being you don’t have to like diabetes BUT you do have to deal with it. Our 4-teens day is designed to be delivered to a group of teenagers rather than one-on-one diabetes education. It is not unusual for young people to experience a sense of isolation in dealing with the dayto-day requirements of diabetes management. While they may know other teens with diabetes, the majority do not have regular contact with each other. This was perceived as a good reason to design a group education session. The challenge was to cover these topics in a ‘nonboring’ and interactive way. In terms of making the day meaningful and ‘teen-friendly’, we needed to acknowledge that although clinicians and parents might not like

it, 14-year-olds are more likely to take on board what their peers tell them. This was another reason for designing a group education day. Some of these young people have had diabetes for many years but we have learned not to make assumptions about what they know/ don't know. The 4-teens day is an opportunity to ensure consistent messages are provided and equally importantly to try to dispel any myths they may have about their future with diabetes. We identified topics to cover during the day based on international guidelines covering diabetes need-to-knows, management, diet, exercise and emotional well-being. These are outlined in the diagram opposite. A key feature of the 4-teens day is the use of a ‘question box’. On arrival participants are encouraged to write down any questions they have about diabetes and pop them in the box. This is done anonymously and confidentially so they can ask about anything they want and not feel embarrassed or stupid. Common themes include pregnancy,

D IABETES ED UCATI O N FO R TEENAG ERS

alcohol, HbA1c and complications. We ensure the answers to these questions are woven through the programme of activities in a natural way. The question box is available all day and, despite some initial hesitation, is used regularly. We see this as a significant benefit to the programme and it has continued to shape how we run the day. ‘What is diabetes?’ is the first topic of the day and forms the foundation from which we build each subsequent topic. We have interactive activities for all but one of the topics we cover. These are designed to get the teenagers to problem solve the issues themselves and they soon realise there is often more than one solution to a problem. Our role is to facilitate and guide them through the discussion rather than provide all the answers. The one area where we take a more traditional teaching approach is when we present information about long-term complications. This is often difficult to discuss with young people. We are very deliberate in broaching this topic because complications are often used as scare tactics to try and motivate better health behaviour. By systematically going through the range of diabetes complications we are able to clarify the

misinformation that young people may have. The key message we reinforce is that complications are typically an outcome of persistently elevated blood glucose levels over time rather than individual blood glucose results. The use of alcohol by teenagers is a controversial topic. We have chosen to include this in our day because the reality is that some teenagers are drinking alcohol at this age and for teenagers with diabetes there are added risks. Our goal is to ensure accurate information is given about the effects of alcohol and how to keep safe if they are going to drink. Recognising that parents play a vital role in their teen’s diabetes management, we developed a parent evening to complement the topics covered during the teen day. A parent-only session allows them to share worries and concerns about their teens outside of the clinic setting and without their teen present. We facilitate the parent evening by actively seeking feedback from teens about specific topics. This ensures that at the parent evening the discussions are more directed and relevant to those specific families while still being anonymous. Much like the teens, it is about parents connecting with other parents in similar situations. We also want

What is diabetes

FAM I LI E S A ND CH ILD REN

Teens talk about diabetes What message would you like to give your parents? “That it’s hard and I want your support through it.” “We know how to manage it on our own, but it is still great to have their support through it all.” What would you tell someone your age if they were just diagnosed with diabetes? “It is not that crap and it gets better.” “That it is hard to deal with it and you will get frustrated when people tell you what to do.”

to give parents permission to stay involved even when their teenager is pulling away towards greater independence. We do this by facilitating open discussions about different ways that they can continue to support their teenager. The 4-teens day is considered successful by the team here at the Waikato Paediatric Diabetes Service based on positive feedback from the young people and their families. The group approach has allowed for a teen-friendly and flexible way of teaching core principles of diabetes education. We have now extended our group education programme to include a day for Year 7 and 8 students as they prepare for high school called Diabetes and stuff.

Pattern management

Peer relationships Community

Family/wha¯nau Alcohol

School, friends, sports and activities

Food & exercise

Child

Diabetes team

Cultural traditions

Hypoglycaemia

Blood glucose targets

Hyperglycaemia & complications

Topics on the 4-teens day are interactive and encourage problem solving. The day is designed to be teen-friendly and flexible, covering the subjects the young people want to know about.

Image adapted from Children’s Circle Tool, DAWN Youth

Autumn 2014 | DIABETES

FO O D

S U GA R AND YOUR HEALTH

Are you a

sugar addict?

Help is at hand if you are worried about eating too much sugar. Beating Sugar Addiction for Dummies by Australian nutritionist Michele Chevally Hedge offers a step-by-step guide to kicking the sugar habit. It includes advice on how to cut down on sugar and live a healthier lifestyle. Below is an extract from Chapter 1 which looks at the difference between having a sweet tooth and being a sugar addict. See our reader giveaway overleaf for details on how to win a copy of the book.

“We’re not exaggerating when we say that sugar is just as addictive as cocaine. It acts on the pleasure centre of the brain just like alcohol and heroin, so the more you eat, the more you want. Combine sugar’s addictive nature with its omnipresence in society, and you get a recipe for a global health disaster.” — Beating Sugar Addiction for Dummies

Understanding sugar addiction As a species, humans evolved eating the small amounts of sugar found naturally in fruits and plants. Today, Australians and New Zealanders consume approximately 31 teaspoons of sugar every day. We consume that in both added, hidden sugar and in natural sugar, so most of us don’t realise how much sugar we’re consuming. More than 75 per cent of most people’s sugar consumption comes from processed, manufactured foods and drinks. Your body isn’t designed to handle the massive load of sugar that the modern diet thrusts upon you, and Australia and New Zealand shoulder the embarrassing obesity, diabetes and metabolic syndrome statistics to prove it.

If Australians and New Zealanders continue with their current lifestyle, obesity rates will continue to rise. In Australia, health experts estimate that, by 2025, 83 per cent of men and 75 per cent of women over 20 will be overweight or obese. New Zealand continues to have one of the highest rates of obesity in the world, only just behind the United States and Mexico in the developed world.

Defining sugar addiction An addiction is anything that you must have to avoid a negative feeling or symptom, or the compulsion to artificially produce a pleasurable sensation. Sugar addicts use sugar as an energy booster (to avoid feeling tired and hungry) and a mood lifter because sugar triggers the production of serotonin and dopamine, which are hormones that make you feel happy and satisfied. Alcohol and cocaine are other addictive substances that trigger serotonin and dopamine production. As with drugs or other addictive substances, those who abuse sugar develop a tolerance to its effects and need more and more of it to yield the same rewards.

DIABETES | Autumn 2014

S UGA R A ND YO UR H EA LTH

FOOD

Do you repeatedly eat too much sugar, even though you promise yourself that you’ll never do it again?

Are you a sugar addict? You’re probably a sugar addict if two or more of the following descriptions rings true for you: • Without sugar, you suffer extreme fatigue or have trouble concentrating. • You eat sugar compulsively, even though you realise the negative consequences. • You experience physical withdrawal symptoms if you go without sugar for a day or two. • You find yourself obsessing over what your next sugar hit will be and when it will be. • You hide your sugar consumption from other people or lie about your eating behaviour. • You need more and more sugar to experience the ‘boost’. Foods that used to taste sweet to you don’t seem so sweet anymore. • You repeatedly eat too much sugar, even though you promise yourself that you’ll never do it again. • You turn to sugar for an emotional lift, such as when you feel lonely or when you’ve had a bad day. In Chapter 2 we categorise four types of stereotypical sugar addicts: the Exhausted Addict, the Sad Eater, the Numb Eater and the Sugar Stalker. Head to Chapter 2 and take the quizzes provided to find out what kind of sugar addict (or which combination of addicts) you are so you can regain optimal health and lower your sugar consumption.

See overleaf for some tips on reducing your sugar intake plus our Beating Sugar Addiction reader giveaway competition.

™

Autumn 2014 | DIABETES

FO O D

FIVE G OOD FOOD HABITS

Kick the sugar habit Many New Zealanders draw as much as a third of their calorific intake from sugar and enriched flour. Global sugar consumption has tripled in the last 50 years and the result is a worldwide obesity and diabetes epidemic. We have three copies of Beating Sugar Addiction for Dummies by Michele Chevalley Hedge (RRP $39.99) to give away. To enter the draw simply email admin@diabetes.org.nz using the phrase BEATING SUGAR ADDICTION in the subject line. Please submit your entry no later than 31 May 2014.

The more sugar we eat, the more sugar our bodies want, leading to a dangerous cycle of sugar addiction, says author and Australian-based nutritionist Michele Chevalley Hedge. She said, “Beating sugar addiction requires more than just staying away from sweet treats. To truly

transition into a new healthy lifestyle, you need to look at the motivation behind your behaviour, figure out what emotional holes you’ve been trying to fill with sugar, and understand how you are going to create this new lifestyle so it becomes habitual – and sustainable.” Michele presents a holistic, stepbased programme in her book Beating Sugar Addiction for Dummies that gradually weans a person off sugar without sacrificing the foods you love. It includes advice on identifying common sugar habits, healthy eating, exercise and over 50 healthy simple meal plans and recipes that include little or no sugar (see the cookie recipe opposite).

Improve your eating with five easy habits Here are some tips from Beating Sugar Addiction for Dummies to help kick the sugar habit.

Eating a high-protein breakfast stimulates your metabolism, stabilises your blood sugar and keeps your energy levels high throughout the morning.

Vegetables should make up the majority of your carbohydrate intake. Vegetables are low in kilojoules and high in vitamins, minerals, fibre and phytonutrients, so they make the ideal carbohydrate choice. Fruits are high in nutrients, but they also contain more sugar, so be judicious in your portions.

DIABETES | Autumn 2014

Try to eat a protein source every time you eat. Protein is essential for rebuilding muscles and organs and for making immune system cells, hormones, enzymes and a host of other necessary components of a healthy body. Eating protein with carbohydrates slows down the release of sugar into the bloodstream, so getting enough protein is important for blood sugar control too. Protein helps keep your appetite at bay longer than carbohydrates do.

Drinking enough water is important to keep all your body’s tissues healthy, including your brain. Being dehydrated decreases your mental and physical functions and triggers your hypothalamus to turn on the hunger and thirst centres in your brain, increasing appetite and cravings. A general guideline is to aim to drink a minimum of 1.5 litres of water every day.

Using the right nutrition supplements is a good way to ensure that you supply your body with optimum nutrition. Nutrition deficiencies can cause food cravings and contribute to a host of degenerative diseases like arthritis, heart disease and cancer.

RECI PES

FOOD

Cooking on a budget Eating healthily doesn’t have to cost a lot. Here is healthy curry recipe that will cost a lot less to make at home than to buy at an Indian restaurant. And it’s much healthier too. Try making a double portion and freeze half for later. Our second recipe is a homemade peanut butter biscuit, sweetened with maple syrup instead of sugar. They're a healthier and tastier option than buying processed biscuits from the supermarket.

Chickpea and spinach curry INGREDIENTS 2 tsp canola oil 1 large onion diced 2 cloves garlic, crushed, peeled and chopped 1 tbsp finely chopped ginger 2 medium potatoes or 250g kumara, cut into 1cm pieces 2–3 tsp curry powder 1 tsp cumin seeds (optional) 3 bay leaves 250g spinach, chopped 400g can of tinned tomatoes 310g can chick peas drained ½ cup water 2 tsp garam masala (optional) 2 tbsp chopped coriander leaves

Saute the onion, garlic and ginger in a pan. Add the potato, curry powder, cumin seeds (if using) and bay leaves. Cook for 1-2 minutes. Add spinach, tomatoes and stir in the drained chick peas. Simmer for 15 minutes until the potato cubes are cooked Add the garam masala (if using), season to taste, and add the chopped coriander leaves. Serve with basmati rice. Serves 4 NUTRITION PER SERVE: Energy: 766KJ, Protein: 7.5g, Fat: 6g, Carbohydrate: 23g, Sodium: 443mg.

Recipe courtesy of the Healthy Eating on a Budget workshop offered by the Diabetes Projects Trust (see p32).

Vegan peanut butter biscuits INGREDIENTS 2½ cups rolled oats 1/8 cup unbleached flour ¼ tsp cinnamon 2 mashed bananas 1/3 cup unsweetened peanut butter 2 tbps unsweetened soy or almond milk ¼ cup melted butter 2 tbsp pure maple syrup 1 tsp pure vanilla extract

Preheat the oven to 175°C. Line a baking tray with baking paper. In a large mixing bowl, stir together the oats, flour and cinnamon. In a separate bowl, combine the mashed bananas, peanut butter, soy milk, butter, maple syrup and vanilla. Mix well. Combine the banana mixture and the oat mixture and mix well. Drop the batter by teaspoons onto the baking tray.

Bake at 175°C for approximately 15 minutes, until firm. Be careful not to let the edges burn. Remove the biscuits from the oven and transfer to wire racks to cool. Vary it! Add 2 tbsps of sesame seeds to the oat mixture for extra crunch! Makes 48 biscuits NUTRITION PER SERVING: Energy: 205KJ, Sodium: 17mg, Carbohydrate: 6g, Sugar: 1.3g, Fat: 2.5g, Protein: 1g.

Recipe courtesy of Sugar Addiction for Dummies by Michele Chevalley Hedge. See p28 for our reader giveaway.

Autumn 2014 | DIABETES

OBITU A RY

LESIELI (R ACHEL) O’ BRIEN

Working to the very end – doing what she loved Wellington diabetes nurse, educator, leader and activist Lesieli Fine (Rachel) O'Brien passed away on 24 January 2014, aged 79 years. From humble beginnings in a tiny village in Tonga, Rachel built a new life in New Zealand, raised a family and committed herself to helping others, most notably those in her community with diabetes. The following edited extract is from her eulogy “My amazing mother” by her son Damian O'Brien.

Rachel started with nothing but achieved everything by doing what she loved: helping others. I understood, therefore, that to succeed in whatever we choose to do, be sure to give it everything. Work hard and good things come. Rachel is a testament to this philosophy.

DIABETES | Autumn 2014

Born August 27 1934, christened Lesieli Fine Lavulo in the tiny village of Utui in Tonga, Rachel always knew she wanted to be a nurse. After her mother died aged 36, she decided as a young teen that she would one day make a positive difference to people’s health. Her selfless attitude in helping others saw Rachel dedicate her life to healthcare after graduating as the first Polynesian to qualify as a registered nurse from Whanganui Hospital in June 1961. Before that, she qualified as a general nurse in Tonga and was given the opportunity to qualify as an NZRN by volunteer matron Stella Mexted, aunt of legendary All Black Murray Mexted. I visited Mum's village of Utui two years ago with her and it was only then that I realised why Rachel drove us so hard as children to succeed. Utui is a tiny village of 600 people in the island group of Vava'u, the northern part of the kingdom of Tonga. Rachel started with nothing but achieved everything by doing what she loved: helping others. I understood, therefore, that to succeed in whatever we choose to do, be sure to give it everything no matter what your circumstances may be. Work hard and good things come.

Rachel is a testament to this philosophy. During the mid 1990s, Mum became the first Service Manager of the Pacific Community Mental Health Service in Porirua. It was during this time that she noticed a growing need for culturally appropriate health education and assistance for Pacific Island people, as the numbers of Pacific Islander peoples with diabetes, heart disease, obesity, mental health and domestic violence spiralled. In addition to working full time, for 15 years, Mum spoke on Access Radio Friday nights, in Tongan, covering major health issues, providing information, advice and resources for Tongan and other Pacific people. She held voluntary, self-funded diabetes clinics at Tongan Church venues after services. She was a Community RN with the Pacific Health Service, Strathmore in 2004 in Wellington and developed a close working relationship with Diabetes New Zealand, including joining the advisory council when it was set up in 2012. Her passion for diabetes education and her love of Tongan and Pacific peoples made it impossible for her to retire, so she didn’t. Diabetes is something she described to me once as ‘pandemic’ among Polynesians. Working for Pacific Health and Compass Health, Rachel

LES I ELI (RACH EL ) O ’ BRI EN

focused on testing for diabetes, diagnosing diabetic symptoms and working hard in her free time to educate Polynesians as to the health risks posed by fast food diets. Rachel also ran free fitness classes for Polynesians to educate them in a practical sense for better health. Her exercise group in Newtown is still going strong. Before passing away, Rachel was in her 80th year and to our knowledge was the oldest registered nurse still working full-time in New Zealand when she was still with us. Such was her passion and dedication to fighting diabetes. Emotion would overcome my mother when she explained to me the work she was doing and her genuine fear of how this terrible disease was devastating Polynesian peoples in particular.” — Damian O'Brien



OBITUARY

Celebrating a dedicated diabetes campaigner Lesieli (Rachel) O’Brien earned the respect and love of all those who knew her work in the diabetes field. Her commitment and dedication were legendary, but above all her love for her people shone through. It was a great privilege to have Rachel as part of our organisation, most recently serving on Diabetes New Zealand’s Advisory Council. She also helped form Diabetes New Zealand Pacific Wellington. Having made a difference in so many lives, Rachel leaves an enormous legacy. She will be deeply missed by all and we will remember and celebrate her as the incredible force she was. — Chris Baty, President, Diabetes New Zealand

*Lesieli Fine (Rachel) O'Brien passed away in Mary Potter Hospice, New Zealand on 24 January 2014, aged 79 years. Dearly loved wife of Terry and much-loved mother of Angela, Theresa and Damian.

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Autumn 2014 | DIABETES

P RO FI LE

DIABETES PROJECTS TRUST

Helping Aucklanders with diabetes for 21 years The Diabetes Projects Trust has just celebrated its 21st anniversary. The Aucklandbased charitable organisation offers an innovative range of diabetes education and prevention projects. We asked Clinical Projects Manager Kate Smallman about the Diabetes Projects Trust’s work over the past two decades and what the future holds. What is the Diabetes Projects Trust? It is a charitable trust that provides training, education and support to people with diabetes or at risk of diabetes in Auckland. It started 21 years ago as a research-based organisation. One early example of this research was the Door-to-Door Study, a comprehensive survey of all South Auckland households.

Researchers knocked on the door of each house and asked whether the occupants had diabetes and if so, were they getting help managing it. That kind of research had never been done before in New Zealand and probably won’t be again and it resulted in a huge collection of valuable information. We still have people here who worked on that project.

Who founded Diabetes Projects Trust? The founding members were Dr David Simmonds and Dr David Scott, who were then diabetes specialists from Middlemore Hospital. The Diabetes Projects Trust was set up to undertake research and develop practical projects, such as local exercise and diabetes support groups, lifestyle and community engagement projects. An audit of care provided by GPs to their patients with diabetes was also set up and continues today.

How do you help people with diabetes? There are now so many people with diabetes in the area that we cannot educate them all individually. We have chosen to concentrate on a train the trainers model – we have a number of different projects (see right) that enable those who work in the community to learn about diabetes and healthy lifestyles so they can go back into their community and pass on all that they have learned. We find this model works very well.

What is special about the Diabetes Projects Trust? We are local to the community, we know what works well here and we have the people who can get things done in different areas, whether it’s a community group, a school, GP practice, or in different cultural settings, such as Māori, Pasifika or Indian communities. Our staff members make the Diabetes Projects Trust special, we have 22 people working here, mostly part-time, coming from all walks of life. Each of them brings a different set of skills and their own specialness and together we make a great team.

What’s coming up next? We have a new Diabetes in Pregnancy project. We want to help improve the situation for the women who develop gestational diabetes in the Counties Manukau District Health Board. Part of this is developing a registry, or collection of data, to allow follow up and support for individual women. The aim is to help prevent them and their babies from developing type 2 diabetes in the future. Celebrating 21 years: the team at Diabetes Projects Trust.

DIABETES | Autumn 2014

DI A BETES PRO J EC TS TRUST

PROFILE

PROGRAMMES OFFERED BY DIABETES PROJECTS TRUST

Cook’nKiwi — Healthy Eating on a Budget This one-day session (it can also be split over several days) can be provided to any organisation or group. It offers practical advice on how to make healthy, delicious food with lots of useful tips on how to cut costs, and how best to pass on this information to others. The training includes a complete toolkit of resources, including a fat and sugar display, and follow up support. Healthy Schools Onsite group or workshop training is offered to teachers, school nurses, and others needing practical tools to help students make better choices around food and physical activity. The training includes a comprehensive resource kit with everything needed to deliver a multi-part programme to Year 9 students. Advice on making changes to the school environment, including the tuckshop, is available, and there can be ongoing telephone support and visits.

Gardens4Health: local community groups work with the Diabetes Projects Trust to set up new vegetable gardens.

Healthy Workplaces This programme starts with a site visit to discuss the needs of the workplace with a view to making a healthier work environment, and encouraging worker health. Recommendations are made and support is provided to make the changes. Diabetes Prevention Train the Trainers This six- to eight-hour (one day or split) Train the Trainers session is delivered by a Diabetes Nurse Specialist and provides the knowledge and skills needed to train others about type 2 diabetes prevention and better diabetes management.

Gardens4Health Practical advice and support is given to help local groups set up new community gardens and the ongoing maintenance of existing gardens. The scheme provides access to a network of other gardens and gardening resources. Gardens4Health is currently involved in over 40 gardens across Auckland. Diabetes Care Support Service Through this Continuous Quality Improvement Audit, Diabetes Project Trust provides confidential support to GP practices to improve the care they give patients with diabetes. Trained auditors visit, identify all patients with diabetes, and an experienced GP Advisor gives practical feedback on where improvements can be made.

For more information see www.dpt.org.nz

Autumn 2014 | DIABETES

Connecting our diabetes community It's hard to believe we are already in March of 2014. The year seems to already be moving incredibly fast and we have a few updates that might interest you. Diabetes Youth New Zealand is happy to announce that we will be working towards unification with Diabetes NZ this year. We are very excited at the opportunity to become one organisation and hope that by becoming one, we will be better placed to serve our many youth families across the country. If you haven't been to our website (www.diabetesyouth.org.nz) lately, you should go take a look. We have started to add links to webcasts from

the World Diabetes Conference to our Links and Resources page. These webcasts are from guest speakers from around the globe who add their particular expertise from a scientific background or share their experiences of living with diabetes. There is bound to be something you find interesting! If you have read the last couple of issues of Diabetes magazine, then you will be aware we are having our first annual National Walk on 16 November. The effort of this walk is to to bring about awareness of diabetes and how it affects our youth and their families, and also to serve as a fundraising event to help our local societies. If you have an interest in participating or assisting with a walk in your area, feel free to contact walk@diabetesyouth.org.nz or keep up with our Facebook page (www.facebook.com/ WalkDiabetesYouthNZ).

Lastly, I am asked often when we will be having our next youth conference. The committee has decided we will have one soon after the new year in 2015. Once we have more details we will make the announcement on our website and Facebook page. We thank all of you for being patient, we do understand how valuable it is to gather with other families to learn and share experiences. Until next time!

Renata Porter

President Diabetes Youth NZ Please share your feedback, suggestions or questions with Diabetes Youth NZ. Email contact@diabetesyouth.org.nz.

Walk for diabetes youth People in cities and towns across New Zealand will gather to walk for diabetes on Sunday 16 November. It will be a great chance to meet other families, raise diabetes awareness, do some fundraising – and above all have fun! Q: How long will the walk be? A: The walk in your area will either be 2km or 5km. Details of the routes will be published nearer the time. Q: What will people taking part receive? A: Every walker will be given a medal at the finish line and if you raise $100 or more you will be sent a ‘Walk for Diabetes Youth’ t-shirt. Your local area may also have prizes for the top fundraisers. Q: How do I get involved? A: You can ask your friends, family and workplace to sponsor you, or make a donation. See www.diabetesyouth.org.nz for details of how to take part in your area.

Diabetes Youth New Zealand

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Make sure it’s there when you need it*

Ask your Healthcare Professional about the importance of having the emergency hypoglycaemia medication, GlucaGen® HypoKit, at home, work or school. Make sure to check the expiry date and renew your GlucaGen® HypoKit as necessary.

HypoHelp Website & App You and your family & friends can visit www.hypohelp.co.nz or download the free HypoHelp app to your smart phone for education and support on hypoglycaemia. HypoHelp also features a handy expiry date Reminder Service for your GlucaGen® HypoKit. To register please enter barcode number 000276 to login and when requested.

*Refer to full indications below

GlucaGen® HypoKit is a Pharmacist Only Medicine that is funded through the PHARMAC with a prescription, or available for purchase without a prescription (normal pharmacy charges apply). Ask your Healthcare Professional if GlucaGen® HypoKit is right for you.

Before prescribing, please review full Data Sheet available at www.medsafe.govt.nz GlucaGen® HypoKit. (glucagon [rys] hydrochloride). Presentation: Each pack consists of a vial containing lyophilised glucagon 1 mg (1 International Units) as hydrochloride and a glass syringe pre-filled with 1 mL water for injections. Indications: Therapeutic: Treatment of severe hypoglycaemic reactions in persons with diabetes mellitus treated with insulin or oral hypoglycaemic agents. To prevent secondary hypoglycaemia, oral carbohydrate should be given to restore hepatic glycogen following response to treatment. The treatment of sulfonylurea-induced hypoglycaemia differs from severe insulininduced hypoglycaemia due to the possibility of secondary hypoglycaemia - it is preferable to use intravenous glucose (see full Product Information (PI/Datasheet)). Medical consultation is required for all patients with severe hypoglycaemia. Contraindications: Hypersensitivity to glucagon or lactose, phaeocromocytoma, insulinoma or glucagonoma. Precautions: Glucagon will have little or no effect when the patient is fasting or is suffering from adrenal insufficiency, chronic hypoglycaemia or alcohol-induced hypoglycaemia. When used in endoscopy or radiography, caution should be observed in diabetic patients, or elderly patients with known cardiac disease. Glucagon should not be administered by intravenous infusion. Interactions: Glucagon is an insulin antagonist. When given in large doses, glucagon may potentiate the anticoagulant activity of warfarin. Glucagon can reverse cardiovascular depression of profound ß-blockade. With indomethacin, glucagon may lose its hyperglycaemic effect or even produce hypoglycaemia. Adverse Effects: Nausea; vomiting. Dosage and Administration: The glucagon solution should be prepared immediately before use. Dissolve powder in accompanying solvent and administer by subcutaneous or intramuscular injection. Therapeutic: Adults and children above 25 kg - administer 1 mg; Children below 25 kg - administer 0.5 mg.

Novo Nordisk Pharmaceuticals Ltd., G.S.T. 53 960 898. PO Box 51268 Pakuranga, Auckland, New Zealand. NovoCare® Customer Care Centre (NZ) 0800 733 737. www.novonordisk.co.nz ® Registered trademark of Novo Nordisk A/S. TAPS (DA):5913RB. McK32787/Diabetes NZ. January 2014.

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